Monthly lifestyle counselling improves heart outcomes

Adapted from Intensive lifestyle counselling and cardiovascular outcomes in patients with diabetes. September 14 2019  Diabetes in Control by Nour Salhab. Pharm. D from Zhang et al Lifestyle counselling and long term clinical outcomes in patients with diabetes. Diabetes Care. Aug. 2019.

Intensive lifestyle counselling has been shown to improve blood sugars in the Look AHEAD study but it was too underpowered to show any significant conclusions regarding cardiac outcomes.

This new study looked at patients with both type one and type two diabetes who had HbAICs over 7% and were over the age of 18. Lifestyle counselling involved diet, exercise and weight loss management. The goal was to get the patient’s HBAICs under 7%.

19,293 patients were involved and the mean HbAIC at the start was 7.8%. My comment: This is a very good average compared to British diabetics! 

The mean counselling sessions were 0.46 a month and the study ran for 5.4 years.

HbAIC reduced by 1.8% for patients who got monthly counselling and 0.7% for those who got less than monthly counselling.

The primary end point was time to the first episode of angina, heart attack or stroke or death from any cause. There was a small but significant decrease in the group who had monthly counselling compared to three monthly counselling.

The counselling occurred in academic centres so may not be applicable to other settings.

My comment: This level of counselling is much more intensive than can probably be delivered in the NHS population. The blood sugar levels in the patients was also much better to start with compared to the UK population. 

A little care goes a long way

Adapted from Annals of Family Medicine 2019 doi:10.1370/afm.2421

People diagnosed by their GP with type two diabetes had a 40-50% lower mortality rate over the next ten years if they experienced their GP and practice nurses as empathetic during the year after diagnosis, compared to those who considered that their primary health carers had low empathy.

This study looked at 879 patients recruited from 49 GP practices in the east of England.

My comment: The first year is when patients get their head round the fact that they have a long term condition that could affect how long they will live and the quality of the life they have left. At diagnosis many are willing to look at lifestyle changes. Encouraging them, helping them, and helping them set appropriate goals makes a good difference to a person’s ability to change their daily routines. If you are newly diagnosed and don’t get on with your health care providers for any reason, then maybe a change of provider makes sense in the light of this research. 

The optimal HbA1C for non low carbing type ones could be 6.5-7%

Adapted from Lind M et al. BMJ 28 August 2019

In type one diabetes in adults and children there could be a sweet spot for blood sugar control.

Under 6.5% severe hypoglycaemia rates increase. Retinopathy and nephropathy risks are not lower however below 6.5% compared to 6.9%. My comment:  In low carbers however, they have considerable protection against severe hypoglycaemia due to more precise meal/insulin matching, although they do experience more episodes of mild hypoglycaemia.

Risks for mild complications begin at levels over 7.0% and severe complications rise with levels over 8.6%.

Current guidelines vary in their HbA1C recommendations, anywhere from 6.5% to 7.5%.

The complication rates were based on 10,398 adults and children with type one diabetes on the Swedish National Diabetes Registry who were diagnosed between 1998 and 2017.

 

 

 

BMJ: Children with type one diabetes do just as well with jags as pumps

 BMJ 13 April 19

Pumps versus Multiple Daily Injections

Across various centres in England and Wales, 294 new onset type one diabetes patients were randomised to receive either pumps or MDI from the very start after diagnosis. The age range was just 7 months to 15 years. There were 144 in the pump group and 147 in the MDI group.

At one year the average HbA1c was around 60 (7.6%) for both groups. There were 14 serious events such as diabetic ketoacidosis or severe hypoglycaemia in the pump group and 8 such events in the MDI group.

It cost £1,863 more to treat the pump group but they had no better outcomes or improvement in quality of life compared to the MDI group. Indeed adverse events were a bit more common in the pump group even though there were fewer of them.

My comment: Looks like they were not advised about low carb diets given the relatively high HbA1Cs at a time that the honeymoon phase can be protective.

BMJ 16 Feb 19

Type one children performed just as well as their schoolmates in exams

Although both high and low blood sugar can affect concentration and memory and cognitive function, Danish researchers found that in national exams, type one children performed just as well as other children.

Enterovirus may act as a trigger for Coeliac Disease

Norwegian researchers looked at infection with adenoviruses and enteroviruses in childhood and later diagnosis of coeliac disease.

They tested children who were already at risk due to a particular genotype. They were recruited between 2001 and 2007 and were followed up till 2016.

They found that infection with enteroviruses but not adenoviruses were associated with higher onset of coeliac later on.

My comment: Enterovirus infection has been associated with the onset of type one diabetes too. People with type one are also more likely to develop coeliac. There could be common genetic susceptibility and environmental triggers.

 

 

Sam Everington: I moved the diabetes consultant into the community and greatly improved results

Adapted from BMJ 26 January 19, Five minutes with Sam Everington,  by Susan Major

Sam Everington worked as a lawyer before re-training as a GP. He is now the chair of Tower Hamlets Clinical Commissioning Group, has served on the Kings Fund, and gained a knighthood.

Tower Hamlets is a very deprived area in east London, despite this they have achieved the best rates of blood pressure control and cholesterol in patients with type two diabetes.

Sam puts this down to a much closer involvement by the hospital diabetes consultant with patients directly in the community instead of the hospital ivory towers which is traditional in the UK.

By mainly giving telephone advice to local GPs and pharmacists, he was able to give quick decisions on optimal treatment.

Sam says, “Diabetes is a complex disease, so you have to have a comprehensive approach, using everything you can to improve lifestyle and motivate patients by focussing on what is important to them. It is key to have a care plan that is individualised to each patient, systematically going through with a nurse and creating the plan in partnership with them.

“If you accept that social factors are responsible for 70% of a person’s health and wellbeing, then there is a big gap in primary care. If we don’t tackle social factors, we are really only having access to 30% of the therapies that we really need. Therefore we have introduced social prescribing in every practice in Tower Hamlets.

“We use a referral form, ticking boxes on lifestyle, environment, social and mental health. Patients then see the social prescribing advisor and talk through what will motivate them. They are then connected to one or more of 1,500 voluntary sector organisations in Tower Hamlets.

“We also encourage patients to access their own notes so they can see their results and take control. All the evidence shows that when patients manage their own illness the outcomes are better. All our patients are offered a half or whole day diabetes education workshop.”

My comment: Well done Sam. A great example of joined up thinking being adequately resourced to achieve great results.

 

 

Type Ones get near normal blood sugars on very low carb diets

Adapted from Management of Type One Diabetes with a very low carbohydrate diet by Belinda S Lennerz et al. Pediatrics Volume 1 number 6, June 2018.

Exceptional glycaemic control of type one diabetes mellitus with low rates of adverse events was reported by a community of children and adults who consumed a very low carb diet. This study was done by recruiting patients via an online survey. Their medical records were then used to confirm their results.

Of the 316 respondents, just over a third were parents of diabetic children. The mean age of diagnosis was 16 years and the duration of diabetes was a mean of 11 years. The mean time of following a VLCD was just over 2 years. The mean daily carb intake was 36g. The mean HbA1c was 5.67%. Only 2% of the respondents reported diabetic hospitalisations. 4 admissions were for DKA and 2 for hypoglycaemia.

In the USA the average HbA1C for type one diabetics is 8.2%.  The ADA target to reduce complications is set at under 7.5% for children and under 7% for adults. Only 20% of children and 30% of adults reach these targets.

A major difficulty is achieving post meal blood sugar targets. The carbohydrate load has the greatest influence on this. A VLCD is regarded as between 20 and 50g of carb at each meal or between 5-10% of total meal calories from carbohydrate. Some practitioners worry about advising diabetics about VLCD because of concerns about DKA, hypos, lipid problems, nutrient deficiency, growth failure and sustainability.

The study was approved by the Boston Children’s Hospital.  The recruitment group were people who were following Dr Bernstein’s Diabetes Solution. They came from the USA, Canada, Europe and Australia. They were all confirmed as having type one diabetes from their medical records.

Symptomatic hypoglycaemia was reported by 69% of the participants but severe hypos were rare. Most people had 1-5 episodes of mild hypos a month.

Most people had the characteristic low triglycerides, high HDL, high total cholesterol and high LDL pattern.  The average trig/hdl ratio was 1:1 indicating excellent cardiometabolic health. BMI was also lower than population averages for age. The DCCT covered 1441 adolescents and young adults and the factors that showed the greatest effect on cardiovascular risk were: HbA1c, then trigs, then LDLc.

The commonly reported growth deceleration noted with type one diabetes is generally thought to be due to poor blood sugar control.  In this study group however the children’s height were modestly above averages for age and gender.

A few participants deliberately did not disclose their low carb diets to their health care providers due to concerns about being criticised, pressured to change behaviour or accused of child abuse. Although 49% of participants thought that their health care provider approved of VLCDs, a robust 82% of the health care providers said they did.

We don’t know how generalisable the findings in this study could be. This group may be particularly well motivated and may be pursuing other health related behaviours such as physical activity. None the less,  the level of glycaemic control and low rates of DKA and severe hypos revealed by this study break new ground in research into diabetes management for type one diabetes.

 

 

 

BMJ: Asking better questions in the diabetic clinic

Adapted from BMJ 24 Nov 18

Are you well controlled?

Judith Hendley writes:

I am a mum who has type one diabetes. It troubles me to be referred to as a “diabetic”. Although this doesn’t bother everyone, I feel that this reduces me to someone with diabetes and nothing more.

Once diagnosed you are referred to as a patient for evermore. No matter how healthy and active I am, I seem to have crossed an invisible line from the “healthy” to the “unhealthy”.  I don’t want assumptions made about me and I don’t want the first question I am asked to be about my most recent HbA1c result.

The language used by healthcare professionals, the media and others makes a big difference to how I feel about living with a long term condition.

Living with type one diabetes requires mental agility, resilience, stamina, perspective and a healthy sense of humour, so state of mind is everything and language plays a big part in that.

There are questions that particularly get on my nerves.

Instead of saying, “Do you suffer from diabetes?” it would be much better to simply ask, “Do you have diabetes?”

I am sometimes asked if I am “well controlled”. It makes me want to reply, “No. In fact you just can’t take me anywhere.”

I often think that health care professionals don’t realise how difficult keeping a consistent equilibrium with diabetes really is. I would like to be asked questions such as,

” How are things going with your diabetes.”

“Are you having any difficulties with your blood sugar at the moment?”

“Are you finding anything particularly challenging?”

Open, non judgemental questioning is best. “How are you feeling about your diabetes at the moment?” “What is most important to you right now?” “What ideas have you thought about for how you could handle that?”

I realise some people may think I’m being overly precious about language, but health care professionals would be seen as much more “on side” and they could still get all the relevant information they need, if they just minded how they phrase things to patients.