medwireNews: The first day of the Diabetes UK 2017 Professional Conference covered topics ranging from physical activity to new technology to the integration of diabetes and mental health services.
The importance of exercise for patients with diabetes
The meeting kicked off with a plenary session on promoting exercise in patients with diabetes.
“Exercise acts just like insulin to push glucose into the skeletal muscle,” explained Michael Riddell (York University, Toronto, Canada).
“Contraction of muscle can increase glucose uptake 50-fold above rest; no wonder it can profoundly lower blood glucose concentration,” he added.
However, Riddell noted that exercise can be a “double-edged sword” as it has beneficial effects on controlling blood glucose levels in patients with type 2 diabetes, but for those with type 1 diabetes, insulin bolus combined with exercise can lead to nocturnal hypoglycemia, which can be fatal.
Rob Andrews (University of Bristol, UK) emphasized that doing the recommended 150 minutes of moderate intensity exercise per week leads to a 26% reduction in the risk for type 2 diabetes, but there is “no ceiling” to the amount of activity that can be done, with 780 minutes of exercise per week halving the risk for type 2 diabetes. However, most people at risk of diabetes do not reach recommended activity targets for preventing type 2 diabetes, he said.
Furthermore, Andrews noted that the majority of people who already have type 2 diabetes do not meet the recommended target of 150 minutes aerobic activity plus two anaerobic sessions per week, with barriers including perceived lack of time, safety, weather, and cultural issues.
“We need to use role models” to encourage people to increase their physical activity, he said.
Andrews recommended that healthcare providers must fit discussions about physical activity into every session with a patient. “With regular contact and support it is possible to increase activity in patients at risk of or with type 2 diabetes,” he said, emphasizing the importance of regular follow-up to ensure people meet their goals.
Ian Gallen (Royal Berkshire Hospital, Reading, UK) outlined the barriers to physical activity among patients with type 1 diabetes, some of which are similar to those in people with type 2 diabetes (such as work schedule and low fitness level), whereas others are specific to type 1 diabetes, for example fear of hypoglycemia. As with type 2 diabetes, Gallen recommended that discussing exercise should be “part of routine questioning” from healthcare providers.
Tom Linton-Neal, a triathlete with type 1 diabetes, provided personal insights into managing diabetes during extreme competitive sport.
“The best way for me to perform at the highest level that I can perform at is to be structured,” he said, explaining that he must take many factors – including temperature, food, caffeine, recovery time, and injection site – into account for optimal glucose management.
He said that “what works today might not work tomorrow” as the body’s demand changes, emphasizing the need to “analyze and modify” training to optimize performance.
Mental health and diabetes: integration is key
For the first time, psychiatrists and diabetologists have come together to produce guidelines for the management of comorbid diabetes and serious mental illness (SMI).
Hermione Price (Southern Health NHS Foundation Trust, UK) introduced these new guidelines, which provide recommendations on the management of diabetes in people with psychiatric disorders in inpatient settings. “Quality of care is poor” for these patients, she said, and she hopes that the guidelines will be used “to develop services to better meet the needs of this group.” The key recommendations include:
- Ensuring the needs of patients with diabetes and serious mental illness are specifically addressed
- Avoiding financial and other barriers to cross-organizational working
- Developing joint care pathways between diabetes and mental health care providers
- Screening for mental ill health setting in patients with unexplained diabetes complications
Price said that the guidelines will soon be available on the JBDS-IP website in the near future.
Three other presentations covered the management of diabetes and eating disorders, SMI and diabetes in children and adolescents, and management of the two conditions in acute medical settings.
“Integration, integration, integration” of diabetes and mental health services is key to achieving better outcomes, stressed Christopher Garrett (King’s College, London, UK).
New technologies for managing diabetes
“What technologies should we be offering now in secondary care?” asked Gerry Rayman, from Ipswich NHS Trust, UK, setting the theme for the subsequent talks.
“We’ve had an explosion in technology, and there’s more to come,” he said.
Rayman discussed the potential of remote glucose monitoring systems to improve glycemic control, citing the results of a Californian study showing that hyperglycemia was reduced by 39%, and hypoglycemia by 36%, with the introduction of a remote monitoring system for hospitalized patients. However, he felt that such systems are “helpful but too remote,” with inpatient nursing teams being essential to provide optimal care.
Similarly, Rayman said that although closed-loop or “artificial pancreas” systems have potential to improve care for patients with type 1 diabetes, such systems are “not practical today” and therefore “can’t really be rolled out.”
Nick Oliver (Imperial College London, UK), felt that there is a “growing evidence base” for artificial pancreas systems for the treatment of type 1 diabetes, “and hopefully soon for type 2.” Although the first hybrid closed-loop device was approved by the US Food & Drug Administration in 2016, Oliver was “unsure if we will see European approval in the near future.”
“We need faster insulins with faster onset of action,” to make closed-loop systems more effective, he added.
Finally, Oliver highlighted the #wearenotwaiting initiative, whereby patients with diabetes have developed their own technological solutions for data sharing and integration of devices into closed-loop systems. Home-engineered solutions have driven commercial development, he said, but cautioned that they are unregulated.
In the final presentation on diabetes technology, Melissa Holloway, Chief Advisor for INPUT Patient Advocacy, presented a poignant image illustrating that the short time healthcare providers spend with each patient in the clinic carries the patients through “many days and many nights of taking care of themselves.”
She outlined two mobile health apps – MySugr and Carbs & Cals – which could help patients with diabetes self-management, and emphasized the importance of ongoing education and support for insulin pump users.
Finally, she recommended a strategy involving discussion, negotiation and SMART (specific, measurable, achievable, realistic, and timebound) goals if things don’t go according to plan.
And she left the audience with the message: “If you have to take something away, what can you offer instead?”
Clinical inertia or overtreatment: which is worse?
In a debate session, Kamlesh Khunti and Melanie Davies, both from the University of Leicester, UK, put forward their views on whether overtreatment or clinical inertia poses the greatest risk for patients with diabetes.
Khunti argued that “we wait far too long” to start diabetes treatment, and that “clinical inertia is a problem throughout the treatment paradigm.”
He presented data from the ACCORD trial showing that among patients with an initial strict glycated hemoglobin target (<6.0%) who were then transitioned to a target of 7.0–7.9%, those with lower pre-transition HbA1c levels were more likely to retain an HbA1c level of less than 6.0% over the following year. Furthermore, data published in early March 2017 showed that failure to achieve target HbA1c levels at 3 months is associated with a 3.70-fold increased odds of not achieving target levels at 24 months, he added.
Davies, on the other hand, pointed out that although physicians must hasten to help their patients, “we also have a real responsibility to do no harm.”
“Protecting the person with diabetes from over medicalization is an important aspect of diabetes care,” she emphasized.
She explained that in a US study, patients who underwent excessive HbA1c testing were 1.35 times as likely to undergo diabetes treatment despite normal HbA1c results compared with those undergoing guideline-recommended testing. Moreover, excessive testing in type 2 diabetes “contributes to the growing problem of waste in healthcare,” she said.
Whereas Khunti said that evidence for overtreatment is “limited to a small patient group,” namely elderly people, Davies noted that the HAT study showed that hypoglycemia is significantly underreported in the elderly. She also pointed out that many older people with type 2 diabetes and dementia are at high risk of hypoglycemia associated with intense diabetes treatment.
Davies also said that nonadherence is “a problem of epic proportions,” and “we are focusing on the wrong problem if we think that just prescribing more drugs will heal things.”
Following an audience discussion covering lack of information in the guidelines about when to deintensify therapy and the need for lifestyle interventions to prevent type 2 diabetes in the first place rather than “seeing medications as the solution”, Davies conceded that “the truth of the matter is that both [clinical inertia and overtreatment] are a problem.”
“There is a huge gap in terms of people not getting to target and having poor outcomes, but simply prescribing things sooner is not going to solve that,” she concluded.
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