GP update handbook - T2 diabetes and prediabetes

[Boo1979]

https://www.gp-update.co.uk/SM4/Mutable/Uploads/medialibrary/GP-Update-Handbook-AW17-Diabetes.pdf

 

[Deleted Account]

Interesting - do you have access to the section(s) which refers to type 1 ... and other types of diabetes?

 

[Art Of Flowers]

Seems they are gradually recognising the benefits of low carb diet.

Tight glycemic control has a J curve risk profile with lower sugar levels having high risk as well as high sugar levels. They haven’t yet associated the risk of too much insulin in the system is the reason for higher mortality with low blood sugars.

Same appears to be true for blood pressure treatments which also have a J curve risk profile.

 

[Boo1979]

Interesting - do you have access to the section(s) which refers to type 1 ... and other types of diabetes?

No - this just popped up when I was ggooglig something else and I thought it would be useful to share I will have another shufty on google and see what pops up re T1 etc

Edit had a quick look - it looks like theres a main handbook behind a suscription paywalll and only updates accessible via google. Latest update re T1 that I saw come up when I googledd type1 diabetes+gp update handbook was from 2016 re DKA

 

[bulkbiker]

Oh dear...

 

[derry60]

Lifestyle change seems to come out on top

 

[Daibell]

Hi. A very interesting document. Good to see how a typical GP would interpret the NICE guidelines

 

[Boo1979]

Lifestyle change seems to come out on top

On its own as a first line intervention with prediabetes and only moderately elevated blood sugars in those above the diabetes diagnostic threshold. Apart from those areas, lifestyle in conjunction with medication, with structured review of progress / progression as appropriate

 

[Kentoldlady1]

I like red whale. Easy to read and understand.

I took a copy of the red whale suggested tx to my gp when I was requesting additional help with my hypothyroidism. They both refused to even look at it. However, I did get a referral to an endo. Some gps will just stick with whatever they were taught years ago. And most certainly do not like patients knowing stuff.

My next comments relate to t2d.
A question? Does the "tight control" mentioned refer only to tight medical control ie drugs, and not tight control by lifestyle? I did not see a difference drawn between the two. I now have fairly tight control, and take metformin.( although I did forget it for a couple of weeks and my bgl remained the same). My question is about the method to achieve good control. If it makes no.difference, and indeed makes for worse outcomes then what is the point?

 

[Bluetit1802]

My next comments relate to t2d.
A question? Does the "tight control" mentioned refer only to tight medical control ie drugs, and not tight control by lifestyle? I did not see a difference drawn between the two. I now have fairly tight control, and take metformin.( although I did forget it for a couple of weeks and my bgl remained the same). My question is about the method to achieve good control. If it makes no.difference, and indeed makes for worse outcomes then what is the point?

I don't know the official answer, but in my opinion it is to do with hypos. Most people I should imagine that have "tight control" are on insulin or insulin promoting meds. (and was it these meds causing the mortality rather than BG levels?) I doubt the researchers saw many diet only people with tight control, unless they were directed to this forum of course!

 

[Grateful]

A question? Does the "tight control" mentioned refer only to tight medical control ie drugs, and not tight control by lifestyle?

This is indeed crucial. The impression I get is that they would not expect tight control without drugs ... the reason I say this is because there is a very brief section that mentions "some people" who manage to achieve diabetes reversal with lifestyle alone and says something to the effect that there is very little guidance available for those cases (!!!). It basically says, "watch out for relapses" and "make sure they get their annual eye checks" and leaves it at that!

It is interesting that they are putting forward the research about a "J-shaped" curve in which both tight control and loose control are more dangerous than moderate control. But I am almost sure they are assuming the tight-controllers are taking drugs, even if they do not say so explicitly. (Edited to add: They also, in a separate section, talk about evidence that hypos themselves cause cardio-vascular damage, in addition to being dangerous events in themselves.)

There was a separate thread about this research a few weeks ago.

 

[ziggy_w]

I like red whale. Easy to read and understand.

I took a copy of the red whale suggested tx to my gp when I was requesting additional help with my hypothyroidism. They both refused to even look at it. However, I did get a referral to an endo. Some gps will just stick with whatever they were taught years ago. And most certainly do not like patients knowing stuff.

My next comments relate to t2d.
A question? Does the "tight control" mentioned refer only to tight medical control ie drugs, and not tight control by lifestyle? I did not see a difference drawn between the two. I now have fairly tight control, and take metformin.( although I did forget it for a couple of weeks and my bgl remained the same). My question is about the method to achieve good control. If it makes no.difference, and indeed makes for worse outcomes then what is the point?

I believe I remember looking at the study quite some time ago (was it the ACCORD study?) and tight control was achieved by using medication rather than diet. I also agree with @Bluetit1802 that one of the reasons advanced for increased more mortality was a higher incidence of hypos with tighter control.

Btw, here is the link to the study: http://www.nejm.org/doi/full/10.1056/NEJMoa0802743

However, might it not also be possible that the reason tight control involving medication (especially insulin and drugs increasing insulin production in the pancreas) may lead to higher circulating insulin levels (especially in already insulin-resistant people), which in turn lead to a number of adverse consequences.

Do we really know which diabetic complications are due to high blood sugar levels and which are due to high insulin levels?
Has anyone seen any studies about this?

Personally, I don't believe that tightly controlling blood sugar levels through diet (and/or exercise) will carry much risk -- especially given the additional benefits that almost all of us experience, such as lower blood pressure, lower triglicerides and higher HDL.

Edited to provide information on and link to the ACCORD study.

 

[ringi]

A question? Does the "tight control" mentioned refer only to tight medical control ie drugs, and not tight control by lifestyle? I did not see a difference drawn between the two. I now have fairly tight control, and take metformin.( although I did forget it for a couple of weeks and my bgl remained the same). My question is about the method to achieve good control. If it makes no.difference, and indeed makes for worse outcomes then what is the point?

All the studies I have seen that show "tight control" to be of no benefit were based on drugs that increased how much insulin was in the body (Drugs that create risk of Hypos). Metformin comes out of the studies looking very good regardless of BG levels.