When I arrived in San Diego, my taxi driver informed me that he was expecting to be very busy over the next few days, with 22 000 people attending the American Diabetes Association (ADA) annual meeting. Indeed, the meeting sounded overwhelming, but also very exciting.
Determined to make the most of the Winston Churchill Memorial Trust travel fellowship I had been awarded, I tried to attend as many sessions as I could. The challenge was to focus on some key areas, as there were topics so many of interest.
Recurrent themes emerged throughout the 4 days I was there, in particular, the overtreatment in type 2 diabetes, the management of exercise in type 1 diabetes and the increased role of technology (in particular closed loop systems and the artificial pancreas).
Hypoglycaemia
I attended many sessions focusing on hypoglycaemia and a number of speakers expressed concern that in the years following the DCCT (The Diabetes Control and Complications Trial) and UKPDS (UK Prospective Diabetes Study) targets have been set based on “the lower the blood glucose the better”. In the US, hypoglycaemia is the second leading cause of drug-related hospitalisation.
Several centres have developed models and programmes that try to predict hypoglycaemia both in inpatient and home settings, and algorithms based on risk factors have been developed. The risk factors are obvious ones, such as insulin therapy (especially if recently initiated as often hypoglycaemia occurs after discharge if insulin was started when an inpatient), previous history of hypoglycaemia, increased age and poorer renal function.
Interestingly, several studies have found that the level of HbA1c and risk of hypoglycaemia follows a J-shaped curve; hypoglycaemia occurs more commonly at lowest and highest levels of HbA1c. I also became aware of the term “food insecurity”, which is when people with diabetes run out of money for food at the end of the month which increases the risk of hypoglycaemia.
Overtreatment versus intensive control
The need to avoid overtreatment to prevent hypoglycaemia in the older age group was discussed in many different sessions. I was very impressed by Dr Rozalina McCoy from the Mayo Clinic, who differentiated overtreatment from intensive control. She defines overtreatment as using more medication than necessary to achieve appropriate HbA1c levels.
Many speakers used the UKPDS findings to remind us that the benefits took 17–20 years to be seen, whereas Dr McCoy reminded us that the harms (in particular, polypharmacy, hypoglycaemia, treatment burden, side effects and cost) are happening now.
The reasons health professionals may be slow to individualise target HbA1c was explained by Dr Elbert Huang from the University of Chicago. Of course, time pressures and target drivers (e.g. the Quality and Outcomes Framework in the UK) are important, but Dr Huang also felt that the reluctance to change treatment if all is well (clinical inertia) is also a factor. There are also no performance measures that reward high quality individualisation. This rings true in UK where care planning has struggled to be widely adopted.
The importance of setting personalised targets in shared decision making was emphasised during the meeting and this prompted me to revisit the decision-making tools produced by NICE (2015).
Exercise in type 1 diabetes
The other main focus of the talks that I attended was that of exercise in type 1 diabetes. It was interesting to hear that some studies have shown that keeping blood glucose stable in exercise is even a challenge when using an artificial pancreas. This is a closed loop system where glucose is measured by a sensor under the skin that communicates with an insulin pump to deliver the appropriate dose of insulin. A number of factors contribute to the challenge, for example, the different types of exercise (aerobic, anaerobic, mixed), the duration of the exercise, whether the exercise is training or competition-focused and the individuals’ level of fitness. I didn’t come away with easy solutions but with the understanding that it can be a challenge. Key points include the importance of cool down for 30 minutes following exercise and the value of using snacks.
Several speakers talked about the value of carbohydrate snacks –especially for unplanned exercise. Francesca Annan from University College of London Hospitals gave an excellent presentation on the role of nutrition in exercise in people with people with type 1 diabetes. She stressed the value of protein to reduce risks of hypoglycaemia post exercise and before bed. She also suggested suggest milk as an alternative to protein shakes. Along with some other speakers, Miss Annan was involved in the development of the recent consensus guidelines for exercise management in type 1 diabetes (Riddell et al, 2017).
Latest therapy developments
Many developments in therapy options were presented at the meeting An exciting area of research at the moment are glucose-responsive insulins, also known as “smart insulins”, which turn on and off in response to blood glucose levels.
I was interested to learn about novel delivery methods for injecting insulin, for example, microneedles (1.5 mm long) that are intradermal rather than subcutaneous and patches that comprise a number of microneedles designed to be used with smart insulins.
Another exciting development discussed during the meeting was nasal glucagon, which has been developed by Eli Lilly. Dr Seaquist from Minneapolis described how the product had been shown to be effective in severe hypoglycaemia. There was agreement among the delegates that would be particularly beneficial for family members or carers to reverse severe hypoglycaemia.
Overall, my attendance at ADA was an amazing experience. Many of the sessions were extremely relevant to my work as a DSN in UK and it was a huge privilege to learn about diabetes research and innovations from around the world.
References
NICE (2015) Patient Type 2 diabetes in adults: controlling your blood glucose by taking a second medicine – what are your options? NICE, London. Available at: https://is.gd/fo3DPE
Riddell MC, Gallon IW, Smart CE et al (2017) Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol 5: 377–90
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