1. Challenges in Diabetes Dr Philippa Feldman

2. Challenge 1 Increasing numbers

3. Numbers 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

4. Challenge 2 Morbidity

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

6. 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

7. Challenge 3 Number of health professional

8. Challenge 4 Cost

9. 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

10. 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

11. 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

12. Challenge 5 Changing lifestyle

13. Challenge 6 The future

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

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

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

17. Joe Bloggs Male –Age 53 –Smokes 20 per day –BMI 36 –BP 160/100155/95160/90 –Alcohol 28-35 units/week –Occupation Manages own business –HobbiesWest ham supporter

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

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

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

21. Group work Reconvene at

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

23. Modifiable risk factors Overweightbmi 25-30 Obesebmi >30 Sedentary lifestyle –60% Men insufficiently active –70% Women insufficiently active

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

25. 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

26. 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

27. Within in General practice Record height, weight and exercise Promote exercise Exercise on prescription Example within the practice

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

29. Joe Bloggs Male –Age 53 –Smokes 20 per day –BMI 36 –BP 160/100155/95160/90 –Alcohol 28-35 units/week –Occupation Manages own business –HobbiesWest ham supporter

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

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

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

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

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

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

36. 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

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

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

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

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

41. Clinical targets BMI 25 Hba1c6.5-7.5 BP140/80 ? 130/80 chol< 5Ldl chol < 3Tg < 2.3

42. 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

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

44. Hyperlipidaemia Statins –Check lft cpk Fibrates

45. Others Aspirin 75mg od Orlistat

46. 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 >

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

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

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

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

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

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

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

54. Challenge 6 The future

55. New drugs –The glitazones –Repaglinide New Insulins –glygargine

56. Science fiction Artificial pancreas Islet cell implants Genetic engineering Obesity drugs