At the start of a new year, I always feel inspired and motivated to think about ways to review and improve the diabetes care we deliver. This year, faced with significant NHS challenges, including lack of hospital capacity, strikes and high workload, I am aware we all need to identify where we can make the greatest impact with the fewest resources. Implementing ready-made, evidence-based guideline recommendations can save precious time, which can be spent updating protocols and templates to ensure we have clear roadmaps to follow, and which may encourage more team members to share our diabetes workload.
Here I have picked out some key revisions and evolving evidence from the updated recommendations in the American Diabetes Association’s Standards of Care in Diabetes – 2023 that are likely to have most impact. A more comprehensive review of the revisions is planned in a future At-a-glance factsheet.
2023 ADA Standards of Diabetes Care
These are “living guidelines” and are updated throughout the year as significant new evidence becomes available, with a full update published each January. The summary of revisions (ElSayed et al, 2023) helps us identify where changes to care delivery may be needed. Although some sections reflect US practice, diabetes care is becoming more globally unified, so most recommendations are relevant to us in the UK. Key guidance in each section of the Standards is highlighted in tinted summary boxes, tables and algorithms, making important information easy to find.
The 2022 ADA/EASD joint consensus on hyperglycaemia (Davies et al, 2022), including the updated management algorithm, has been fully incorporated into the 2023 Standards, and our previously published journal resources provide concise summaries of these recommendations. Significantly, weight loss is given equal importance to reducing cardiovascular disease (CVD) risk, improving heart failure outcomes, slowing renal disease progression and achieving glycaemic control in the algorithm and guidance. Both the benefits of smaller weight loss (5–7% of body weight) and the potential disease-modifying effects of greater weight loss (10–15%) achievable with total diet replacements or current pharmacotherapy are highlighted throughout the guidance, reminding us that encouragement to lose weight should underpin our type 2 diabetes care.
Prevention and self-management
With rapid increases in new cases of type 2 diabetes and evidence that non-diabetic hyperglycaemia increases CVD risk, the Standard on preventing and delaying progression to type 2 diabetes has been expanded to include recommendations for pharmacotherapy alongside lifestyle behaviour change for weight management, slowing hyperglycaemia progression and CVD risk reduction. Monitoring and lifestyle guidance to reduce type 2 diabetes for those with prediabetes who are on statins, and consideration of pioglitazone to reduce the risk of stroke and myocardial infarction in those with prediabetes and previous stroke, are new recommendations.
Since the beginning of the pandemic, I have been informally exploring food insecurity and have been surprised at the number of people relying on food banks, often intermittently. The ADA recommends formal questioning, and to consider households at risk if the person confirms one or both of the following statements:
“Within the past 12 months:
- “we worried whether our food would run out before we got money to buy more.” or
- “the food we bought just didn’t last, and we didn’t have money to get more.”
NAFLD and NASH
The 2023 Standards section on diagnosis and management of non-alcoholic fatty liver disease (NAFLD) has been updated, in the face of a predicted epidemic of non-alcoholic steatohepatitis (NASH; Kanwal et al, 2021). Around 25% of the UK adult population is believed to have NAFLD, and diabetes is a risk factor for worse outcomes, including progression to fibrosis and cirrhosis (Stefan and Cusi, 2022), as well as increased mortality from cardiovascular disease, liver disease and hepatocellular carcinoma.
The ADA reminds us that normal liver function tests (LFTs) do not rule out NAFLD. Those with persistently elevated LFTs should be investigated, and fatty liver on ultrasound or abnormal LFTs should prompt non-invasive fibrosis assessment using FIB-4 or NAFLD fibrosis scores, with further investigation or referral for intermediate fibrosis risk and referral for high risk scores. For those at low fibrosis risk, 5–10% weight loss and CVD risk reduction strategies (smoking cessation, lipid and blood pressure control) are recommended in primary care, with reassessment of fibrosis risk every 3 years. Those with type 2 diabetes should be treated with SGLT2 inhibitors or GLP-1 receptor agonists, which facilitate weight loss and reduce CVD risk.
It is likely we all have a large undiagnosed burden of NAFLD/NASH and fibrosis in our practice, and the British Association for the Study of the Liver and the British Society of Gastroenterology have developed quality standards for the management of NAFLD which could facilitate useful audits and improve care (McPherson et al, 2022).
My ambitions for 2023
I hope you will dip into sections of the ADA Standards of Care yourself and identify areas of practice to update or make changes this year. You can also expect a more in-depth analysis of the changes to the Standards soon in this journal. In the meantime, these are my aspirations for improving diabetes care in our practice in 2023. I hope one or more will inspire you to do something different in your own practice this year.
• Explore ways to motivate self-management.
• Support all our practice clinicians to upskill in order to recognise and manage diabetes emergencies, feel confident dealing with acute care needs including foot problems, and improve their knowledge of insulin safety.
• Develop a simple “Need to know” resource to help clinicians preview electronic records in preparation for undertaking diabetes reviews.
• Identify and share additional diabetes resources in languages used by people in our practice.
• Identify mums with previous gestational diabetes, ensure follow-up, offer lifestyle education and encourage weight loss.
• Undertake face-to-face review of people with diabetes who are housebound.
• Review people with diabetes in our care homes; identify and fulfil staff education needs.
• Review lipid management using searches and opportunistically; increase combination therapy and help people achieve targets.
• Ensure people on insulin and sulfonylureas have access to blood glucose monitoring; encourage discussion of their data and CGM, where available, during reviews.
• Continue to review all those with HbA1c >86 mmol/mol and ensure urgent management and follow-up.
In this issue
In these days of rare home visits, we are less aware of the hidden waste and potential dangers from fridges full of expensive insulins past their expiry dates. Jane Diggle’s How to calculate the amount of insulin to prescribe per month assists in calculating quantities of insulin to prescribe, reducing future waste. In tribute to the centenary of insulin in 2022, Jane has also updated her How to resources on best practice injection technique and avoiding insulin errors. Meanwhile, the PCDS Six Steps to Insulin Safety e-Learning module has just been updated, is free to access and is highly recommended to everyone who prescribes insulin.
David Morris’ case studies provide a useful opportunity to test our knowledge of management of older people, while Sarah Stevens and Martin Rutter’s At-a-glance factsheet on diabetes and sleep provides information on an oft-overlooked aspect of lifestyle and self-care. Paul Newman’s At-a-glance factsheet on diabetic peripheral neuropathy includes a useful summary of neuropathic pain treatment.
My latest Conference over coffee report summarises key take-home messages from the lipids and hypertension Masterclasses at the PCDS National conference, and in Diabetes Distilled, Kevin Fernando and I share journal articles on foot self-care, lipid lowering and diabetes screening pertinent to us in primary care.
Farewell as Editor-in-Chief
I am sad to announce that this is my last editorial as Joint Editor-in-Chief, as I have thoroughly enjoyed this opportunity. However, I know I am leaving the journal in Jane Diggle’s safe and highly competent hands.
Jane and I took over from Colin Kenny and Gwen Hall in January 2015 – a challenging act to follow – and have adapted the journal to optimise its online format, and to focus on concise, practical resources for busy clinicians coping with a demanding workload (including the COVID-19 pandemic) and increasingly complex diabetes care. Over the past 8 years, we have harnessed our clinical experience and honed our editorial and writing skills to develop new article formats, including the How to guides, At-a-glance factsheets,
Conference over coffee summaries and Need-to-know resources, and we will continue to develop and update these.
My thanks to George Posford and Richard Owen, and all those working behind the scenes in our in-house editorial team; our Editorial Board members; and all our authors over the last 8 years – we could not have achieved so much without you!
It has been a huge privilege to work with Jane, and I greatly value her friendship, her knowledge, expertise, innovative ideas, hard work and support throughout the time we have worked together. I know she will continue to ensure the journal supports us in our delivery of quality diabetes care going forward.
I will continue jointly editing Diabetes Distilled with Kevin Fernando, and I am looking forward to having more time to spend on hands-on diabetes care, delivering diabetes, obesity and lifestyle medicine education, and enjoying time with family and friends, playing golf and growing vegetables on our allotment.
Pam Brown first joined Diabetes & Primary Care in 2015. What was originally a commitment to head the journal for only three years has since turned into the longest tenure for an Editor-in-Chief in the journal’s history, during which time Pam has truly transformed it.
As well as overseeing our transition away from print, with an online audience that has grown enormously year on year, Pam has revolutionised the content of the journal. Under her guidance, we have moved away from the long-form prose that is typical of most academic publications to the short, concise and practical materials, including How to guides, At-a-glance factsheets and Conference over coffee summaries, that our audience finds so useful.
Pam understands as well as anybody the pressures that our readers in primary care are under, and so she has always strived to create resources that are as accessible as possible, and which readers will want to refer to over and over again. The brevity of the articles belies the time and effort that go into them, and nothing has been published without first passing under Pam’s precise eye, and meeting her maxim of “will this be helpful for our readers?”. Quite where she has found the time to devote so much care and attention to the journal – in addition to her clinical work, speaking engagements, tribunal service, educational activities and, perish the thought, a life outside of work – will forever remain a mystery. However, both the journal and its readers have benefited from her ever-high standards and her seemingly inexhaustible energy, for which we offer our most sincere thanks.
Although we are losing Pam at the head of the journal, we are thrilled that she will remain on the Editorial Board as a GP advisor to the new Editor-in-Chief, as well as continuing to co-produce the Diabetes Distilled series.
As intimidating as it must be for anyone to take over the mantle from Pam, we know we have a worthy successor in the form of Jane Diggle, who has nobly partnered with Pam, first as Associate and then Joint Editor-in-Chief. We are delighted to welcome Jane to the role of sole Editor-in-Chief, and we join her in thanking Pam for her monumental effort over the past eight years, and for her patience, kindness and integrity throughout.
Editors, Diabetes & Primary Care