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The top 5 burning issues in diabetes

As GPs cope with ever growing numbers of patients with diabetes and a chequered recent history of drug development, Dr Richard Quigley gives his view on the five burning issues in diabetes.

As GPs cope with ever growing numbers of patients with diabetes and a chequered recent history of drug development, Dr Richard Quigley gives his view on the five burning issues in diabetes.

1. The rising tide of obesity

Heat and light have been generated in equal measure in the variety of views on this subject lately.

The argument for healthcare interventions goes something like this. Obesity accelerates coronary artery disease, independently of associated risk factors such as hypertension and dyslipidaemia. We know that it robs patients on average of 10 years of life. And of course it is a major risk factor for type 2 diabetes.

Epidemiological evidence suggests the downward trend in CHD mortality will level off over the coming years and we as frontline healthcare professionals really ought to square up to the challenge.

But the contrary view also has many protagonists – that obesity is largely a matter of personal responsibility, modifiable behaviours and willpower. Exercise programmes are poorly attended, and pharmacological interventions produce modest weight loss (3-5kg) but have little evidence on long-term patient-orientated outcomes.

Bariatric surgery results are impressive over the longer term but it's hardly for the millions. Certain structured weight intervention programmes have been shown to be of benefit but some are dogged by post-intervention weight gain.

My own view is a pragmatic one. My role is to inform, treat and support with the knowledge that regular exercise without weight loss has benefits for CV health and that modest weight loss has disproportionate benefits for a variety of CV risk factors. Being a GP affords me the opportunity to revisit the issues over time.

2. Therapeutic advances – and setbacks

The highly complex nature of the metabolic syndrome has brought a posse of similarly complex drugs.

Faced with an epidemic involving hundreds of millions of patients, we need to be alert to potential drug-related risks as never before. Recent research surrounding rosiglitazone, for example, has highlighted potential unexpected cardiac risks.

More recently the incretin enhancers have become available which work by inhibiting the enzyme which breaks down incretins, hormones which inhibit glucagon release and increase insulin secretion. These drugs appear to offer a reasonable efficacy and safety profile, but we have had little experience of them yet.

So there is a resurgent interest in returning to the ‘old faithful' combination of metformin and sulphonylureas.

As patients fail on oral medication, large numbers of type 2 diabetes patients will require insulin, but views on insulin conversion differ widely.

Education and training needs in primary care will rocket in the near future. Perhaps the advent of long-acting insulin analogues will be useful for many of these patients.

On other fronts, inhaled insulin has been withdrawn recently and clinical trials on oral forms of insulin continue, but are clearly some way off clinical use.

The incretin mimetic, exanetide, is now being prescribed in secondary care and offers hope in a variety of patient groups, including those who are highly insulin resistant and offering a strategy for delayed insulin conversion. Its associated weight loss is useful but more widespread use seems unlikely at present, given that it is a bd injection and costs about £70 a month.

3. Self management, education and empowerment

From every angle this is clearly the most important principle underlying care of patients living with diabetes. Patients want it, we in primary care would like to deliver it – but are constrained by time – and it is known to be effective.

We've recently seen validated and accredited educational programmes being rolled out in the community, DAFNE for type 1 patients and DESMOND for type 2 being the best known nationally.

A raft of other educational programmes have been developed around the country according to local needs and service availability. But these programmes can be time-consuming for the patients and are certainly resource intensive for the health service. Clearly, a variety of educational approaches are necessary.

Patient health records, including online access to clinical data, web-based initiatives surrounding education, local support groups and encouragement to access the wealth of information provided by organisations like Diabetes UK all contribute to best practice.

4. Benefits of early intervention

It seems self-evident that a disease with a long pre-diagnostic phase should be targeted for screening and early intervention. But the National Screening Committee has found a number of problems with population-based screening. These include a lack of evidence on interventions in screened populations and arguments surrounding the best screening test to use.

But we can make some headway by adopting targeted screening and those with an interest in diabetes have been doing this for a number of years.

Protocols vary, of course, but most will include family history of diabetes, central adiposity, ethnic background, presence of cardiovascular disease and the like.

The presence of impaired glucose tolerance and impaired fasting glucose define a group at much higher risk of developing type 2 diabetes.

There is abundant evidence that intensive dietary and exercise interventions in these dysglycaemic groups, can dramatically cut progression towards diabetes.

The strategy of targeted screening is regarded as an important one and it is likely that the issue will be revisited and discussed at national level in the near future.

5. Collaboration and organisation

We all know that GPs and practice nurses cannot intervene effectively in isolation. Properly co-ordinated Government initiatives can work and we may now be seeing some movement in this direction. The frightening ‘50 by 50' warning – 50% of adults will be dangerously overweight by 2050 – has certainly focused political will.

There has been increasing and helpful dialogue between patient groups and healthcare professionals in cross-party political committees.

But it's unlikely that voluntary codes of conduct will produce the changes necessary to alter our so-called obesogenic environment.

The new Statutory Broadcast Code restricting the targeted advertising of foods high in salt, fat and sugar at children under 16 is a welcome development and gives us some of the strictest advertising rules around.

Physical exercise in schools needs to be encouraged and the widespread practice of selling off spaces and parks needs to halt.

We must redouble our efforts to educate parents on the dangers of the screen dominant/calorie rich environment that so threatens our younger generations.

The fact that the clinical management of diabetes and obesity represents a smallish cog in a big wheel should not lead to a kind of management nihilism. It may be small but it is important.

Dr Richard Quigley is a GP in Glasgow and executive committee member of the Primary Care Diabetes Society

Blood test for diabetes

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