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Type 2 diabetes in the frame: an important year

Michael Hall
FRCGP
Chair
Diabetes UK

Bridget Turner
MA
Head of Policy Diabetes UK

Since self-care is vital to the successful achievement of good diabetes control, the patient and their carers must be recognised as a central part of the team. Given education, training and support, people with diabetes can become experts in their own care.
Diabetes, having such multisystem risks, ideally requires continual monitoring and surveillance by an experienced team of health professionals. In the practice, this will usually be a GP and a practice nurse. This contribution looks at monitoring and control from the medical viewpoint.

Background
Diabetes is a common disease. In the UK it is the third most common chronic disease and accounts for about 9% of the healthcare budget - about £500,000/hour or £4.9b/year.(1) There are 130m people with diabetes in the world today and this number is expected to increase to 300m in the next 25 years. The important complications of diabetes are blindness, renal failure, an increased risk of cardiovascular disease and stroke. It is the most common cause of non- traumatic amputation of the lower limb. People with diabetes on average have a life expectancy that is reduced by 5-15 years. Primary care must take diabetes seriously.
The good news is that research has shown that good glycaemic control and tighter control of blood pressure has a significant effect in reducing the incidence of these serious complications.(2) It has also been shown that greater involvement of the patient through education and training in exercise and healthy eating assists in achieving lower glycaemia levels and thus better control.(3,4) Education of the person with diabetes may be as important as other medical interventions.

Diagnostic criteria
In last year's RCGP Members' Reference Book we referred to the World Health Organisation's changed diagnostic criteria for diabetes.(5) Since these changes are still in the process of being adopted in the UK they are worth reiterating (see Table 1). The main changes include the recommendation that the cut-off point for diagnosis using fasting plasma glucose should be lowered from 7.8 to 7.0mmol/l. The changes reflect research evidence regarding the development of the complications. Inevitably, because diagnostic levels have become more stringent, this will have the one-off effect of increasing the number of people with diabetes.

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Help for the practitioner
As in any epidemic, it is GPs and practice nurses who are in the frontline. The RCGP, along with Diabetes UK and the RCN, is developing practical evidence-linked guidelines for the management of people with type 2 diabetes (T2D) - now the responsibility of NICE (National Institute of Clinical Excellence). The work to date includes guidelines on diabetic foot care and renal care; others will be issued later in 2001.
However, for guidelines to be really useful they need to reflect the local resources. Because of the frequency and seriousness of diabetic complications, the primary care team needs to work closely with the specialist team, especially with diabetes specialist nurses. When agreeing local care protocols, a list of "who does what and when" is a valuable way of developing a system that works for you and your patients. Use the national guidelines as a basis for developing your own system.

Identifying those at high risk of developing T2D
At the time of writing, the national screening committee has not yet decided to recommend a national screening programme. However, given that data exist which suggest that people with T2D may have had the condition for 4-7 years before diagnosis, and that 40% at diagnosis have signs of developing complications,(6) many in primary care would wish to use their practice database to highlight those most at risk. When those patients attend the practice for other reasons, they can be checked for diabetes. The following risk factors are accepted:

  • Diabetes in a first-degree relative.
  • Being overweight.
  • Age over 40 years.
  • Being of Asian or Afro-Caribbean origin.
  • Previous gestational diabetes mellitus, baby over 4kg in weight.

Monitoring and control
Monitoring needs to be carried out annually for all diabetic patients; some will need more frequent review, especially those with poor control or those with complications. There are a few simple rules that may help:

  • Ensure a positive follow-up: use a recall register and chase those who fail to attend.
  • Discuss eating and exercise and review weight.
  • Monitor glycaemic levels, blood pressure, albumin and microalbumin, and serum creatinine.
  • Check for diabetic retinopathy.
  • Examine feet for early signs of damage.
  • Ask males about erectile function.
  • Check medication.
  • Discuss self-management, and issues such as employment, driving, education and needs.
  • Usually, refer those with complications to the specialist team for further assessment.

Medication
When it comes to medical intervention, there is little space in this article to cover the whole range available. The importance of attaining good glycaemic and blood pressure control is crucial in reducing the risk of complications. The GP and practice nurse need to be aware of this and to recognise that, since diabetes is a progressive condition, additions to drug therapy will become the rule. Newer medicines like the glitazones will have a place with patients who are achieving less than ideal glycaemic control, and some people with T2D will need to be transferred onto insulin. Keeping blood pressure at normotensive levels will frequently require beta-blockers or ACE inhibitors and a diuretic.

Future developments
The upcoming publication of the Diabetes National Service Framework (www.doh.gov.uk/nsf/diabetes/index.htm) should help in the provision of diabetes services by identifying priorities and providing greater resources. Increased attention to the delivery of information to those with diabetes, so that they can accept more responsibility for self-care, may result in the wide establishment of educational programmes, perhaps after the model of diabetes schools elsewhere in Europe.
Further developments in transplant technology will bring a "cure" closer. The best advice is to avoid risks by paying attention to lifestyle, especially eating healthily and keeping physically active.

Five-year forecast

  • Education for self-care will be routine
  • Multiple drug therapy will be commonplace
  • Monitoring of type 2 diabetes will routinely take place in primary care
  • New hypoglycaemic drugs and more short-acting insulins will be available
  • The first experimental islet cell transplant for type 2 diabetes will take place

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References

  1. Currie CJ, et al. NHS acute-sector expenditure for diabetes: the present, future, and excess in-patient cost of care. Diabet Med 1997;14:686-92.
  2. British Diabetic Association. UKPDS: implications for the care of people with type-2 diabetes. London: BDA; 1998.
  3. Berger M, et al. Intensified treatment and education of type-1 diabetes as a clinical routine: a nationwide quality-circle experience in Germany. Diabetes Care 1999;22(Suppl 2):29-34.
  4. The DAFNE Study Group. Preliminary findings presented at Diabetes UK Annual Professional Conference, Glasgow 2001.
  5. British Diabetic Association. Criteria for the definition, diagnosis and classification of diabetes mellitus and its complications. London: BDA; 2000.
  6. Harris MI, et al. Onset of NIDDM occurs at least 4-7 years before clinical diagnosis. Diabetes Care 1992;15(7):815-9.

Resources
Diabetes UK (formerly British Diabetic Association)
W:www.diabetes.org.uk

Association of Community Health Councils for England and Wales (ACHCEW)
W:www.achcew.org.uk

Further reading
Diabetes UK Position Statement on Early Identification of Type 2 Diabetes; 2001 (see website)