The Diabetes Professional Care conference is a two-day event where healthcare professionals come together to discuss the challenges and latest developments within diabetes care.
Deputy Editor Jack Woodfield and Research Editor Camille Bienvenu reported the highlights live from day one at Olympia London, where childhood obesity, diabetes burnout and the FreeStyle Libre were among the focus topics.
Dr Alex Miras, a Senior Clinical Lecturer in Endocrinology at Imperial College London, reviewed the latest evidence regarding bariatric surgery and type 2 diabetes.
He also touched on the mechanisms through which different types of bariatric surgery can improve weight, metabolic control and diabetes-related microvascular complications.
Through his research, he found that the reversal of type 2 diabetes in patients post-operatively seems uncoupled from their weight loss. In other words, adiposity, while associated with type 2 diabetes, is not likely the cause.
Dr Miras reported that the three most important determinants of success of bariatric surgery are insulin requirements, HbA1c levels and the duration of diabetes – patients who had had type 2 diabetes for a long period of time before surgery are overall less likely to experience dramatic improvements.
In non-responders, like people who have had type 2 diabetes for a long time, weight loss medications after surgery may help boost the effects of surgery but this is still currently under discussion.
While NICE guidelines are fixated on body mass index (BMI) to determine if bariatric surgery is a viable treatment option for a given patient, Dr Miras put forward data showing that those with a BMI lower than 35 kg/m2 have a similar type 2 diabetes remission (achieving normal glycemia without any medication) rate – of about 70 per cent – than those with a BMI equal to or greater than 35 kg/m2.
Bariatric surgery in those with prediabetes also leads to a massive (80 per cent) drop in the risk of development of type 2 diabetes.
According to Dr Miras, there is no need to operate on patients if they are well-controlled with medication. However, it might be appropriate when therapies aren’t working or if insulin requirements increase.
Although bariatric surgery is not without risk, it is not as risky as previously thought. The risk of complications can be up to 20 per cent higher, but it is generally only in presence of surgical complications that it can become risky.
Certain types of addictions and a higher occurrence of postprandial hypoglycemia can result from surgery. In some cases, microvascular complications can worsen after surgery but, Miras says, bringing blood glucose down before surgery in patients with “bad acting diseases” could minimise the risk.
Obesity surgery is the only clinically proven way to reverse type 2 diabetes to date. If we better understand how the surgery exerts its effects on blood glucose and weight, we may one day be able to mimic the effects of surgery without a knife.
“There’s always more than you think you can do”
We’ve just heard from Jerry Gore, a professional climber who co-founded the charity Action4Diabetics to encourage more primal movement among young people with type 1 diabetes and help them cope with a diabetes diagnosis.
Gore was himself diagnosed with type 1 diabetes in January 2001, and was told that this meant his career as an alpinist had come to an end, but he wouldn’t have it any other way.
He has resolved not to let diabetes stop his active outdoor lifestyle and used his diagnosis as a motivator instead. After running multi-activity courses in Southern France for schools and colleges across Europe through AlpBase.com, Jerry co-founded Action4Diabetics (A4D).
A4D raises funds by organising outdoor challenges, like climbing the treacherous north face of the Eiger in the Swiss Alps. The money raised by participating goes towards supporting young people with type 1 diabetes aged 18 to 25 years old in emerging countries across South East Asia.
The charity focuses on setting up personal development workshops and family camps there to help the youth with type 1 diabetes take ownership over their condition and plan for a life with no limiting factors.
Gore also passionately advocates for young people to do more exercise and daily movement, but not in the way that many people think. He encourages multi-plane movements, such as crawling, climbing, jumping, pushing and pulling, and getting in the fresh air, for long-term health.
“It’s been there for years, but no one has done anything about it.”
The opening words from Debbie Hicks, a Diabetes Nurse Consultant at Enfield Health, set the tone for a harrowing insight into why more needs to be done to tackle diabetes burnout.
Also known as diabetes distress, burnout is intrinsically linked with poor HbA1c levels and occurs when people feel overwhelmed or defeated by their diabetes, leading to poor decision-making regarding their medication and jeopardising their long-term health.
Hicks revealed that she has twice suffered from diabetes burnout, and both times “not one healthcare professional was able to help”.
She attributes this void to doctors lacking the knowledge or the skills to help patients with diabetes burnout – being told you’re a “bad diabetic” is counterproductive and likely to worsen a person’s well-being – but Hicks lauded the impact of psychologists in helping to identify the crux of patients’ problems that may have sparked their burnout.
Among her key messages for healthcare professionals was to recognise burnout and signpost patients to help. Healthcare professionals can make a massive difference, Hicks said.
She urged transparent communication between patients and doctors and/or therapists, with a focus on explaining to patients why it’s normal to have negative feelings regarding their diabetes, and why setting realistic goals is pivotal to help patients break out of burnout.
Prediabetes and transparency in medical guidelines were the major talking points from a conference discussing type 2 diabetes care in general practice.
Kate Sidaway-Lee, a PhD student at the University of Exeter, presented long-term research from patients at St Leonards Medical Practice, Exeter, all of whom had prediabetes.
Fifty per cent of those with prediabetes went on to develop type 2 diabetes, with obesity increasing this risk further. The impact of socioeconomic factors and deprivation further heightened the likelihood of type 2 diabetes development.
“General practice can help establish these long-term trends within diabetes,” said Sidaway-Lee.
However, a more positive finding was that improved diagnosis rates consequently led to earlier diagnoses, encouraging early treatment and reducing the risk of complications. Sidaway-Lee added that type 2 diabetes is wholly preventable when addressed thoroughly.
Professor Sir Denis Pereira-Gray, Emeritus Professor, University of Exeter, called for greater transparency in medical guidelines and within journals and editorials.
He highlighted a recent study where 20% of journal editors were fined for conflicts of interest, adding that more safeguards should be in place to reduce financial conflicts.
Richard Sangster, the Head of Obesity Policy at the Department of Health, discussed new development (or so we thought) on the watered-down Childhood Obesity Plan released in August 2016.
The original plan fell short of expectations in several key areas for action that could have made the strategy more effective. These include controlling supermarket promotions, imposing further restrictions on junk food marketing, introducing clearer labelling for food and drinks, and enforcing an obligatory (not voluntary) sugar reduction target for industry, among other things.
At the time, many experts from across the UK have come out and say that efforts need to be better coordinated between sectors such as government, education and industry. It was also suggested that an international alliance of healthcare organisations combating childhood obesity should be created to support the implementation of the plan.
In today’s talk, Sangster did talk about setting up a new Obesity Policy Research Unit for addressing social inequalities, but nothing like an international alliance.
He then went on to present startling statistics about the level of involvement that people expected from the UK government in encouraging healthier food and lifestyle habits as a way to illustrate the complexity of introducing new measures that strike a balance between “manning” and supporting people.
He also pointed out that healthcare professionals need to find new ways to engage parents, children and young people about the impact of childhood obesity. He suggests that parents tend to underestimate body weight issues in their offspring and plans to address this in part by developing digital weight management tools.
An extension of the existing soft drink industry levy plan will be introduced in April 2018, which will give more unnecessary time to industry players to reformulate their products and finding innovative ways to dodge that bullet. Sangster said the industry showed commitment through “a lot of positive announcements,” so there’s that.
For further progress on the Childhood Obesity Plan and lowering obesity rates, Sangster is looking at targeting excess calories and is currently reviewing evidence for this move.
Dr Joseph Wherton, a senior researcher at the University of Oxford, has been telling us about how virtual consultations can benefit diabetes management.
Remote patient monitoring represents an advantage, as it increases access to care while reducing costs. Sometimes, months can go by without a touchpoint with anything. A simple video chat can alert doctors if anything is amiss.
In the diabetes setting, we’re starting to see digital tools, like Skype, become a default approach for some but there are challenges in its sustained use in large NHS Trusts. Concerns were also raised about the potential for leaked confidential information.
Dr Wherton has probed those challenges, and tried to find solutions to make the use of skype in the clinical setting safer. Today, he presented results from a two-year study called VOCAL he has been spearheading which looked at the use of Skype and how to embed it into care.
His findings echo previous research, conducted between 2011 and 2014, known as the DREAMS study, which showed that Skype use was associated with increased engagement, less A&E attendance for complications and improvement to blood glucose control.
The VOCAL study recorded 30 virtual consultations and conducted an in-depth analysis of the interaction in different settings. Some limitations and requirements to embed online consultations in the care setting were identified.
First, virtual online consultations need to be co-evolved with the clinical setting, which requires key organisational changes. There needs be a set of criteria defining what makes a quality virtual consultation.
Carers need to apply some level of clinical reasoning in the implementation of the technology and decide when it is appropriate to do a virtual consultation and when an office visit is needed.
Finally, building some sort of one-to-one relationship before turning to online consultations makes for better virtual interactions.
Virtual consultations could soon be more widely used in place of office visits, reducing or eliminating the need to travel for appointments. However, integrating Skype or Facetime-type technologies into care will take time and further experimentation.
“This is the future”
This is the message from Dr Anna Brackenridge, Consultant in Diabetes at Guy’s and St. Thomas’ hospital, who has been speaking about the FreeStyle Libre.
Dr Brackenridge presented four case studies where patients with type 1 diabetes who had elevated HbA1c levels all benefitted from using the FreeStyle Libre.
One patient, a 36-year-old man whose HbA1c levels were between 70-80 mmol/mol (8.6-10.4%) for years, began using the Libre in 2016 and his HbA1c is now below 55 mmol/mol (7.2%). Another patient was able to identify regular episodes of nocturnal hypoglycaemia as a result of using the device.
While Dr Brackenridge said “This is the future” regarding the Libre’s potential for people with type 1 diabetes, she is disappointed that access to the device is not greater.
The Libre was made available on the NHS at the beginning of November, but all of Dr Brackenridge’s patients currently pay for the Libre, which can cost up £1,250 a year (£910 on the NHS).
She believes the current situation is unfair, but says that much like how blood glucose monitoring eventually became widespread in diabetes monitoring, it won’t be long before the Libre is available to all people who would benefit, and not just those who can afford it.
11:20: Dr Partha Kar, Associate National Clinical Director for Obesity and Diabetes for NHS England, took the stand alongside Prof Jonathan Valabhji to discuss the digital transformation of our health services. Dr Kar advocates a collaborative approach to care and interconnectivity between patients and healthcare professionals.
He is responsible for innovations such as the hypoglycemia hotline and the e-diabetes passport, and is the man behind the award-winning Superhero-style comic book about a young person’s journey into type 1 diabetes, Origins.
Dr Kar places a lot of importance on practical care management and giving a voice to people with diabetes. He created the Talking About Diabetes (TAD) talks, reminiscent of TED talks, to that end.
While a consultant at Portsmouth Hospitals NHS Trust, he launched the Super Six Model of diabetes care, which offers people more comprehensive care that suits their needs. This equated to having a multidisciplinary team in place consisting of specialists in six different specialties that he felt were most needed: inpatient diabetes, foot diabetes, poorly controlled type 1 diabetes including teens, insulin pump services, impaired kidney function (low eGFR), and antenatal diabetes.
Kar has been very vocal about making existing technology, like Skype, more secure for remote care management rather than spending NHS money on creating new platforms.
While there is now a more positive attitude towards supporting the implementation of digital interventions across CCGs and the NHS, Kar feels like digitally enabled educations programs are still resistant to change. The technology, he says, should adapt to us consumers and not the reverse, or we’ll continue to see poor compliance rates and outcomes that are not improving.
Kar does however recognise that the NHS is being prodded into doing things differently and that this time the change is coming from within the system. This, he believes, may be a result of increased mobilisation after the famous tagline campaign “We are not waiting” was introduced in Stanford University in 2013.
There is a rallying cry to make diabetes data more accessible, intuitive and actionable, and we’re headed in the right direction to see a real digital care revolution in the diabetes space.
We’re at stand G16 promoting the benefits of our award-winning Low Carb Program. The program has shown to help people with type 2 diabetes come off their medication, lose weight and improve their blood sugar levels.
09:30: The venue is packed as a tannoy announces Professor Jonathan Valabhji and Dr Partha Kar’s Keynote Session will begin at 10:10. Really quite incredible to see how many people are here. It promises to be a fascinating day full of debate and learning (let’s just hope my near 10-year old laptop holds up).