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Stuffed and shafted by the new contract

Diabetes patients treated by diet alone are less stringently monitored

by GPs, but still have high rates of complication ­ Dr Roger Gadsby advises on closing the gap

There is a perception among patients that diet-alone controlled diabetes is just 'mild diabetes' or as some people describe it 'just a touch of sugar'. As a result patients may not realise the importance of attending for regular review of their care. And because they may not be on any regular medications this group will not be recalled by the practice repeat prescribing system for review.

But as the figures for vascular disease, IHD and diabetes-related eye disorder in a recent study show (see box below) this group's diabetes is anything but mild.

And the 'mild' diabetes perceptions may also be present among GPs as evidenced by the fact that the diet-alone group had a greater percentage of people with raised blood pressure and cholesterols above 5 but with less statin and blood pressure lowering medications prescribed.

The new GMS contract

If the nGMS diabetes marker had been in place at the time of this study then these 42 practices' recording of parameters was good but there would be room for significant improvement. There were very clear deficiencies in foot examination (43.6 per cent), microalbuminuria testing (14.5 per cent) and recording of retinal screening results (9 per cent)

for all people with diabetes in the study. And quality target achievements in HbA1c, blood pressure and cholesterol would all need to be improved to gain maximum quality points.

The new contract quality and outcomes framework does not distinguish between those treated with diet alone and those on oral agents and so I think the gap should improve between the two groups. In order to maximise income through achieving good points scores, both process and quality of care will need to be optimised for all people with diabetes. The message that everyone with diabetes needs regular review and intensive management of risk factors is supported by the new contract.

How to improve care

Here is a checklist to ensure patients with diet-controlled diabetes do not slip through the net.

·Recognition Ensure patients and all staff recognise that diet-alone diabetes is not 'mild diabetes' and that this group needs regular review.

·Improved process measurements Once people are attending for regular review they need to have all the appropriate process measurements made.

·Optimise blood glucose control If diet alone is not achieving satisfactory HbA1c targets, oral agent therapy needs to be started (see below).

Wide variation in the numbers treated with diet alone across the 42 practices (from 15.6 per cent to 73.2 per cent) suggests this may not be happening, and that too many people may be being left with HbA1c levels of say 8 per cent plus, because they are wrongly thought to have 'mild diabetes'.

·Optimise blood pressure control If blood pressure is consistently raised, antihypertensive therapy needs to be started, just as much as in someone on oral hypoglycaemic agent therapy. If one agent alone

is not controlling blood pressure a second and perhaps a third or fourth agent may be needed.

·Optimise cholesterol levels Statins should be considered in all people with diet-controlled diabetes, just as it should be considered in those on oral hypoglycaemic agent therapy.

·Ensure people attend for retinal screening and that the results are recorded in the practice clinical computer system. This applies equally to all people with diabetes whether they are treated with oral hypoglycaemic agents or diet.

·Check foot pulses and for signs of neuropathy and refer those who are found to have 'feet at risk' to the podiatry service1. Again this applies equally to all people with diabetes whether they are treated with oral hypoglycaemic agents or diet.

·Ensure all people with diabetes have microalbuminuria testing and those that are positive are given ACE inhibitor or ARB drug therapy. Again this applies equally to all people with diabetes whether they are treated with oral hypoglycaemic agents or diet.

Roger Gadsby is a GP in Nuneaton, Warwickshire, and senior lecturer in primary care, University of Warwick

Two common dilemmas for GPs

How long do you give someone to control their diabetes by diet before switching to tablets?

The standard answer is three months. If someone newly diagnosed with type 2 diabetes doesn't reach the appropriate glycaemic target (HbA1c below 7.4 per cent) after three months' diet and exercise therapy, oral treatment should be started.

In practice I tend to be a bit more flexible than three months. For example, if at diagnosis someone had an HbA1c of 9 per cent and was obese, I would initially monitor them monthly ­ and if their

weight was going down well and their HbA1c had dropped to say

7.8 per cent I would continue on diet and exercise with monthly monitoring of weight to see if they could get to the HbA11c target, say by five months.

My view is that diet and exercise is the best initial therapy for type 2 diabetes and if I can keep people losing weight and edging towards the HbA1c target I would be happy to wait for up to six months.

What level of HbA1c or blood glucose would suggest a need for tablets straightaway?

No easy answer to this. It depends on how symptomatic people are and how much sugar they take in their diet. I have a 72-year-old woman who presented with type 2 diabetes and had a blood glucose of 42mmol/l at diagnosis and an HbA1c of 11 per cent.

She was completely asymptomatic and was drinking two litres of high-sugar/caffeine fizzy drinks a day and six cups of tea each with three spoonfuls of sugar in them. When she switched to diet soda and stopped added sugar her blood glucose and HbA1c fell rapidly and she was well controlled on diet alone for two years.

I have also had a person newly presenting with type 2 diabetes with a blood glucose of 14 at diagnosis and an HbA1c of 8 per cent who was thin, took no added sugar, and was very symptomatic who needed tablets almost straightaway to control the symptoms of diabetes.

Useful websites Website of Diabetes UK ­ lots of useful information for people with diabetes Diabetes specialist library of the national electronic library for health ­ contains all the important information on diabetes

102248 NICE guidance on prevention and management

of foot problems in people with type 2 diabetes

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