R. I. G. Holt

Diabetes specialist nurses and role evolvement: a survey by Diabetes UK and ABCD of specialist diabetes services 2007

Aimsu2002 To review the working practices of UK diabetes specialist nurses (DSNs), specific clinical roles, and to examine changes since 2000.

Psychosocial support for people with diabetes: past, present and future

The marked increase in prevalence of diabetes has not been matched by equivalent improvements in diabetes outcomes. Despite the acceptance that near-normal glycaemia is associated with optimal outcomes and the increasing number of medical treatments and therapy options, most people do not achieve target blood glucose levels. Although psychosocial support for people with diabetes has improved over the last 10 years, in many clinical settings the availability and delivery of this support falls short of what it should be and this shortcoming may mitigate against improvements in other health outcomes. Improved psychosocial outcomes will depend on an accurate assessment of the availability and performance of psychosocial support and, where needed, appropriate action to eliminate gaps, including training in psychosocial support for healthcare professions. Diabetes mellitus continues to represent a major public health burden both globally and in the UK. It is estimated that approximately 366 million people worldwide had diabetes in 2011 and by 2030 it is projected that more than 552 million people will be affected as a consequence of changing population demographics and changes in lifestyle [1]. In England, an estimated 3.1 million people had diabetes in 2011 and by 2030 this number is predicted to rise to 4.6 million [1]. This marked increase in prevalence, however, has not been matched by equivalent improvements in diabetes outcomes. Despite the acceptance that near-normal glycaemia is associated with optimal outcomes, most people are still not achieving target blood glucose levels. National Diabetes Audit data in 2009– 2010 [2] reported that 66.5% of adults with Type 2 diabetes and only 28.2% of adults with Type 1 diabetes achieved HbA1c results of less than 58 mmol ⁄ mol (7.5%). Furthermore, 17.0% of adults with Type 1 diabetes and 6.7% of adults with Type 2 diabetes had markedly elevated glucose levels [HbA1c > 86 mmol ⁄ mol (10%)]. These results have remained consistent over the past 3 years, indicating little improvement in diabetes control. Medical treatments and therapy options for people with diabetes have never been greater. Self-blood glucose monitoring, including new devices such as continuous glucose monitoring systems, improved means of insulin delivery, including a range of insulin pump choices, insulin analogues and a broader range of oral medications have all contributed to improved biomedical diabetes care for millions of people. Alongside these technological improvements, patient self-management education has improved with the development of behaviourally oriented, theory-based programmes. Given these advances, it is perhaps surprising that outcomes have not improved more, but this lack of improved treatment outcomes may reflect a lack of psychosocial care. When discussing the stigma associated with having diabetes, people with the condition often describe the burden as not only affecting health issues but also social functioning and quality of life. Diabetes burnout is reported to be common, with people feeling overwhelmed and defeated by diabetes and frustrated by self-care regimens. Many describe how diabetes is controlling their lives yet feel unable or unmotivated to change. This is compounded by a high prevalence of depressive and anxiety symptoms which occur 2–3 times more frequently in people with diabetes than the general population [3,4]. The psychosocial sequelae of diabetes have been recognized in a number of UK and international guidelines that have set out standards of psychological care, which individuals with diabetes should expect. Despite these guidelines, there remains a gulf in the provision of psychological services, with widespread evidence of poor service despite clinical need. In the UK, the National Service Framework (NSF) 2001 [5] aimed to ensure that people with diabetes are empowered to enhance their personal control over the day-to-day diabetes management in a way that enables them to experience the best possible quality of life. Similarly, the National Institute of Health and Clinical Excellence (NICE) states that ‘diabetes professionals should ensure they have appropriate skills in the detection and basic management of non-severe psychological disorders in people from different cultural backgrounds... while arranging prompt referral to specialists of those in whom psychological difficulties continue to interfere significantly with well-being or diabetes self-management’ [6]. NICE recommends all service developments should be needs-led, and the psychological needs of people with diabetes should be addressed in an organized and planned way. Other national and international guidelines provide similar recommendations; the International Diabetes Federation (IDF) states that healthcare professionals should, in communicating with a person with diabetes, adopt a whole-person approach and respect the person’s central role in their ongoing diabetes education and care [7]. Well-being and psychological status (including cognitive dysfunction) should be assessed periodically, with outcomes and clinical implications discussed with the person with diabetes. The American Diabetes Association (ADA) guidelines state that assessment of psychological and social situations should be included as an ongoing part of the medical management of diabetes. They specifically state that psychosocial screening should examine attitudes about the illness, expectations of medical management and outcomes, DIABETICMedicine

Identifying risk and preventing progression to Type 2 diabetes in vulnerable and disadvantaged adults: a pragmatic review

To identify effective approaches to recognize diabetes risk and prevent progression to Type 2 diabetes in vulnerable groups, whose diabetes risk may be difficult to identify or manage.

A national survey of the current state of screening services for diabetic retinopathy: ABCD-diabetes UK survey of specialist diabetes services 2006.

The main aims were to ascertain the progress made in the implementation of retinal screening services and to explore any barriers or difficulties faced by the programmes. The survey focused on all the essential elements for retinal screening, including assessment and treatment of screen‐positive cases. Eighty‐five per cent of screening programmes have a coordinated screening service and 73% of these felt that they have made significant progress. Eighty‐five per cent of screening units use ‘call and recall’ for appointments and 73.5% of programmes follow the National Screening Committee (NSC) guidance. Although many units worked closely with ophthalmology, further assessment and management of screen‐positive patients was a cause for concern. The fast‐track referral system, to ensure timely and appropriate care, has been difficult to engineer by several programmes. This is demonstrated by 48% of programmes having waiting lists for patients identified as needing further assessment and treatment for retinopathy. Ophthalmology service for people with diabetic retinopathy was provided by a dedicated ophthalmologist in 89.4% of the programmes. Sixty‐six per cent of the programmes reported inadequate resources to sustain a high‐quality service, while 26% highlighted the lack of infrastructure and 49% lacked information technology (IT) support. In conclusion, progress has been made towards establishing a national screening programme for diabetic retinopathy by individual screening units, with a number of programmes providing a structured retinal screening service. However, programmes face difficulties with resource allocation and compliance with Quality Assurance (QA) standards, especially those which apply to ophthalmology and IT support. Screening programmes need to be resourced adequately to ensure comprehensive coverage and compliance with QA.

Alcohol health literacy in young adults with Type 1 diabetes and its impact on diabetes management

To investigate the knowledge of alcohol and carbohydrate content of commonly consumed alcoholic drinks among young adults with Type 1 diabetes and to explore alcohol consumption while identifying diabetes self‐management strategies used to minimize alcohol‐associated risk.

Correlates of psychological outcomes in people with diabetes: results from the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study.

To assess country‐ and individual‐level correlates of psychological outcomes, and differences among countries in the associations of individual characteristics with psychological outcomes among adults with diabetes.

Deficiencies in postgraduate training for healthcare professionals who provide diabetes education and support: results from the Diabetes Attitudes, Wishes and Needs (DAWN2) study.

To consider the global provision of self‐management diabetes education and training for healthcare professionals using data from the second Diabetes Attitudes, Wishes and Needs (DAWN2) study.

The effects of two weeks of recombinant growth hormone administration on the response of IGF-I and N-terminal pro-peptide of collagen type III (P-III-NP) during a single bout of high resistance exercise in resistance trained young men

OBJECTIVEnRecombinant human growth hormone (rhGH) is used by some athletes and body builders with the aim of enhancing performance, building muscle and improving physique. Detection of the misuse of rhGH has proved difficult for a number of reasons. One of these is the effect of preceding exercise. In this randomised, double blind placebo-controlled study, we determined the effects of rhGH administration in male amateur athletes on two candidate markers of rhGH abuse, IGF-I and N-terminal pro-peptide of collagen type III (P-III-NP), following a bout of weightlifting exercise.nnnDESIGNnSixteen men entered a four-week general weight training programme to homogenise their activity profile. They then undertook repeated bouts of standardised leg press weightlifting exercise (AHRET-acute heavy resistance exercise test). Blood samples were taken before and up to one hour after the AHRET. After the first laboratory visit (Test 1), the subjects were randomly assigned to receive daily injections of either rhGH (0.1 IU kg(-1) day(-1)) or placebo for two weeks. The AHRET was repeated after the two-week dosing period (Test 2) and a further test was undertaken following a one-week washout (Test 3).nnnRESULTSnThere was no effect of exercise on either IGF-I or P-III-NP in any test. Both markers were markedly elevated at Test 2 (p<0.001), with P-III-NP remaining elevated at Test 3 in the GH administration group (p<0.05). Application of the GH-2000 discriminant function positively identified GH administration in 17 of 40 blood samples taken at Test 2 from the rhGH group and none from the placebo group.nnnCONCLUSIONnThe data show that rhGH results in elevated levels of IGF-I and P-III-NP in well-trained individuals and that leg press weightlifting exercise does not affect these markers. The GH-2000 discriminant function identified four of eight subjects taking rhGH with no false positive results.

Personalized medicine for diabetes: a special issue

For many centuries, physicians have strived to provide personalized care for their patients in the hope that their treatments will deliver the maximum benefit with minimal side effects. Although the diseases may be the same, how an individual responds to these illnesses is unique, and consequently treatment must be tailored accordingly. With the advent of ever more sophisticated diagnostic techniques and therapies, our ability to personalize treatment has never been better. In diabetes care, a recognition of individualized care has made a resurgence. Prior to the last decade or two, there was little guidance to help healthcare professionals and people with diabetes in their treatment choices and so there was much freedom for clinicians and people with diabetes. There was perhaps too much art and too little science involved, resulting in variable diabetes outcomes in different locations. Then came several initiatives to improve the quality of diabetes care and reduce geographical variation in diabetesrelated morbidity. While overall standards improved, a criticism of these guidelines and reimbursement mechanisms was that they provided rigid protocol-driven treatment pathways, with limited scope for personalization; many fared worse as inappropriate decisions about aggressive glucoselowering led to hypoglycaemia. The pendulum, led by the European Association for the Study of Diabetes and American Diabetes Association guidelines, is swinging back now, with much greater emphasis on choosing the right treatment for the right person at the right time. But, how do we implement this without reverting to the previous status quo? The month’s Diabetic Medicine is a special issue that includes five invited reviews and an invited research paper devoted to the subject of delivering personalized care for people with diabetes. In the first article, Pearson [1] describes how our understanding of the aetiology and pathophysiology of diabetes and genetic predictors of treatment response is moving rapidly and the ways in which we can use these new insights to improve treatment choices. Carr [2] then discusses how new therapies are brought to our clinics, by drawing on the example of the development of dipetidyl peptidase-4 inhibitors, which arose from a clear understanding of a distinct pathophysiology in Type 2 diabetes. People with diabetes form a heterogeneous group and it is well recognized that diabetes affects disadvantaged populations disproportionately. In the review by Ruddock et al. [3], the health inequality experienced by those living in lowand middleincome countries and by certain ethnic and socio-economic groups is explored, together with initiatives to reach into these communities to improve their outcomes. Diabetes places a huge burden of self-care management on those living with diabetes and we need to support our patients better to achieve this. The next two reviews look at two aspects of this facet of care. O’Connor et al. [4] describe how we can improve outpatient care decisions by making use of better support systems that prioritize care recommendations, improve communication of treatment-relevant information to people with diabetes, and integrate patient-reported information including data from remote sources. Serrano et al. [5] then teach us how to improve shared decision-making in the clinic by considering each individual’s personal, social and biomedical situation as well as their values. The final article in the special issue describes the specific challenges of providing diabetes care in Peru, where low political commitment and several system-level health service barriers mitigate against high-quality diabetes care [6].

Language matters. Addressing the use of language in the care of people with diabetes: position statement of the English Advisory Group

The language used by healthcare professionals can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it day‐to‐day. At its best, good use of language, both verbal and written, can lower anxiety, build confidence, educate and help to improve self‐care. Conversely, poor communication can be stigmatizing, hurtful and undermining of self‐care and can have a detrimental effect on clinical outcomes. The language used in the care of those with diabetes has the power to reinforce negative stereotypes, but it also has the power to promote positive ones. The use of language is controversial and has many perspectives. The development of this position statement aimed to take account of these as well as the current evidence base. A working group, representing people with diabetes and key organizations with an interest in the care of people with diabetes, was established to review the use of language. The work of this group has culminated in this position statement for England. It follows the contribution of Australia and the USA to this important international debate. The group has set out practical examples of language that will encourage positive interactions with those living with diabetes and subsequently promote positive outcomes. These examples are based on a review of the evidence and are supported by a simple set of principles.