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Effective self-management of type 2 diabetes

Diabetes prevalence is increasing significantly in the UK. Between 2006 and 2011, the numbers of people with diabetes in England increased by 25%, has now reached three million, and is predicted to reach five million by 2025.1 The majority of these people have type 2 diabetes; this is a condition of relative insulin deficiency typically due to insulin resistance associated with being overweight. Diabetes is expensive: it consumes approximately £10 billion of the NHS budget annually, 80% of which is spent on potentially avoidable complications.1 These include micro-vascular complications of retinopathy, nephropathy and neuropathy and macro-vascular conditions such as heart disease and stroke. Cardiovascular disease is the commonest cause of death in people with type 2 diabetes and accounts for 52% of deaths.2 Life expectancy may be reduced by up to 10 years in people with the condition.3

Evidence from the UK Prospective Diabetes Study showed that optimising control of blood pressure, blood glucose and cholesterol levels can reduce risk of developing complications.4 A holistic approach to improving all risk factors including lifestyle behaviours confirms this.5 Regular review of potential risk factors, identification of the presence of complications, and timely intervention is the basis of the diabetes annual review, recommended for all people with diabetes.6 Unfortunately, there is huge variation in the completion of annual diabetes reviews, with only between six and 69% of people with diabetes receiving all the necessary checks.7

However, as for all long-term conditions (LTCs), people with diabetes will spend just a few hours each year with a healthcare professional. The daily management of the condition is the patient's responsibility. There is an increasing awareness of the importance of self-management skills in maintaining health in LTCs: indeed, in the current financial constraints of the NHS, promoting successful self-management is one of the major ways the NHS can meet the increasing demands of an ageing population. Increasing access to appropriate information, providing choice about care providers and treatments, and encouraging referral to structured education programmes are included in recent changes to national health policy.8

Living with type 2 diabetes: managing lifestyle and medications

There are an increasingly complex number of different medications for controlling blood glucose levels. Unless contra-indicated, most people start with metformin, with the National Institute of Health and Care Excellence (NICE) guidelines recommending sequential use of sulphonylurea and then insulin, with alternatives if these are not suitable, to achieve glycated haemoglobin (HbA1c) targets. Targets are less than 48 mmol/mol (6.5%) in the early stages of the condition and 59 mmol/mol (7.5%) as the condition progresses, individualised to the person's circumstances.6 With less regard to cost, recent guidelines by the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) suggest any agent could be added after metformin to achieve glycaemic target.9

Underpinning any medication should be healthy lifestyle behaviours. People with type 2 diabetes are encouraged to consume a healthy diet (regular meals, including low glycaemic index carbohydrate, reducing fats especially saturated fats, and increased fibre intake).6 When considering another glucose-lowering agent, review and support for lifestyle improvements should be considered at each stage.

Living with diabetes does not just mean eating a healthy diet and taking some pills. People with diabetes have to manage the relationship between food, activity and medications; may be self-monitoring blood glucose, blood pressure, weight; ensure they attend annual screening for complications and risk factors; manage episodes of sickness and acute complications such as hypoglycaemia; be aware of legislation and diabetes pertaining to driving and employment; and eventually perhaps living with disability resulting from long-term complications. The success of this relies on developing new skills and knowledge and gaining confidence from practicing new behaviours, which takes time and needs support.

Formal support for people with diabetes is generally available as individual consultations, using a shared decision, care-planning approach, or through attendance at an accredited structured education programme. The latter is included in the NICE Quality Standard for diabetes,10 with diabetes education and self-management for ongoing and newly diagnosed (DESMOND)11 and XPERT12 most commonly available. 

The concept of shared decision-making is being recommended in all consultations with users of health services,13 with the Year of Care programme (developed through a collaboration between the department of health, the Health Foundation and the National Diabetes Support Team) encouraging this when planning care for people with diabetes.14 Patients are supported to understand their condition, clarify what they hope to achieve from their treatment or self-management programme, be aware of what treatment options are available, understand the benefits and risks of each, and then come to a mutual agreement with their clinician about what is best for them.15

Independence and new technology

It was acknowledged earlier in this discussion that most people with diabetes will spend very little time with a healthcare professional and so the increasing availability of web-based information, self-help tools, monitoring tools and decision aids is to be welcomed.

Insulin and the new GLP-1 receptor agonist therapies (liraglutide, exenatide and lixisenatide) are available in simple pen delivery devices, including disposable pens which require very little preparation. Eli Lilly have produced a durable pen that has a memory function.16 Insulin pump therapy, however, is not recommended as cost-effective by NICE for use with people with type 2 diabetes.17 

Blood glucose monitors are becoming smaller, faster, and requiring a very small blood sample. Some are very sophisticated, enabling the user to identify blood glucose patterns and support appropriate treatment adjustment. The Freestyle InsuLinx meter, for example, after programming by a healthcare professional, advises on insulin adjustment to correct blood glucose levels that are out of the target range for the individual using it.18

Encouraging people to use pedometers, weighing scales and home blood-pressure monitoring devices enable feedback to reinforce healthy behaviours or identify problems early. The use of social media sites such as Facebook, or phone apps, enables easy access to information. For example, information about calorie and carbohydrate content of different foods can be a useful tool for anyone interested in controlling their weight or for calculating the appropriate insulin dose for a meal.19

Decision aids vary from one page sheets with treatment choices, to computer programmes, DVDs and interactive web sites (eg. NHS Direct, Diabetes UK website) It has long been recognised that use of these can improve knowledge and increase active participation by patients20 and enhance the care planning process if the patient arrives at a consultation fully informed about choices available.

Who most benefits from self-management strategies?

Almost everyone with diabetes can benefit from learning how to manage their diabetes themselves. Apart from emergency diabetes services, most routine diabetes care is usually only available from Monday to Friday. People live with the condition at weekends, on public holidays, in the night, and abroad on holiday, and have to cope with the variations in activity, food, and other factors that can impact on their diabetes control during these times. Also, despite the enormous cost to the NHS, current diabetes care is not doing very well: the National Diabetes Audit showed only 19.9% of people in England and 18.5% in Wales achieved blood pressure, blood glucose and cholesterol targets.7 In the current financial situation, patients are a relatively under-used resource for the NHS to deliver health outcomes required to keep people well.

 

Conclusion

Type 2 diabetes is expensive and the number of people with the condition is increasing at a time when the NHS is functioning within difficult financial constraints. There is an economic rationale therefore to encourage self-management as an alternative to traditional paternalistic care. However, supported self-management also improves patient experience and a number of other favourable outcomes. Support is available in a variety of forms, from care planning, education programmes, and technology like websites, devices and phone apps.

 

References

1. Diabetes UK. State of the Nation 2012. Available at: www.diabetes.org.uk/Professionals/Publications-reports-and-resources/Rep....

2. Morrish NJ, Wang SL, Stevens LK et al. Mortality and causes of death in the WHO multinational study of vascular disease in diabetes. Diabetologia 2001;44:s14-s21.

3. Department of Health. National Service Framework for Diabetes: Standards. London: DH; 2001. 

4. Stratton IM, Adler A, Neil HAW, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321:405-12.

5. Gaede P, Lund-Anderson H, Parving H, Pederson O. Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes. N Eng J Med 2008;358:580-91.

6. NICE. Type 2 diabetes-newer agents (partial update of CG66) CG87. 2009. Available at: http://guidance.nice.org.uk/CG87.

7. Health and Social Care Information Centre. National Diabetes Audit 2011-2012. Available at: www.hscic.gov.uk.

8. Equity and Excellence: Liberating the NHS. 2010. Available at:  www.gov.uk/government/publications 

9. Inzucchi SE, Bergenstal RM, Buse JB et al. Management of hyperglycaemia in type 2 diabetes: A patient-centred approach. Diabetes Care 2012;35:1364-79.

10. NICE. NICE Quality Standard QS6:Diabetes in Adults. 2011. Available at: http://guidance.nice.org.uk/QS6.

11. DESMOND. Available at: www.desmond-project.org.uk

12. XPERT. Available at: www.xperthealth.org.uk 

13. NICE. NICE Quality Standard QS15 Patient experience in adult NHS Services: improving the experience of care for people using adult NHS services. 2012. Available at: http://guidance.nice.org.uk/QS15.

14. Diabetes UK. Year of Care for diabetes. 2010. Available at: www.diabetes.org.uk/Guide-to-diabetes/support_for_managing_your_diabetes....

15. Coulter A, Collins A. Making shared decision-making a reality. No decision about me, without me. London: The Kings Fund; 2011.

16. Memoir insulin device product information. Available at: www.lillypro.co.uk/diabetes/hcps/our-insulin-pens 

17. NICE. Diabetes insulin pump therapy TA 151. 2008. Available at: http://guidance.nice.org.uk/TA151.

18. Freestyle InsuLinx product information. Available at: www.abbottdiabetescare.co.uk 

19. Carbs and cals: Facebook. Available at: www.facebook.com/pages/Carbs-Cals/18402002828842.

20. O'Connor AM, Rostom A, Fiset V, Tetroe J et al. Decision aids for patients facing health treatment or screening decisions: systematic review. BMJ 1999;319(7212):731-4.