Three papers published in Archives of Internal Medicine looks at the effectiveness of different patient education/counseling strategies on diabetes self-management and glycemic control (hemoglobin A1c [HbA1c] levels).
The real question being asked is “What type of patient education or counseling program will improve glycemic control for patients with diabetes in whom usual diabetes care is failing in high-functioning clinical settings?”
Counseling-based behavior change interventions depend heavily on a patient’s readiness to change and self-efficacy related to diabetes self-management and hence its not surprising that the various interventions only had limited success.
What we need is a way to filter out essential ingredients of the education program that are crucial particularly with regard to the educator counseling, intensity of support provided, and level of individual tailoring.
The National Diabetes Audit in England has just published its results. Far too many excess avoidable deaths.Full report here
Some shocking statistics include
- women between 15 and 34 years of age who have type 1 diabetes are nine times more likely to die than women in the general population, and women of this age with type 2 diabetes are six times more likely to die.
- risk of death for a person with type 1 diabetes is 2.6 times higher than that of the general population. For people with type 2 diabetes it is 1.6 times higher.
- Strong link between deprivation and increased rates of early death. Among under-65s with diabetes, death rates among people from the most deprived backgrounds were double that of those from the least deprived.
Motivating patients is a big part of chronic disease management and often the most difficult to maintain in the long run. Modern tech could help with constant reinforcement.
One area that needs to be tacked is care of young people with diabetes. Old models of care are not working. Regular attendance at clinic model is not very effective and needs revisited. I think the new world of apps, remote monitoring etc will make a difference in the long run.
Endocrine Society has published updated guidelines on use of Real time continuous glucose monitoring in patients with diabetes.
A summary of guidelines include (Joslin news)
- Currently approved RT-CGM devices be considered for use by children (over 8-years old), adolescents, and adults with type 1 diabetes whose A1C levels are below 7 percent to help maintain target levels while reducing the risk of hypoglycemia.
- Recommend the use of these devices to assist with intensification of diabetes control in children (over 8-years old), adolescents, and adults with Type 1 Diabetes whose A1C levels are at 7 percent or higher, provided they have a history of responsible self-care, and will keep up proper use of the device
- Occasional use of short-term CGM monitors could be helpful in keeping track of blood glucose levels when reviewing conditions such as nocturnal hypoglycemia, dawn phenomenon, and post-prandial hyperglycemia; hypoglycemic unawareness; and in patients who have recently made major changes in their care, such as the use of new insulin or the switch to insulin pumps. This suggestion was made for children (over 8-years old), adolescents, and adults.
- Recommend against the use of RT-CGM on its own during treatment in an intensive care unit or in an operating room until more studies are done to asses the technology’s accuracy and safety under those conditions.
I think the old model of diabetes care will become redundant for many of our patients. In Scotland Primary care doctors look after about 80% of patients with diabetes and only the complex ones come to secondary care. Even in these patients clinic visits once or twice a year is not adequate. They need to be seen(unlikely to happen) or monitored regularly. This is where remote monitoring will become the norm. I see it of particular value in young people with diabetes who are natural at adopting new tech.
QualcommLife announcement is another space which we need to monitor.
Not many would have missed news reports a few weeks ago claiming “Cure for type 2 diabetes”. This resulted in a lot of calls to our diabetes team asking for the “cure”. When 600kcal/day diet was mentioned and what it actually entailed most politely lost interest! So what is the hoopla about?
In the Counterpoint (Counteracting the Pancreas Inhibition by Triglyceride) study eleven people with type 2 diabetes went on a 600kcal/day diet (sound difficult!!!). Lots of the metabolic abnormalities in type 2 diabetes were corrected and at the end of the study volunteers were given advice about healthy eating with goal to avoid weight gain. Three months later only 3 out of 11 has blood glucose within the diabetic range. Thus in the early stages after diagnosis, type 2 diabetes is a reversible diagnosis. Of course a very low calorie diet is not easy and not for every one there- in fact maybe only a small proportion. But, I think diabetes teams should be poised to help the motivated patient(s) who refuse to take type 2 diabetes as a life sentence. In the long term gains for the individual and the society will be significant.
Further information can be accessed here
JAMA published a paper recently asking the question- should patients be given direct access to their test results. May not be ideal in case of radiology or pathology reports but in certain group of patients this will be very useful. In the U.K. both Renal Patient View and SCI-DC (Scottish Diabetes Database) give patients access to their test results and other info. Granted these are patients with chronic conditions in whom it works best.
In a study published in the NEJM, Warfarin, Insulin, anti-platelet agents and Oral diabetic medications were alone or in combination responsible for 67% of adverse drug reaction related hospitalizations among the elderly in the US. I don’t think its any different in the UK. Striving for tight glycemic control in the elderly is counterproductive as evidence by the above study. In most elderly symptom control and a sensible individualized glycemic target is essential. Primum non nocere.