10th National Conference of the Primary Care Diabetes Society: Poster Abstract Book

P1. Improving quality: the impact of formal impaired glucose regulation reviews in the primary care setting
Milne N, Northenden Group Practice, Manchester

Background: Against the backdrop of an expanding diabetes population and its associated burdens, prevention of type 2 diabetes (T2D) is becoming increasingly important. Persons most at risk are those with impaired glucose regulation (IGR). IGR has become more readily diagnosed since HbA_1c tests have been introduced and included within NHS health checks. We now have an identifiable IGR population which affords the opportunity to deliver preventative lifestyle advice and intervention. Aims/objectives: To quantify the impact of formal consultations giving lifestyle advice and intervention in improving outcomes for persons with IGR. Methods: Persons with HbA_1c 42–47 mmol/mol inclusive were invited for review in 20-minute clinics with a practice nurse. Explanation of IGR was given, BP, pulse and BMI measurements were taken, and kidney function and lipids profile were reviewed. Advice regarding lifestyle, signs and symptoms of T2D and smoking cessation advice (where appropriate) was given. The population was reviewed again after 12 months. The study includes data from 95 persons. Results: In the second review: 55% had reduced HbA_1c with 37% having a normal HbA_1c. Three per cent had progressed to T2D. Sixty per cent had reduced BMI, of which 31% had reduced more than 5 kg. Initially, 44% had cholesterol higher than 5 mmol/L, falling to just 18% during second reviews. Four per cent were found to have hypertension and three persons were identified as having irregular heart rhythms. Conclusion: Formal reviews of the IGR population appear to trigger positive lifestyle changes in the majority of the population, reducing their risk of developing T2D and cardiovascular disease.

P2. A nurse-led community renal clinic for people with diabetic nephropathy
Foster S, Buckinghamshire Healthcare NHS Trust, Buckinghamshire; Brain H, High Wycombe Hospital, High Wycombe; Chatterjee S, Stoke Mandeville Hospital, Aylesbury

Background: Diabetes is the single largest cause of end-stage renal failure and is linked to increased cardiovascular disease. Aims/objectives: To assess the effectiveness of a renal nurse-led clinic by reducing deterioration of nephropathy and cardiovascular disease by optimising medication and addressing life-style issues. This was achieved by reducing blood pressure and albumin excretion using ACE-inhibition to the maximum tolerated doses. Cardiovascular risk was assessed and managed by addressing smoking cessation, weight loss and physical activity. HbA_1c targets were individually assessed with a target of 48 mmol/mol. Self-management was encouraged with the use of a hand-held record book. Methods: Twenty-six patients were seen at chronic kidney disease (CKD) 3a, 3b, and 4 and followed up at monthly intervals. Two questionnaires were completed on three occasions – initial clinic, 3 months and 6 months. The patient’s test results were completed by the nurse and a WHO (Five) Well-Being Index (1998 version) was completed by the patient. A patient experience survey was completed after the 6-month clinic. The GP and diabetes consultant were kept informed of the patient’s progress after each consultation. Results: At 6 months systolic and diastolic blood-pressure had significantly improved (P≤0.0037; P≤0.0015). For the albumin creatinine ratio: P≤0.06. For the protein creatinine ratio: P≤0.23. The patient experience survey suggested that all patients had an improvement in their knowledge of renal disease since coming to the clinic. Summary: Our data reveal that there were improvements in blood pressure which has a significant effect in reducing diabetic nephropathy and cardiovascular disease.

P3. Are X-PERT centres meeting the NICE structured patient education (SPE) key criteria for Quality Assurance?
Deakin T, X-PERT Health, West Yorkshire

Aim: To comply with NICE guidance, X-PERT Educators are assessed with the X-PERT Quality Assurance Programme within their first year of delivery. Method: The X-PERT Quality Assurance Programme contains 62 standards that are linked to learning outcomes. Each standard is either fully, mostly, partly or not met. Guidance defines the criteria required for each category and points are allocated accordingly. Delivery to patients is assessed via direct observation or videos. Educators receive a report and constructive feedback. If Educators score below 198 (80%) a timed action plan is prepared and the quality assurance process repeated within 1 year. Results: 431 X-PERT Diabetes Educators were eligible to be assessed by 20/2/14. Number of Educators who have: completed the QA process = 260 (60.3%); are in progress = 86 (19.9%); have not done it = 77 (17.8%); are on long-term leave = 8 (1.8%). Mean score = 221/248 (89%, SD 6.7%) with scores ranging from 167 (67%) to 248 (100%). Six Educators (2.3%) required a timed action plan to increase score. Lost marks were mainly due to lack of interpersonal/facilitation skills to support group education and goal setting. Conclusion: Adherence to quality standards for delivery of X-PERT Diabetes ensures that patients receive a high standard of structured education. Three hundred and forty-six X-PERT Educators (80.2%) have either been assessed or are currently going through the process. The remaining Educators will be assessed during the following 12 months or removed from registration. A handbook has been prepared to assist Educators in developing the relevant interpersonal/facilitation skills.

P4. Are X-PERT centres meeting audit standards for structured patient education?
Deakin T, X-PERT Health, West Yorkshire

Aim: X-PERT Structured Education has demonstrated improved clinical, lifestyle and psychosocial outcomes. To ensure national implementation replicates results from the randomised controlled trial and standards identified in NICE Guidance, continuous audit is conducted. Methods: X-PERT Educators collect and enter patients’ baseline, 6-month and annual results onto the X-PERT Audit Database. Results: Seventy-nine X-PERT Centres (100%) have submitted data for 42823 people with new or established diabetes. Ethnicity: 84% white and 16% BAME groups. Time to access education from diagnosis: 8% within 1 year, 58% within 5 years, 14% within 10 years and 20% more than 10 years. Audit standards have been met with excellent attendance scores: 95.7% attend at least one session and 81.9% four sessions or more; patient evaluation scores of 95%; empowerment scores increased by 22.9%; HbA_1c reduction of 6.7 mmol/mol (95% CI, 6.2–7.2 mmol/mol) at 6 months and 6 mmol/mol (95% CI, 5.5–6.5 mmol/mol) at 1 year; weight loss of 2.1 kg (95% CI, 1.4–2.6 kg) at 6 months and 3.7 kg (95% CI, 2.8–4.1 kg) at 1 year; 2.5 cm (95% CI, 1.6–3.3 cm) waist circumference reduction at 6 and 12 months; 1.6 mmHg (95% CI, 1.1–2.1 mmHg) reduction in systolic and 2.3 mmHg (95% CI, 2.0–2.6 mmHg) reduction in diastolic blood pressure at 1 year; 0.3 mmol/L reduction in total/LDL cholesterol and 0.2 mmol/L reduction in triglycerides at 1 year. Conclusions: National implementation of the X-PERT Programme has met audit standards. X-PERT is well attended and evaluated, and results in improved clinical and empowerment outcomes amongst people with newly diagnosed and existing diabetes.

P5. Natural History of Renal Function with Exenatide usage in Diabetes – An Observational Audit
Ali I, University of Birmingham, West Midlands; Wijesinghe H, University of Birmingham, West Midlands; Tariq S, Mid Staffordshire NHS Foundation Trust; Baskar VB, Wolverhampton Hospital, West Midlands

Background: Exenatide is a glucagon-like peptide-1 (GLP-1) agonist. It is cleared by renal excretion, with renal impairment being a contraindication. Case studies have reported occurrences of acute and reversible renal impairment in some GLP-1 agonist users. Aim: To monitor the natural history of renal function in patients on exenatide therapy and to also measure the incidence of acute renal impairment. Methods: Patients identified were using exenatide alone or with insulin. Patients were divided according to pre-treatment renal function using the Modification of Diet in Renal Disease (MDRD) formula (n=448). Adverse renal events, discontinuation and changes in weight, BMI, systolic blood pressure, and HbA_1c were monitored and compared between renal groups over a 12-month period. Results: Median values of eGFR and creatinine remained stable in both the exenatide-only and exenatide–insulin groups. Four patients were identified with criteria fulfilling acute renal impairment. However, patient notes further clarified that these were merely fluctuations with no significant deterioration. In terms of weight, the groups had a median reduction of 6.6 kg and 10.2 kg for exenatide–insulin and exenatide-only groups respectively with subsequent improvement in BMI. Blood pressure improved in both groups. HbA_1c values for the group comprising exenatide only showed a percentage drop of 1.4% (P<0.05), while the exenatide–insulin had no change at 12 months. Conclusion: In contrast to existing literature, exenatide therapy was not consistent with a decline in renal function. The risk of acute renal failure was apparent in patients who suffered from other dose-related adverse effects such as diarrhoea and vomiting.

P6. Stepping Up: Exploring the impact and implementation of a new model of care for insulin initiation in general practice
Manski-Nankervis J-A, University of Melbourne, VIC, Australia

Background: Stepping Up is a cluster randomised controlled trial testing a new model of care for insulin initiation in general practice in which the role of the practice nurse is enhanced. Aims/objectives: To explore the views of GPs and practice nurses (PNs) about the impact of this model of care and factors affecting its implementation. Methods: Purposive sampling identified six GP–PN pairs in the intervention arm of Stepping Up. The aim was to achieve maximal variation based on factors such as location and previous experience with insulin initiation. Individual semi-structured interviews were analysed using an applied thematic approach. Results: Three overarching themes were identified. 1: GPs identified clinical benefits from participating, for example related to the study tools and clinical resources. However, 2: The realities of generalist care and organisational issues are barriers to a focus on a single condition such as diabetes and the PN’s role. And 3: Mentoring and Credentialed Diabetes Educator-Registered Nurse (CDE-RN) support were essential elements for PN involvement in insulin initiation. However, PNs highlighted additional needs, including further education and support to further develop relationships with local CDE-RNs. Conclusion: Engagement of local CDE-RNs, organisational ± structural changes in clinics and additional practice nurse education are important factors in increasing insulin initiation in general practice. These issues will need to be addressed at both the individual (relational) and practice (organisational) level and have implications for the provision of services such as by Primary Health Care Networks.

P7. Assessing Cardiometabolic Risk in Middle-Aged Adults Using Body Mass Index and Waist-Height Ratio – Are Two Indices Better Than One?
Millar SR, University College Cork, Cork, Ireland

Objectives: A novel obesity classification method has been proposed utilising BMI and waist–height ratio (WHtR) together. In this study we compare the metabolic profiles in subjects defined as overweight or obese by both measures. We examine a range of metabolic risk features, pro-inflammatory cytokines, acute-phase response proteins, coagulation factors and white blood cell counts to determine whether a combination of both indices more accurately identifies subjects at increased cardiometabolic risk. Methods: This was a cross-sectional study involving a random sample of 2047 men and women aged 50–69 years. Metabolic and anthropometric profiles were assessed in study participants. Independent t or Mann–Whitney U tests were used to compare lipid, blood pressure, glycaemic and inflammatory biomarker levels between BMI and WHtR tertiles. Multinomial logistic regression was performed to determine cardiometabolic feature and biomarker risk factor associations for BMI and WHtR groupings. Results: In both overweight and obese groups, the combination of BMI and WHtR tertiles identified consistent metabolic variable differences relative to those characterised on the basis of one index. Similarly, odds ratios for cardiometabolic risk factors were noticeably increased in subjects classified as overweight or obese by both indices when compared to study participants categorised by either BMI or WHtR individually. In obese subjects within the highest BMI and WHtR percentile, the prevalence of high blood pressure, insulin resistance and pre-diabetes was 81%, 55% and 17% respectively. Conclusions: Risk stratification using a composite index may provide a more effective and precise method for identifying high-risk subjects.

P8. Optimal Central Obesity Measurement Site for Assessing Cardiometabolic and Type 2 Diabetes Risk in Middle-Aged Adults
Millar SR, University College Cork, Cork, Ireland

Objectives: Despite recommendations that central obesity assessment should be employed as a marker of cardiometabolic health, no consensus exists regarding measurement protocol. This study examined a range of anthropometric variables and their relationships with cardiometabolic features and type 2 diabetes in order to ascertain whether measurement site influences discriminatory accuracy. In particular, we compared waist circumference (WC) measured at two sites: (1) below the lowest rib (WC rib) and (2) between the lowest rib and iliac crest (WC midway), which has been recommended by the World Health Organization. Methods: This was a cross-sectional study involving a random sample of 2002 men and women aged 50–69 years. Metabolic profiles and WC, hip circumference, pelvic width and BMI were determined in study participants. Logistic regression and area under the receiver operating characteristic curve analyses were used to evaluate obesity measurement associations and discrimination of metabolic risk phenotypes and type 2 diabetes. Results: Rib measurements displayed the strongest associations with non-optimal lipid profiles, high blood pressure, insulin resistance, impaired fasting glucose, a clustering of metabolic risk features and type 2 diabetes. Rib-derived indices improved discrimination of type 2 diabetes by 3–7% compared to BMI and 2–6% compared to WC midway (in men) and 5–7% compared to BMI and 4–6% compared to WC midway (in women). Conclusions: WC rib is easier to measure and is a better method for determining obesity-related cardiometabolic risk than WC midway. The clinical utility of rib-derived indices as potentially more accurate predictors of type 2 diabetes requires further investigation.

P9. The Prevalence and Determinants of Undiagnosed and Diagnosed Type 2 Diabetes in Middle-Aged Irish Adults
Millar SR, University College Cork, Cork, Ireland

Objectives: The prevalence of type 2 diabetes within the Republic of Ireland is poorly defined, although a recent report suggested 135 000 cases in adults aged 45+, with approximately one-third of these undiagnosed. This study aims to assess the prevalence of undiagnosed and diagnosed diabetes in middle-aged adults, and compare features related to either condition, in order to investigate why certain individuals remain undetected. Methods: This was a cross-sectional study involving a sample of 2047 men and women, aged 50–69 years, randomly selected from a large primary care centre. Logistic regression was used to explore socio-economic, metabolic and other health-related variable associations with undiagnosed or diagnosed diabetes. A final multivariable analysis was used to determine odds ratios and 95% confidence intervals for having undiagnosed compared to diagnosed diabetes, adjusted for gender, age and significant covariates determined from univariate models. Results: The total prevalence of diabetes was 8.5% (95% CI, 7.4–8.8%); 72 subjects (3.5%) had undiagnosed diabetes (95% CI, 2.8–4.4%) and 102 subjects (5.0%) had diagnosed diabetes (95% CI: 4.1%–6.0%). Obesity, dyslipidaemia, and family history of diabetes were positively associated with both undiagnosed and diagnosed type 2 diabetes. Compared with diagnosed subjects, study participants with undiagnosed diabetes were significantly more likely to have low levels of physical activity and were less likely to be on treatment for diabetes-related conditions or to have private medical insurance. Conclusions: A considerable proportion of diabetes cases were undiagnosed (41%), emphasising the need for more effective detection strategies and equitable access to primary healthcare.

P10. Associations of iron indices with impaired fasting glucose and diabetes among Korean adults
Bak HJ, Samsung Seoul Hospital, Seoul, Korea

Background and aims: Previous studies indicated that excessive iron stores induce organic damage, leading to diabetes. This study evaluated the relationship between iron indices – serum ferritin and transferrin saturation (TSAT) – and impaired fasting glucose (IFG) and diabetes. Methods: We performed a cross-sectional study of a representative sample of South Korean adults aged ≥19 years using data from the Korean National Health and Nutrition Examination Survey 2010–2012. In total, 14468 participants were included after excluding those who were pregnant and those with chronic liver disease, chronic kidney disease, or anaemia. The subjects were classified into the following three groups: normal fasting glucose, IFG (defined as fasting glucose, 100–125 mg/dL), and diabetes. We also measured fasting plasma glucose, HbA_1c, serum ferritin, and TSAT (percentage of iron-saturated transferrin). Results: IFG increase and diabetes prevalence were related to increasing ferritin quartiles and decreasing TSAT quartiles. After adjusting for age, education level, smoking, drinking, and BMI, IFG was significantly elevated in the highest ferritin quartile compared with the lowest quartile in women (adjusted OR, 1.37; 95% CI, 1.05–1.78) and men (adjusted OR, 2.12; 95% CI, 1.66–2.71). Diabetes prevalence was also significantly higher in the highest quartile group, in women (adjusted OR, 1.88; 95% CI, 1.32–2.69) and men (adjusted OR, 2.08; 95% CI, 1.55–2.79). In contrast, IFG and diabetes were less prevalent in the highest TSAT quartile for both sexes. Conclusion: Increased serum ferritin and decreased TSAT levels are independently associated with IFG and diabetes among Korean men and women.

P11. Reviewing the care planning of diabetes care within a mental health trust
Wiltshire L, Birmingham and Solihull Mental Health Foundation Trust, West Midlands

Aims/Objectives: To review if the implementation of a diabetes service and education around diabetes has had an impact on the quality of care plans for service users with diabetes within a mental health trust. Method: All inpatient units within Birmingham and Solihull mental health trust were audited in 2012 and re-audited in 2014 to assess if they were having their service users with diabetes given appropriate “diabetes care plans” and if it was relevant to their needs. Care plans were observed for the individual “9 care processes” in 2012 and 2014; however, 2014 also reviewed for an overarching diabetes care plan. Results: In both 2012 and 2014, patients had some individual care plans for individual elements of diabetes; there has been an improvement in HbA_1c and weight/BMI care planning in 2014; however, there had been little impact on the other care processes, suggesting the staff still don’t consider these elements to be diabetes related. However, in 2014 over 68% has an overarching diabetes care plan and another 18% had diabetes included in a physical health care plan, which is a considerable improvement. Conclusion/Summary: It is recognised that there has been minimal improvement in the care-planning of the individual elements of the diabetes “9 care processes” within a mental health trust. However, diabetes is an area which is being actively care-planned, and there has been an improvement in overarching general diabetes care plans and including diabetes in the physical health care plans.

P12. A Safer Ramadan: promoting safer fasting during Ramadan
Northern A, Leicester Diabetes Centre, Leicester

Aims: To develop a toolkit to aid primary care organisations to educate communities, staff and patients with diabetes about fasting safely during the holy month of Ramadan. Method: Based on principles of the DESMOND Programme an education package of three components was written and piloted in five primary care organisations in the UK: 1) Community Awareness – designed to increase awareness of the impact of diabetes during Ramadan throughout communities. 2) Healthcare Professional Training – a chance for healthcare professionals to discuss how best to manage their patients before, during and after Ramadan. 3) Patient Self-Management Education: a) Understanding Diabetes for Ramadan – 2-hour session looking at the basics of how the body works and what diabetes is; b) A Safer Ramadan – 2.5-hour session designed to provide knowledge of how to observe Ramadan safely. Results: In the pilot seven Community Awareness sessions were delivered to groups of up to 20 people, seven Healthcare Professional Training events took place and there were 10 patient education sessions. Positive feedback was received by attendees from all three components about the impact of the intervention. In addition, 19 patients were followed up and showed weight reduction at 8 weeks post-attendance and mean HbA_1c had not deteriorated post-Ramadan. Conclusion: Providing a “whole systems approach” to raising awareness of fasting safely during Ramadan is the key. It addresses the patient needs, healthcare professional needs and the needs of the wider community all at once, whilst positively impacting on patient outcomes and levels of self-management.

P13. Similar Efficacy and Safety With LY2963016 Insulin Glargine Compared With Lantus Insulin Glargine in Patients With T1DM: The ELEMENT 1 Study
Blevins T, Texas Diabetes & Endocrinology, TX, USA; Dahl D, Gemeinschaftspraxis für Innere Medizin und Diabetologie, Hamburg, Germany; Rosenstock J, Dallas Diabetes and Endocrine Center at Medical City, TX, USA; Ilag J, Eli Lilly and Company, Indianapolis, IN, USA; Huster WJ, Eli Lilly and Company, Indianapolis, IN, USA; Pollom RK, Eli Lilly and Company, Indianapolis, IN, USA; Prince M, Eli Lilly and Company, Indianapolis, IN, USA
Presenting non-author: Balogh E, Eli Lilly and Company, Windlesham, UK

Background: LY2963016 (LY IGlar) and Lantus^® (IGlar) are both insulin glargine products, with identical amino acid sequences. Even with identical primary structure, protein-based therapeutics manufactured by distinct processes must be shown to be clinically similar. Aims/objectives: The aim was to test the non-inferiority of LY IGlar to IGlar. Methods: A 52-week, Phase 3, randomised, open-label, parallel study was undertaken to compare the efficacy and safety of LY IGlar QD versus IGlar QD in combination with pre-meal insulin lispro TID in patients with T1DM (HbA_1c ≤11.0%). The primary aim was to test the non-inferiority of LY IGlar to IGlar (0.4% non-inferiority margin and if 0.4% was met then 0.3% was tested) as measured by change in HbA_1c, from baseline to 24 weeks. Safety assessments included hypoglycaemia, AEs and antibody responses. Results: Both treatment groups had within-group statistically significant (P<0.001) decreases in mean HbA_1c values from baseline. The change in HbA_1c from baseline with LY IGlar was non-inferior to IGlar (−0.35% versus −0.46%, respectively; least square mean difference [95% CI] of 0.108 [−0.002 to 0.219]). Non-inferiority of IGlar to LY IGlar was also demonstrated; thus, the criteria for equivalence in clinical efficacy between LY IGlar and IGlar were met. There were no treatment differences in secondary efficacy or safety outcomes including hypoglycaemia. AE frequency was the same with LY IGlar (62%) and IGlar (62%) (P>0.999). Conclusions: LY IGlar compared with IGlar, used in combination with lispro, provided equivalent efficacy and a similar safety profile in patients with T1DM.

P14. A health economic assessment of Exenatide once weekly versus Insulin glargine for patients with type 2 diabetes mellitus based on 3-year clinical trial data and a 6-year follow-up study
Charokopou M, Pharmerit International, Rotterdam, the Netherlands

Objective: When patients start their first injectable therapy, clinicians can choose between GLP-1 receptor agonists and basal insulins. The relative efficacy and costs of exenatide once weekly, a GLP-1 receptor agonist, compared with insulin glargine were assessed in patients inadequately controlled with metformin (± sulfonylureas) based on long-term clinical evidence and a health-economic modelling framework. Methods: Clinical inputs were derived from a 26-week randomized clinical trial (DURATION 3) comparing exenatide once weekly (ExQW) versus insulin glargine once daily. The durability of the treatment effects was taken from 3- and 6-year follow-up (DURATION 3/DURATION 1) of patients treated with ExQW. These clinical parameters were included in a health-economic model and were combined with costs associated with drug treatment, diabetes-related complications and other healthcare resources. Total Quality-Adjusted Life-Years (QALYs) and total costs, along with the incremental cost-effectiveness ratio (ICER), were calculated for a lifetime horizon. The uncertainty around the model inputs was analysed by means of sensitivity analyses. Results: Long-term treatment with ExQW was well tolerated and associated with sustained glycaemic control and sustained weight loss over at least 3 years. Compared to glargine, ExQW in combination with metformin was associated with an incremental benefit of 0.123 QALYs (95% CI, 0.057–0.178) at an additional cost of £1722 (95% CI, £1396–£2089), resulting in an ICER estimate of £13967/QALY. Conclusion: ExQW in combination with metformin (± sulfonylureas) was shown to be a cost-effective treatment option as first injectable therapy in patients inadequately controlled with metformin. The robustness of this statement has been addressed and confirmed within extensive sensitivity analyses.

P15. Can Type 2 Diabetes Mellitus Be Reversed With Very Low Calorie Diets: A Systematic Review
Fernando K, North Berwick Health Centre, East Lothian

Background: There is recent evidence suggesting that type 2 diabetes mellitus (T2DM) is reversible with certain diets. This has ignited the interest of medical and patient communities. Aims: This systematic review explores whether there is evidence that T2DM can be reversed with very low calorie diets (VLCDs), and whether any effects on glycaemia and bodyweight are sustained in the longer term. Methods: A systematic review was undertaken to investigate the effects of a VLCD intervention conducted in T2DM populations. PubMed, Medline and Web of Knowledge were searched from database start to September 2013. In all, 2516 publications were screened and 36 studies included using the criteria of a VLCD intervention comprising less than 800 kcal daily, in those with T2DM regardless of age, duration of disease or bodyweight.Results: There was a strong association between weight loss and improved glycaemic control in the short term. Four of the 36 included studies reported reversal of T2DM using the WHO 2011 diagnostic criterion of HbA_1c <6.5%. Thirteen of the 36 included studies reported reversal of T2DM using the WHO 2006 diagnostic criterion of FBG <7 mmol/L. Six of the 36 included studies reported glycaemic outcome measures spanning greater than 12 months. These studies did not report reversal of T2DM, or a sustained reduction in bodyweight after a VLCD. Conclusions: VLCDs can improve glycaemia in the short term. However, there is no evidence of a sustained improvement in glycaemic control or maintenance of weight loss. There remains a great need for robust longer-term outcome data. 

P16. Physicians’ Challenges When Discussing the Type 2 Diabetes Diagnosis With Patients: Insights From a Cross-National Study (IntroDia™)
Polonsky WH, University of California San Diego, San Diego, CA, USA, and Behavioral Diabetes Institute, San Diego, CA, USA; Belton A, International Diabetes Federation, Brussels, Belgium, and The Michener Institute for Applied Health Sciences, Toronto, ON, Canada; Down S, Somerset Partnership NHS Foundation Trust, Somerset; Capehorn M, National Obesity Forum, London, and Clifton Medical Centre, Rotherham; Gamerman V, Boehringer Ingelheim Pharm