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Meeting highlights: 16th National Conference of the PCDS

The 16th National Conference of the PCDS was held virtually on 5–6th November 2020. Over 2000 primary healthcare professionals attended live sessions covering a variety of topics including COVID-19 and diabetes, diet and lifestyle, medicines optimisation and mental health, and similar numbers have since accessed the on-demand sessions online. In this article we provide a brief overview of the key learning points from each of the sessions and masterclasses; however, we encourage readers to attend the on-demand sessions in their own time: click here to access.

The national picture

Jonathan Valabhji, National Clinical Director for Diabetes and Obesity
  • Among people with all forms of diabetes, HbA1c and raised BMI are modifiable risk factors for COVID-19-related mortality.
  • Roll-out of online structured education to support self-management of diabetes has been accelerated in response to the pandemic:
    –  For adults with type 1 diabetes: MyType1 Diabetes is now available without any referral requirement.
    –  For children and young people with type 1 diabetes: the DigiBete App and web platform are now in place.
    –  For adults with type 2 diabetes, Healthy Living for People with Type 2 Diabetes is available for direct patient registration.
  • Evaluation of the first 2.5 years of activity of the NHS Diabetes Prevention Programme in England shows significant effects on weight loss and HbA1c reduction in people with non-diabetic hyperglycaemia (NDH). Click here to read the study.
    –  To adapt to the COVID-19 pandemic, eligibility for referral to the Programme has been extended to people with a blood test confirming NDH in the previous 24 months (formerly 12 months).
    –  People have also been allowed to self-refer until March 2021, using the Know Your Risk tool.
  • A new Quality and Outcomes Framework (QOF) Indicator for NDH (The percentage of patients with non-diabetic hyperglycaemia who have had an HbA1c or fasting blood glucose performed in the preceding 12 months) is planned for introduction in financial year 2021/22.

 

What has COVID-19 taught us?

Kamlesh Khunti, Professor of primary care diabetes and vascular medicine, University of Leicester
  • It is unclear if people with diabetes are more likely to contract COVID-19.
  • Current data suggest that COVID-19 is associated with worse outcomes in people with diabetes.
    –  People with type 2 diabetes were roughly twice as likely to die in hospital, while those with type 1 diabetes were three times more likely.
    –  The increased risk is largely attenuated in those with good glycaemic control.
  • The pandemic also risks contributing to worse diabetes outcomes due to the disruption it has caused, including stress and changes to routine care, diet, and physical activity.
  • Outcomes are disproportionately worse in black, Asian and minority ethnic populations. See the evidence review and recommendations from the South Asian Health Foundation.

 

New ways of working post-COVID-19

Jane Diggle, Specialist Diabetes Nurse Practitioner, West Yorkshire

 

Masterclass: Prescribing fundamentals in type 2 diabetes

Sarah Davies, GPwSI in diabetes, Cardiff
  • The ADA/EASD Consensus Statement is a good “living” guideline to keep us up to date with our prescribing according to recent evidence.
  • Diet, lifestyle and education remain fundamental.
  • Metformin remains first-line therapy.
  • After metformin, establishing whether the patient has CVD, is at high risk of CVD, or has HF or CKD will guide the  early use of SGLT2 inhibitors and GLP-1 RAs.
  • Individualised prescribing to the patient sat in front of us is key.
  • Safe prescribing and awareness of cautions and side effects is crucial.
  • Sick day guidance needs reinforcing to patients wherever applicable.

 

Updates in lifestyle

Jason Gill, Professor of cardiometabolic health, University of Glasgow
  • The amount of objectively measured physical activity needed for substantial health benefits may not be very large (only 5–10 minutes per day of moderate-to-vigorous physical activity).
  • Muscle-strengthening (resistance) exercise is important for health; low strength is a significant risk factor for adverse health outcomes.
    –  Early evidence suggests that one set per week of each major muscle group (equating to a few minutes per day) may be enough for health benefits.
  • Sleep may be a third modifiable “lifestyle” risk factor to focus on (in addition to diet and physical activity) to optimise cardiometabolic health; however, research into this is in its infancy.

 

The opportunity that lies in every crisis

Stephen Lawrence, Associate Clinical Professor, University of Warwick
  • COVID-19 has been an accelerant for the need to embrace digital technology into the care model approach.
  • The digital technology model of care can transform how people with diabetes engage with services.
  • Healthcare professionals have a focal role in upscaling public confidence in government programmes, including vaccination, and communicating good evidence in an unbiased fashion.
  • Delivering large-scale digital transformation involves both risks and opportunities.
  • To maximise uptake, the benefits of digitisation must be made clear, while reassuring about data security and use.
  • Innovation and integration must be individualised.

 

Funny numbers

Clare Hambling, GP, Norfolk, and PCDS Chair; Patrick Wainwright, Consultant in Chemical Pathology and Metabolic Medicine, Betsi Cadwaladr University Health Board
  • Always consider liver health in people with diabetes.
    –  Non-alcoholic fatty liver disease, non-alcoholic steatohepatitis and cirrhosis are of increasing concern.
    –  It is vital to assess the extent of fibrosis.
  • Think about haematological factors which may affect interpretation of HbA1c. If in doubt, call your local biochemistry lab for advice.
  • People aged ≥60 years with new-onset diabetes and weight loss should be referred for abdominal CT or ultrasound to exlude pancreatic cancer (NICE NG12 – Suspected cancer: Recognition and referral).
    –  Also consider in those with sudden worsening of existing diabetes (e.g. rapid progression to requiring insulin, unexplained weight loss).

 

Mental health

Mark Davies, Consultant Clinical Psychologist, Belfast
  • Remember the three “core conditions” of a good relationship with a patient:
    –  Empathy (a sense that their healthcare professional understands their point of view).
    –  Congruence (authenticity; using the same voice when addressing patients as you would anyone else).
    –  Unconditional positive regard (valuing the patient irrespective of their words or lifestyle).
  • Primary care practitioner empathy has been associated with a lower risk of all-cause mortality in people with type 2 diabetes (Dambha-Miller et al, 2019).
  • Many people may not see much value in looking after their own health, particularly if they have been brought up to have low self-worth or if they see this as secondary to looking after other people (e.g. parents, children). Discussion of good diabetes self-care should be framed around these perceptions.
  • Autonomy is crucial to happiness and wellbeing. Diabetes education should be conducted with this in mind, aiming for autonomy and confidence rather than conformity with instructions from healthcare professionals.

 

Masterclass: Diabetic foot disease

Vanessa Goulding, Highly Specialist Podiatrist, Cardiff
  • Examine and assess foot risk at least annually (see NICE NG19 guidance). Include subjective questioning, vascular, neurological, skin, musculoskeletal and footwear assessments.
  • Know your patient: identify their level of activation, how important they consider their footcare and how confident they are to provide their own care and manage their own foot health. Remember: “their feet, their risk, their health” – making the patient an equal partner in decision-making leads to greater activation with self-care.
  • Provide advice on management to reduce risk:
    –  Information about how diabetes affects feet and the importance of blood glucose control.
    –  Advise the person of their individual risk of developing a foot problem. Low risk does not mean no risk.
    –  Provide basic foot care advice and promote the importance of foot care.
    –  Advise on foot emergencies and who to contact.
  • Know when and how to refer in more serious cases. Get to know your local foot protection team (FPT) or multidisciplinary foot care team (MDFT). Know your local pathways.
  • Rapid referral to FPT or MDFT within one working day, for triage within one further day, for:
    –  Ulceration
    –  Spreading infection
    –  Suspicion of acute Charcot foot or unexplained hot red swollen foot with or without pain
    –  Critical limb ischaemia
    –  Gangrene.

 

Dietary advice in diabetes

Pamela Dyson, Research Dietitian, Oxford
  • All people with diabetes should be referred to appropriate structured education programmes for ongoing lifestyle and dietary advice and support.
  • Weight loss is a key feature for those with type 2 diabetes living with excess weight and obesity.
  • Weight loss for those with type 2 diabetes is associated with remission, lower HbA1c, lower cardiovascular risk and improved quality of life.
  • There is no evidence supporting one specific dietary strategy for people with type 2 diabetes, and a variety of diets can be offered, including low-fat healthy eating, low-carbohydrate, low-energy (including total diet replacement), Mediterranean-style diets and intermittent fasting.
  • Acknowledging personal preference and using behavioural strategies improves outcomes.

 

Masterclass: Insulin management

Su Down, Diabetes Nurse Consultant, Somerset
  • Insulin should be considered, either as part of a combination regimen or temporarily to normalise acute hyperglycaemia, but it is frequently initiated much later than is optimal.
  • There are many educational videos on starting insulin, correct injection technique, etc., that can reassure patients about starting the therapy as well as teaching them how to self-administer in their own time.
  • Following inititation, the insulin dose will need to be titrated. However, consider other factors (e.g. insulin storage, meal/injection timing, lipohypertrophy) that may cause an otherwise optimised dose to be ineffective.
  • Do not forget to consider de-escalation of therapy, particularly in older/frail people. See: How to manage diabetes in later life and: How to switch from twice-daily to once-daily basal insulin

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