Chinnadorai Rajeswaran, Chair of the National Diabesity Forum, welcomed delegates to the 6th National Diabesity Forum Conference.
Taking positive action on obesity
Martin Hadley-Brown, GP, Thetford
Dr Martin Hadley-Brown kicked off the conference with a presentation on the latest facts and figures of the rising prevalence of both obesity and diabetes over time across the USA and other countries, providing clear evidence for the diabesity pandemic. He considered the non-modifiable and modifiable factors contributing to the rise of diabesity, including environmental and social aspects (e.g. the rise of fast-food outlets in socially deprived areas and exercise becoming less frequent).
Basing the second part of his talk on the Royal College of Practitioners’ Call for Action, Dr Hadley-Brown discussed the steps to improving care for people with diabesity. The speaker covered the effectiveness of bariatric surgery for people with diabesity and how healthcare professionals can take steps to reduce the rise of diabesity by meeting local needs with appropriate services for the community and using every consultation as an opportunity to make a positive impact on the health of the individual.
Overcoming the complexities surrounding type 2 diabetes and service delivery
Roger Gadsby, Visiting Professor, University of Bedfordshire and GP Clinical Lead for the National Diabetes Audit
Prof Roger Gadsby presented practical advice on type 2 diabetes drug management based on the NICE CG87 guidelines published in 2009. However, therapies have developed over the past 5 years, and with the new guidelines due to be published in 2015, Prof Gadsby guided delegates on how to incorporate newer therapies into today’s care for people with type 2 diabetes, and type 2 diabetes and hypertension. He also made predictions on the recommendations to come from the new guidelines.
The second part of the presentation focussed on the results of the 2011/2012 National Diabetes Audit (NDA), which measured the completion of a composite of nine care processes and a composite of three intermediate outcomes (HbA1c, blood pressure and cholesterol) in centres across England and Wales. The NDA showed a rapid improvement of completion of eight care processes since 2004/2005 across Clinical Commissioning Groups (CCGs), which has since plateaued at 60.5% in 2011/2012. Huge variation between CCGs and practices within a CCG were also reported.
Variation between CCGs can be reduced by sharing best practice and looking at the centres in the bottom 25% to investigate why performance is low. Prof Gadsby provided links to NDA data at national level (http://bit.ly/1mMwVQX) and at CCG level (CCGs from A–C [http://bit.ly/XHaEyX]). GP practice level data is available for each practice that submitted to the NDA raw data and can be accessed via Open Exeter by calling the Health & Social Care Information Centre (HSCIC) on 0845 3006016 or emailing [email protected].
Individualised care in diabesity: Succeeding through a joined-up approach
Chinnadorai Rajeswaran, Consultant Physician, Mid Yorkshire NHS Trust, and Chair of the National Diabesity Forum
Chinnadorai Rajeswaran’s interactive presentation focussed on how clinicians can provide individualised care for people with diabesity. He began by explaining the vicious cycle of type 2 diabetes, whereby drug therapies have the potential to cause weight gain, thus exacerbating the situation people with diabesity find themselves in.
Dr Rajeswaran took delegates step-by-step through how to achieve a joined-up approach to diabesity care. Members of the “ideal” team were listed (endocrinologist, diabesity nurse specialist, dietitian, physiotherapist, occupational therapist, social worker, psychologist, bariatric surgeon) and what to discuss with individuals during consultations was included. How best to prescribe insulin therapy to minimise weight gain was discussed. Dr Rajeswaran concluded that, while optimising glycaemic control is paramount for people with type 2 diabetes, weight gain should be avoided, and that a holistic approach to diabesity care is the best way to ensure good outcomes.
Diet and exercise: Practical considerations along the care pathway
Pam Dyson, Research Dietitian, Oxford
After lunch and the sponsored symposium, Pam Dyson began the afternoon session with a talk on the practical considerations of combining diet and exercise following the NICE care pathway. She showed that providing lifestyle advice to people with diabesity is effective in improving HbA1c and weight loss, and included advice for delegates on the latest dietary trends.
Integrated weight management programmes are recommended by NICE guidelines and Dr Dyson ended her presentation by promoting behavioural strategies as a key component of successful weight loss programmes (e.g. goal setting and planning, rewards and relapse prevention).
Pharmaceutical treatments: Impacts of treatments for diabesity
Cliff Bailey, Professor of Clinical Science, Aston University, Birmingham
Cliff Bailey took delegates on a tour of the treatments available for type 2 diabetes, and focussed on their effects on weight gain, bringing the link between diabetes and obesity to the forefront.
A complicating factor of using drugs to manage diabetes is the tendency for improved insulin action or increased insulin concentrations to cause weight gain. Prof Bailey explained how incretin-based therapies, such as glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors (gliptins), do not cause weight gain, and how selective inhibitors of sodium–glucose co-transporter-2 reduce renal glucose reabsorption and offer a new approach to reduce hyperglycaemia by eliminating excess glucose in the urine, which also facilitates weight loss.
Other approaches, such as commencing weight loss drug therapy prior to glucose control management, are advancing in development, but currently only orlistat is licensed for weight loss in the UK.
Bariatric surgery: The same patients, but new thinking
Roger Ackroyd, Consultant General Surgeon, Sheffield
Roger Ackroyd outlined the surgical options for obesity and diabesity. He explained the importance of ensuring that the patient is suited to the surgical option. Patient criteria for gastric surgery treatment include the following: a minimum of 5 years of obesity, no alcoholism or psychological illness and no chance of pregnancy in the 2 years following surgery.
Selecting the correct patient is simple if using the NICE criteria, but the individual should be able to commit to lifelong follow-up and be able to understand the implications of surgery. Once the correct patient is selected, the correct surgery should then be chosen (of which there are many from purely restrictive techniques to purely malabsorptive techniques). In Sheffield, 1600 laparoscopic gastric bypasses were given between 2004 and 2014: 36% of individuals had type 2 diabetes of whom 96% had improved or been “cured” after the surgery. A band might be better for younger people with a BMI of <49 kg/m2 who do not have diabetes. Bypass may be better for those with type 2 diabetes who are super-obese.
The best options for those with diabetes are bypass (resulting in 95% resolution of diabetes), biliopancreatic diversion (99% resolution) and duodenal switch (100% resolution). Banding results in about 50% resolution and sleeve 50–60% resolution.
Bariatric surgery can result in excellent resolution of type 2 diabetes and obstructive sleep apnoea, and improvements in blood pressure, as well as other comorbidities.
Head-to-head debate: “Psychological considerations are just as important as clinical considerations in bariatric surgery”
Roger Ackroyd, Consultant General Surgeon, Sheffield; Damian Edwards, Senior Behavioural Advisor, National Obesity Forum and Behavioural Trainer, Manchester
Surgeon Roger Ackroyd began the debate by showing the delegates a graph depicting weight over time following surgery and psychological treatments: surgery clearly decreased weight, while psychological therapy had no effect on weight. He argued that bariatric surgery was objective, with well-known efficacy and mechanisms of treatment, compared to psychological treatments, which do not work for everyone. However, he added that the psychotherapy field is poorly funded at present and there is a lack of available care providers to provide care for people seeking psychological therapy, which is in contrast to funding and availability of surgeons. Psychological therapy does affect comorbidities and can deal with the emotional complications of surgery but not the physical problems of significant weight loss that surgery can.
Looking at the alternative view, Damian Edwards, a Senior Behaviour Advisor, explained that psychological considerations are just as important as clinical considerations in bariatric surgery for diabesity management among morbidly obese people. The speaker described how over the past 5 years, the significance of psychological factors in all clinical interventions has become more apparent, which has been noted particularly in the area of clinical compliance and post-surgery response, since without psychological support, drug adherence and behavioural change can falter. In order to truly help in cases of obesity, he stressed the need for delegates to recognise how attitude obviously affects behaviour, and explained how some of the models of behaviour can be applied. In particular, Damian emphasised that psychotherapy is not meant to replace surgery but to work alongside to create a more holistic solution.
