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Multidisciplinary approach is the way forward in diabetes

Geoffrey M Hall
Medical Journalist and Writer
Past President
European Medical Writers Association

A key member of this team, according to Philip Home, Professor of Diabetes Medicine, University of Newcastle-upon-Tyne, and clinical adviser to the National Collaborating Centre for Chronic Conditions (NCCCC), is "the real professional", the person who has type 1 diabetes. "A patient may have tens of years living with diabetes," Prof Home commented. "The doctor only sees the patient for a couple of hours a year."
In practical terms, the clinical guideline - the 15th published by the National Institute for Clinical Excellence (NICE) since its inception in 1999 - is presented as two guides. One considers the needs of children and adolescents diagnosed with the disorder and was developed by the National Collaborating Centre for Women's and Children's Health (NCCWCH). The second deals with type 1 diabetes in adults and was developed by the NCCCC.
Both guidelines stress the need for a team approach that involves the patient and family and is dedicated to patient-centred care. As with previous NICE guidelines, the authors have identified practices that are evidence-based. When these are fully implemented, the authors believe that the guidelines will improve detection of diabetes across England and Wales and reduce the impact of the condition on the lives of people with diabetes.
Dr Stephen Greene, leader of the Guideline Development Group responsible for the children's guideline, said that it would set acceptable targets that are in line with others in the world. "If our young people need it, we should move to new technologies," he said. He commented that, in the past, the UK has been relatively slow in taking up innovations in diabetes care.
Professor Home said that the guideline will encourage the earlier detection of risk factors and early intervention to prevent complications associated with diabetes. "Blindness ought to not now occur," he said.

Diagnosis and management of type 1 diabetes in children
The guide on the diagnosis and management of children and young people with type 1 diabetes was developed for NICE by the NCCWCH, and it sets out how health professionals should diagnose and care for people with type 1 diabetes who are under the age of 18.
The guideline states that children and young people with type 1 diabetes should be offered an ongoing integrated package of care by a multidisciplinary paediatric diabetes care team. To ensure the highest standards of care, and so reduce the risk of complications, the diabetes care team should include people with expertise in clinical, educational, dietetic, lifestyle, mental health and foot care aspects of diabetes for children and young people.
The guide also states that, at the time of diagnosis, children and young people with type 1 diabetes should be offered home-based or inpatient management according to clinical need, family circumstances and wishes, and depending on how far away they live from inpatient services.
The authors state that home-based care with support from the local paediatric diabetes care team is safe and as effective as inpatient initial management. Specialist support should include 24-hour telephone access to advice.
The guideline also urges that children and young people with type 1 diabetes and their families be given opportunities to receive accurate and consistent information about their condition so that they can fully participate in making informed decisions.
The guideline places particular importance on the haemoglobin A(1c) (HbA(1c)) test, the laboratory test that reveals average blood glucose over a period of 2-3 months. Children and young people with type 1 diabetes and their families should be informed that the target for long-term glycaemic control is an HbA1c level of less than 7.5% without frequent disabling hypoglycaemia, and that their care package should be designed to attempt to achieve this.
Other main points in the guideline state that children and young people with diabetic ketoacidosis should be treated according to the guidelines published by the British Society for Paediatric Endocrinology and Diabetes, and that they should be offered screening for coeliac disease and thyroid disease at diagnosis and at regular intervals until they transfer to adult services. They should also be checked for retinopathy, micro-albuminuria and raised blood pressure annually from the age of 12 years.
Since children with diabetes may experience psychological disturbances, such as anxiety, depression, behavioural and conduct disorders, they and their families should be offered access to mental health services.
The guide also stresses the need to involve the family. Dr Neil McIntosh of the Royal College of Paediatrics and Child Health, commented on the guideline and the challenge of caring for the child with diabetes: "The appropriate and timely diagnosis of the child with type 1 diabetes is a sentinel event for the whole family. Their lives change dramatically from that point. Maximising understanding for the child and family and minimising the intrusion to life are the key management strategies that promote a life with a minimum of complications. This requires a team of people supporting clinical, emotional and social needs. This care must not dissolve as the adolescent passes on to adulthood. These are critical guidelines for a common condition seen by paediatricians throughout the country."

Diagnosis and management of type 1 diabetes in adults
As with children, the guideline on the care of adults with type 1 diabetes makes it clear that this should be patient-centred and provided by a multidisciplinary team. The views and preferences of patients should be integrated into their healthcare.
In addition to clinical management, the care team members should have specific training to cover educating and informing patients, nutrition and foot care counselling and psychological care. The team should offer expertise in the identification and management of diabetic complications.
Education should aim to give the patients the necessary understanding of arterial risk factors and late complications involving feet, kidneys, eyes and the heart.
Again, as with the guideline requirements for young people, the adult guide stresses the role of HbA1c targets for prevention of microvascular and arterial disease. This, however, should fit in with the experiences and preferences of the insulin user, in order to avoid hypoglycaemia.
The guideline emphasises the need for advice from professionals knowledgeable about the range of available mealtime and basal insulins and how best to use these in combination.
Adults with type 1 diabetes should have an annual assessment for arterial risk and appropriate interventions when problems are discovered. Patients should also be assessed for microalbuminuria in particular, as well as for metabolic syndrome. Patients with type 1 diabetes should also be counselled regarding conventional risk factors, including abnormal lipids, raised blood pressure and smoking.
Finally, the adult guide insists that adults with type 1 diabetes should be assessed annually for early markers and features of eye, kidney, nerve, foot and arterial damage. They should be offered appropriate interventions and/or referral in order to reduce the progression of these late complications and their impact on the patient's quality of life.
Professor Home commented: "Type 1 diabetes may seem to be all painful injections, blindness and lifestyle restriction. But it does not have to be that way. These guidelines set a direction that encourages people with diabetes and the professional teams that advise them to discuss and agree how they use the technological advances of the last decade to live a close to normal life, while avoiding the devastating late-developing complications. Diabetes management is about self-management. The guideline espouses the need for full education about diabetes and how to handle it. It also emphasises preventive screening and therapy, so avoiding future health problems, rather than needing more intensive and costly salvage medicine. Thus these guidelines are a subtle marriage within the NHS of structured care with individual choice."

Implementation of the guideline
While the full text of the guideline may be somewhat unwieldy, the two "Quick Reference Guides" succinctly summarise the recommendations for adults and for children and young people. These are available online at the NICE website (see Resources). Hard copies of the "Quick Reference Guides" have been sent to every GP practice in England and Wales.
The authors of both aspects of the guideline are clear that publication alone will achieve nothing in the way of improvement in the quality of the health and lives of people with type 1 diabetes unless the recommendations are implemented and funded.
NICE insists that local health communities should review their existing practice for type 1 diabetes against the new guideline. The review should consider the resources required for the recommendations to be implemented, the people and processes involved, and the speed with which full implementation is envisaged.
Since it is in the interests of adults and children and young people with type 1 diabetes that implementation is as rapid as possible, NICE advises that "relevant local clinical guidelines, care pathways and protocols should be reviewed in light of this guidance and revised accordingly."
NICE also suggests that the new guideline be used in conjunction with the National Service Framework for Diabetes and the Children's National Service Framework.

National Institute for Clinical Excellence
National Service Framework for Diabetes
National Service Framework for Children, Young People and the Maternity Services