Challenges in Diabetes Dr Philippa Feldman

Challenge 1 Increasing numbers

Numbers One million diabetics in England 1 in 20 people age > 65 1 in 5 people age > 85 2% - 3% of population have diabetes patients per General Practitioner

Challenge 2 Morbidity

Life expectancy Life expectancy decreased 20 years IDDM Life expectancy decreased 10 years NIDDM

Morbidity 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 3 Number of health professional

Challenge 4 Cost

Costs 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 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 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 5 Changing lifestyle

Challenge 6 The future

The challenge Increasing number of diabetics Man power needed to provide care Hospital costs/social services costs Improving care Changing lifestyles

NSF Diabetes Improve quality of service Tackle variations in care Best practice the norm Reach communities at greatest risk Reduce complication rates Eliminate discrimination

Group 1 Strategies to decrease incidence of diabetes Modifiable risk factors –Actions within communities –Actions within general practice

Joe Bloggs Male –Age 53 –Smokes 20 per day –BMI 36 –BP 160/100155/95160/90 –Alcohol units/week –Occupation Manages own business –HobbiesWest ham supporter

Group 2 Strategy to identify –Undiagnosed diabetics –People with impaired glucose tolerance –Decrease progression to Diabetes

Group 3 Methods to decrease complications –Lifestyle changes –How to achieve them Clinical targets –Drugs to achieve these

Group 4 Lifelong surveillance –How frequent –Aspects of care covered –Non attenders –Housebound

Group work Reconvene at

Group 1 Strategies to decrease rising incidence of diabetes. Modifiable risk factors –Actions within communities –Actions within general practice

Modifiable risk factors Overweightbmi Obesebmi >30 Sedentary lifestyle –60% Men insufficiently active –70% Women insufficiently active

Community action Start early Education from Health Visitors Parent craft classes Active playing with children Less TV/Computers

School 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

Adults 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 practice Record height, weight and exercise Promote exercise Exercise on prescription Example within the practice

General practice advice Advise on –Healthy eating –No snacking –No high fat high energy snacks in house Refer to dietician Weight loss clinic

Joe Bloggs Male –Age 53 –Smokes 20 per day –BMI 36 –BP 160/100155/95160/90 –Alcohol units/week –Occupation Manages own business –HobbiesWest ham supporter

Group 2 Strategy to identify –Undiagnosed diabetics –People with impaired glucose tolerance –Decrease progression to Diabetes

Identifying diabetics Population education –TV adverts –Magazine articles –Soap opera themes –Leaflets –PSE in schools –Health advocates

Identifying IGT Screen everyone with IHD Hypertension Gestational diabetes Obesity Family history of diabetes

Screening methods Opportunistically Send urine glucose stick through post Send fasting blood sugar form Consultation with nurse Invitation to group sessions

Decrease the risk Lifestyle advice –Healthy eating –Weight loss –Regular exercise

Decrease the risk Annual fasting blood sugar tests –Those with IGT –Those with gestational diabetes

Joe Bloggs Male –Age 53 –Smokes 20 per day –BMI 36 –BP 160/100155/95160/90 –Alcohol > 50 units/week –Occupation Manages own business –HobbiesWest ham supporter

Group 3 Methods to decrease complications –Lifestyle changes –How to achieve them Clinical targets –Drugs to achieve these

lifestyle changes Advice on –Stopping smoking –Diet –Weight loss –Alcohol reduction –exercise

Producing change Education –Verbally –Leaflets –Diabetes UK –Internet Motivational interviewing

Other agencies Stop smoking clinics Slimming clubs Dietician Exercise classes Alcohol agencies

Clinical targets BMI 25 Hba1c BP140/80 ? 130/80 chol< 5Ldl chol < 3Tg < 2.3

drugs 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

Antihypertensives Ace inhibitor/Angiotensin 2 blocker Thiazide Beta blocker Alpha blocker Calcium antagonist

Hyperlipidaemia Statins –Check lft cpk Fibrates

Others Aspirin 75mg od Orlistat

Joe Bloggs Male –Age 53 –Smokes 20 per day –BMI 36 –BP 160/100155/95160/90 –Alcohol > 50 units/week –Occupation Manages own business –HobbiesWest ham supporter >

Group 4 Lifelong surveillance –How frequent –Aspects of care covered –Non attenders –Housebound

Annual review clinic Responsible health professional Disease register Diabetic clinic Clinic protcol Recall scheme Regular audit

Annual review Discussion –General health –Glycaemic control –Diabetic knowledge –Tobacco and alcohol –Symptoms of complication

Examination WeightBMI Blood pressure Visual acuity Fundi Foot examination –Pulses, vibration, nylon monofilament. Reflexes

Investigations Urinalysis for protein Hba1c U&e’s Cholesterol – hdl ldl triglycerides

Management Glycaemic control Blood pressure Lipids CHD risk factors Long term complications Targets and management plan for next year

Recidivists Identify non attenders –Fta’d appointment –Never sent appointment Send new appointment Letter Flag notes

Challenge 6 The future

New drugs –The glitazones –Repaglinide New Insulins –glygargine

Science fiction Artificial pancreas Islet cell implants Genetic engineering Obesity drugs