Challenges in DiabetesChallenges in Diabetes

Dr Philippa Feldman

Challenge 1Challenge 1

Increasing numbers

NumbersNumbers

• One million diabetics in England

• 1 in 20 people age > 65

• 1 in 5 people age > 85

• 2% - 3% of population have diabetes

• 40-60 patients per General Practitioner

Challenge 2Challenge 2

Morbidity

Life expectancyLife expectancy

• Life expectancy decreased 20 years IDDM

• Life expectancy decreased 10 years

NIDDM

MorbidityMorbidity

• Mortality CHD 5 times higher

• Mortality CVA 3 times higher

• Leading cause of renal failure

• Leading cause of blindness in workers

• Second commonest cause of lower limb

amputation

Challenge 3Challenge 3

Number of health professional

Challenge 4Challenge 4

Cost

CostsCosts

• Personal– £802 per year plus lost earnings

• NHS– 5% total NHS resources

– 10% inpatient resources

• Social Services– 1 in 20 diabetics incur costs of £2450 pr year

High risk populationsHigh risk populations

• South Asians– Up to 6 times more common

• African– Up to 3 times more common

• African-Caribbean– Up to 3 times more common

• Middle Eastern

High risk individualsHigh risk individuals

• Overweight– Bmi > 25 Waist Men 90cm Women 83cm

• Obese– Bmi > 30 Waist Men 100cm Women 93cm

• Physically inactive

• Family history

• Less affluent people

Challenge 5Challenge 5

Changing lifestyle

Challenge 6Challenge 6

The future

The challengeThe challenge

Increasing number of diabetics

Man power needed to provide care

Hospital costs/social services costs

Improving care

Changing lifestyles

NSF DiabetesNSF Diabetes

• Improve quality of service

• Tackle variations in care

• Best practice the norm

• Reach communities at greatest risk

• Reduce complication rates

• Eliminate discrimination

Group 1Group 1

• Strategies to decrease incidence of

diabetes

• Modifiable risk factors

– Actions within communities

– Actions within general practice

Joe BloggsJoe Bloggs

• Male – Age 53– Smokes 20 per day– BMI 36– BP 160/100 155/95 160/90– Alcohol 28-35 units/week– Occupation Manages own business– Hobbies West ham supporter

Group 2Group 2

• Strategy to identify

– Undiagnosed diabetics

– People with impaired glucose tolerance

– Decrease progression to Diabetes

Group 3Group 3

• Methods to decrease complications

– Lifestyle changes

– How to achieve them

• Clinical targets

– Drugs to achieve these

Group 4Group 4

• Lifelong surveillance

– How frequent

– Aspects of care covered

– Non attenders

– Housebound

Group workGroup work

Reconvene at

Group 1Group 1

• Strategies to decrease rising incidence of

diabetes.

• Modifiable risk factors

– Actions within communities

– Actions within general practice

Modifiable risk factorsModifiable risk factors

• Overweight bmi 25-30

• Obese bmi >30

• Sedentary lifestyle– 60% Men insufficiently active– 70% Women insufficiently active

Community actionCommunity action

• Start early

• Education from Health Visitors

• Parent craft classes

• Active playing with children

• Less TV/Computers

School AgeSchool Age

• Walking to school

• Healthy food in lunch boxes

• Government fruit in school initiative

• Less fast food

• More sport in school and after school

• Joining local sports clubs

AdultsAdults

• Involvement in sport for adults

• Exercise must be fun social side

• Less use of cars

• Less ready meals high fat content

• More home cooking

Within in General practiceWithin in General practice

• Record height, weight and exercise

• Promote exercise

• Exercise on prescription

• Example within the practice

General practice adviceGeneral practice advice

• Advise on

– Healthy eating

– No snacking

– No high fat high energy snacks in house

• Refer to dietician

• Weight loss clinic

Joe BloggsJoe Bloggs

• Male – Age 53– Smokes 20 per day– BMI 36– BP 160/100 155/95 160/90– Alcohol 28-35 units/week– Occupation Manages own business– Hobbies West ham supporter

Group 2Group 2

• Strategy to identify

– Undiagnosed diabetics

– People with impaired glucose tolerance

– Decrease progression to Diabetes

Identifying diabeticsIdentifying diabetics

• Population education

– TV adverts

– Magazine articles

– Soap opera themes

– Leaflets

– PSE in schools

– Health advocates

Identifying IGTIdentifying IGT

Screen everyone with

IHD

Hypertension

Gestational diabetes

Obesity

Family history of diabetes

Screening methodsScreening methods

• Opportunistically

• Send urine glucose stick through post

• Send fasting blood sugar form

• Consultation with nurse

• Invitation to group sessions

Decrease the riskDecrease the risk

• Lifestyle advice

– Healthy eating

– Weight loss

– Regular exercise

Decrease the riskDecrease the risk

• Annual fasting blood sugar tests

– Those with IGT

– Those with gestational diabetes

Joe BloggsJoe Bloggs

• Male – Age 53– Smokes 20 per day– BMI 36– BP 160/100 155/95 160/90– Alcohol > 50 units/week– Occupation Manages own business– Hobbies West ham supporter

Group 3Group 3

• Methods to decrease complications

– Lifestyle changes

– How to achieve them

• Clinical targets

– Drugs to achieve these

lifestyle changeslifestyle changes

• Advice on

– Stopping smoking

– Diet

– Weight loss

– Alcohol reduction

– exercise

Producing changeProducing change

• Education

– Verbally

– Leaflets

– Diabetes UK

– Internet

• Motivational interviewing

Other agenciesOther agencies

• Stop smoking clinics

• Slimming clubs

• Dietician

• Exercise classes

• Alcohol agencies

Clinical targetsClinical targets

• BMI 25

• Hba1c 6.5-7.5

• BP 140/80 ? 130/80

• chol < 5 Ldl chol < 3 Tg < 2.3

drugsdrugs

• Hypoglycaemics

– BMI > 25 metformin up to 1g tds

– BMI < 25 gliclazide up to 160mg bd

• Combination therapy

– Metformin + gliclazide

– Metformin + rosiglitazone up to 8mg od

– Gliclazide + rosiglitazone up to 4mg od

AntihypertensivesAntihypertensives

• Ace inhibitor/Angiotensin 2 blocker

• Thiazide

• Beta blocker

• Alpha blocker

• Calcium antagonist

HyperlipidaemiaHyperlipidaemia

• Statins

– Check lft cpk

• Fibrates

OthersOthers

• Aspirin 75mg od

• Orlistat

Joe BloggsJoe Bloggs

• Male – Age 53– Smokes 20 per day– BMI 36– BP 160/100 155/95 160/90– Alcohol > 50 units/week– Occupation Manages own business– Hobbies West ham supporter

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Group 4Group 4

• Lifelong surveillance

– How frequent

– Aspects of care covered

– Non attenders

– Housebound

Annual review clinicAnnual review clinic

• Responsible health professional

• Disease register

• Diabetic clinic

• Clinic protcol

• Recall scheme

• Regular audit

Annual reviewAnnual review

• Discussion

– General health

– Glycaemic control

– Diabetic knowledge

– Tobacco and alcohol

– Symptoms of complication

ExaminationExamination

• Weight BMI

• Blood pressure

• Visual acuity

• Fundi

• Foot examination– Pulses, vibration, nylon monofilament.

• Reflexes

InvestigationsInvestigations

• Urinalysis for protein

• Hba1c

• U&e’s

• Cholesterol – hdl ldl triglycerides

ManagementManagement

• Glycaemic control

• Blood pressure

• Lipids

• CHD risk factors

• Long term complications

• Targets and management plan for next year

RecidivistsRecidivists

• Identify non attenders

– Fta’d appointment

– Never sent appointment

• Send new appointment

• Letter

• Flag notes

Challenge 6Challenge 6

The future

The futureThe future

• New drugs– The glitazones– Repaglinide

• New Insulins– glygargine

Science fictionScience fiction

• Artificial pancreas

• Islet cell implants

• Genetic engineering

• Obesity drugs