Editorial: Turning learning into practice: inspiration from the past and present

Despite this year’s European Association for the Study of Diabetes (EASD) conference being virtual, global key opinion leaders enthusiastically presented groundbreaking and practice-changing studies and perspectives, some of which we share in our breaking news section and in the Diabetes Distilled articles in this issue of the Journal. The exciting news for primary and community care is that many of the new studies involve interventions we can safely initiate ourselves, if only we can find the time to identify those who will benefit.
 
The NICE guideline for the management of type 2 diabetes, published in 2015, is significantly out of date and being updated, yet many of our readers tell us this guidance is still being enforced in their areas. This is difficult to understand, except on the grounds of prescribing cost. At the EASD conference, guidelines were a dominant theme, including during the Michael Berger Debate which encouraged us to consider the European Society for Cardiology’s 2019 guideline recommendation to replace first-line metformin with GLP-1 receptor agonists and SGLT2 inhibitors in those at high risk of cardiovascular and renal complications (Cosentino et al, 2020) versus initiating early dual therapy or step-wise introduction of drugs starting with metformin, as recommended in the 2019 update to the American Diabetes Association (ADA)/EASD consensus on glycaemic management (Buse et al, 2020). Primary Care Diabetes Europe shared its recently published guideline, which joins the ADA/EASD consensus in recommending early combination glucose-lowering therapy to offer cardiovascular protection for those at very high risk of cardiovascular disease events.
 
The star of the conference, for many people I spoke to, was Professor Naveed Sattar (University of Glasgow) who delivered the Camillo-Golgi lecture. He reminded us that although age and genes, including gender and ethnicity, set the susceptibility for diabetes, it is weight gain that pulls the trigger and, therefore, more focus on weight loss is needed both to prevent and to reverse type 2 diabetes. Finding ways to lose weight and stay under our own personal weight threshold for developing diabetes is important not just in achieving remission, but in improving all aspects of diabetes. For many people with diabetes, and indeed for many healthcare professionals, achieving the 10–15 kg body-weight loss recommended by the DiRECT study to help people achieve remission can seem an unachievable goal, yet several recent papers provide us with a much clearer picture of what works and, indeed, what doesn’t. Helping people achieve weight loss is such an important and far-reaching theme that we will return to it in our next issue.
 
Other themes from the conference included an in-depth focus on modes of action of drugs. Metformin is an old drug – in fact, as old as I am, since it first came to market in 1957 – and it was good to be reminded of old and new understanding of its modes of action, anti-inflammatory and antithrombotic benefits, and effects on microvascular complications, as discussed by Professor Peter Grant (University of Leeds), particularly when considering whether it should remain our first-line glucose-lowering therapy. Likewise, it was exciting to hear Milton Packer’s passionate discussion of the proposed cellular modes of action of the SGLT2 inhibitors on the myocardium and renal tissue, and to learn that they appear to encourage these tissues to think they are starving, thus stimulating them to repair and renew themselves. We will explore more about how drugs work in future issues of the Journal.
 
Others argued that it does not matter which guideline one follows, provided we empower and educate people to manage their own diabetes, since we spend so little time with them and they are actually the ones taking the day-to-day decisions that will influence the course of their disease for better or for worse. Empowerment was the theme of one of my favourite parts of the conference, a Meet the Expert session featuring John Buse (University of North Carolina) in discussion with Melanie Davies (University of Leicester), who both talked eloquently about their personal approaches to empowering people and delivering diabetes care.
 
A very big “thank you” to friends in the PCDS and Lead GP WhatsApp groups whose prompts ensured I did not miss valuable sessions and stimulated real-time (albeit virtual), valuable discussion throughout the week. The plus side of yet another virtual conference was that we did not need to travel for hours to and from the conference, and delegates were able to participate from all parts of the world this year, potentially greatly facilitating information dissemination to a much wider, global, rather than just European, audience. However, I felt cheated not to meet up with friends face to face, to stay up late debating the days’ events, and to share our usual cycle tour and sample the wonderful cake and coffee houses in Vienna.
 

In this issue

Most practices have accumulated a backlog of diabetes reviews while we have been forced to focus on acute care delivery due to the demands of the COVID-19 pandemic. Across the four nations, many different organisations have made recommendations on which parameters we should use to prioritise who to review urgently. In our PCDS “How to prioritise primary care services during and post COVID-19 pandemic”, Jane Diggle and I share guidance summarising the evidence base and the more lengthy documents, which we hope will prove useful and save everyone having to reinvent the wheel. It has been well received at the national and local meetings where we have shared it with colleagues, so, if you have developed a backlog of reviews, please take a look. Our newest “At a Glance” factsheet, written by David Morris (Royal Shrewsbury Hospital and retired GP), is on pancreatogenic (type 3c) diabetes. It summarises what we need to know to recognise and manage this increasingly common type of diabetes.
 
Diagnosing diabetic kidney disease (DKD) is often surrounded by confusion, yet making an early accurate diagnosis allows us to do everything we can to reduce further decline in renal function, as well as tackle the high cardiovascular risks associated with DKD. In this issue, we are, therefore, excited to share “Testing for kidney disease in type 2 diabetes: consensus statement and recommendations”, written by an expert UK panel, including PCDS committee members Jane Diggle and Sarah Davies.
 
Rachel Pryke, in her comment, “Will COVID-19 be the game changer?”, raises Julian Tudor Hart’s Inverse Care Law, which is as relevant today as when he published it in The Lancet in 1961. Arriving in Wales as a newly qualified doctor 20 years later, his work made a huge impact on me, not least that a local GP had achieved publication in such a prestigious journal and influenced medical thinking on a global scale. Reading about his work as part of the Medical Research Council unit he set up in his practice in Glyncorrwg changed my view of general practice from an option if I failed to make it as a surgeon, to a proactively chosen career choice where one might make a small difference to people’s lives at the grassroots level and perhaps be able to protect some free time to write. Returning from hearing him speak on salt, hypertension and cardiovascular risk a few years later, our practice team were enthused to plan what now seems a surprisingly innovative screening project for the 1980s, looking at cardiovascular risk factors across our practice population, a study that resulted in publication in the BMJ in 1988 and led to my career-long interest in nutrition and preventive and lifestyle medicine.
 
If you were too busy to attend the PCDS Wales and PCDS Scotland conferences, you missed great speakers and much practical information, but the sessions are now available on demand and free to view. Look out for our PCDS Wales conference report in the next issue of the Journal, and highlights from PCDS Scotland and PCDS National conferences early in 2021.
 

Putting the learning into practice

I am off to the practice to continue reviewing how to prioritise our backlog of diabetes reviews, to explore how we might empower those who will have delayed reviews to self-manage their diabetes in the meantime, and to update our searches on people with chronic kidney disease and heart failure to identify where we can use the new evidence to further improve the care we deliver.
 
With COVID-19 cases on the increase again, and more lockdown restrictions here in Wales and across the UK expected to be announced, I hope the articles in this issue will inspire and encourage all of us to find time to help our most vulnerable people with diabetes reduce their risk from COVID-19 as soon as possible.