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Content developed and funded by the Boehringer Ingelheim and Lilly Diabetes Alliance

For healthcare professionals only

Intended for UK and Ireland healthcare professionals only. This article has been developed and funded by the Boehringer Ingelheim and Lilly Diabetes Alliance. Practice Nurse Jane Diggle received an honorarium for developing and writing the content. Boehringer Ingelheim and Eli Lilly & Co (Lilly) reviewed the content for medical accuracy and compliance with the ABPI Code of Practice

The critical role nurses play in recognising and addressing the hidden cardiovascular risks in people with type 2 diabetes

Cardiovascular disease (CVD) is the leading cause of death and disability in the population and the most common complication of type 2 diabetes.1 Compared to people without diabetes, those with type 2 diabetes are 2.0 to 2.5 times more likely to have a cardiovascular complication.Nearly a third of those with type 2 diabetes have cardiovascular disease.1 It occurs earlier than in those without diabetes3 and is responsible for more than half of all deaths in this population.1

However, type 2 diabetes is often regarded as a mild condition and much less serious than type 1 diabetes. It is described by some as simply a glucose problem that needs to be addressed which fails to acknowledge the cardio-renal-metabolic impact that can be life-limiting and in some cases life-threatening. The number of people living with diabetes in the UK is rising and every day around 700 people are diagnosed.4

Type 2 diabetes often exists without any obvious symptoms making a timely diagnosis difficult, yet the underlying mechanisms including hyperinsulinemia, dyslipidaemia and inflammation may have already caused considerable damage, particularly to blood vessels, thereby increasing a person’s CV risk.

A more proactive approach to screening for type 2 diabetes is being encouraged. However, while there are around 3.9 million people diagnosed with diabetes in the UK, it is estimated that over half a million have type 2 diabetes but are unaware because it has not been diagnosed.5

Additionally, since the COVID-19 outbreak, there has been a lot of attention on how type 2 diabetes can impact the risk of developing severe COVID-19 and lead to poor prognosis. The reason for a worse prognosis in people with diabetes is likely to be multifactorial and related to the combined impact of risk factors namely, advancing age, gender, ethnicity and co-morbidities such as hypertension, CVD and obesity.6

Jane Diggle, Practice Nurse with Specialist Role in Diabetes, provides her perspective on the critical role nurses can play in raising awareness of the serious implications of CVD in type 2 diabetes, help people understand why there is this link, what happens within the body to damage the blood vessels and practical advice for reducing risk. She also provides her advice on how to help people manage their diabetes through the COVID-19 outbreak.

Over one third of people living with type 2 diabetes also have CVD1
CVD can occur 10-15 years earlier in patients with diabetes compared to those without diabetes 3
CVD is responsible for over half of all deaths in people with type 2 diabetes1
There is an increased risk of death from COVID-19 in people with all types of diabetes, with one third of all deaths in hospital with COVID-19 occurring in people with diabetes7

Why do you think people don’t always fully appreciate the seriousness of type 2 diabetes?

People often think that type 2 diabetes is the milder form of diabetes. This is an important myth to dispel because of the insidious nature of the damage caused by type 2 diabetes particularly to blood vessels throughout the body.

Ultimately the goal is to prevent diabetic complications – the majority of which are CV in nature. The challenge is to convey the hidden damage that can occur over time and explain how healthy lifestyle choices and appropriate treatments reduce risk. Importantly, it is the combined impact of high blood glucose, together with high blood pressure and dyslipidaemia that drives diabetes-related complications. People often focus solely on control of their blood glucose, so we have to make sure people understand that there are other important CV risk factors that increase the chances of developing diabetic complications such as heart attacks, strokes, peripheral arterial disease, kidney disease and retinopathy.

A diagnosis of type 2 diabetes has a devastating impact on some individuals. Some feel stigmatised by the label of what is often regarded as a self-inflicted illness associated with being overweight or obese. Some individuals simply cannot come to terms with the diagnosis especially in the context of feeling well and not having any symptoms.

We should focus on preventing damage to blood vessels caused by high glucose levels
The impact of high blood glucose, together with high blood pressure and dyslipidaemia is what drives diabetes-related complications8
Ultimately the goal in type 2 diabetes management is to prevent diabetic complications – the majority of which are CV in nature

What do people understand about the complications associated with type 2 diabetes?

People often do not realise that it’s the damage type 2 diabetes can cause to blood vessels which can lead to complications such as blindness and foot amputations. Far fewer are aware of the association between diabetes and other CV complications including heart attack, heart failure, stroke and kidney disease. If people were more aware of this and had a better understanding of the underlying processes which lead to these complications, I feel they may be more willing and able to address CV risk factors such as smoking, poor diet and sedentary lifestyle, and accept appropriate medications to treat hypertension and dyslipidaemia.  

One quarter of people who end up in hospital because of a heart attack or a stroke have diabetes2

People with type 2 diabetes are twice as likely to have a stroke than those without9

Why can type 2 diabetes cause complications for those people with COVID-19 and impact on outcomes?

We are still learning a lot about COVID-19 and its course. However, everyone with diabetes, including those with type 1, type 2, gestational and other types, is vulnerable to developing a severe illness if they do contract coronavirus, but we must remember the way it affects each person can still vary.10

As we gather more data from the outbreak, we are learning that for those with type 2 diabetes outcomes are less stable, ventilators are more commonly needed, and severe complications are more likely. Reasons for this are complex – in people with type 2 diabetes, insulin resistance gives rise to chronic, low-grade inflammation, leaving the immune system “dulled” by this ongoing state of alert. When the body experiences a new infection, the immune system does not react quickly and adequately, therefore allowing the virus to gain and maintain a foothold.11

The additional risk factor of CVD is also an important consideration for people with type 2 diabetes who contract COVID-19 as it not only causes viral pneumonia but has major implications for the CV system.12 For more information, visit the European Society of Cardiology guidance here: https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance

How can nurses help support people to better understand and reduce CV-related complications?

Practice Nurses are ideally placed to have conversations around CV risk. It is a fundamental part of their role in the management role of many other long-term conditions. They already possess the knowledge, skill and competency to support people to manage CV risk in other clinical areas such as heart failure and stroke management.

At diagnosis the initial consultation should ideally last 40 minutes as there are many issues to discuss including the diagnosis, lifestyle choices, treatment and medication, short and long – term complications, and risk factors. It can be difficult for a person to absorb so much information at this first meeting. It is often necessary to follow up with them to reinforce this information and answer any queries and concerns they may have. They may also wish to have a family member or friend attend the meeting so they can help with navigating the information.

The management focus is very much around tackling the modifiable CV risk factors including smoking, lack of physical activity, obesity (especially abdominal obesity), hypertension, dyslipidaemia.

Remote consultations during the COVID-19 pandemic and beyond 13

To provide care and support for people with diabetes during the COVID-19 pandemic, to minimise the risk of transmission, a predominantly remote approach is preferable with greater reliance on the technology of telephone and video consultations. In my experience one approach that has worked successfully is to adopt a 2-stage process which involves:

  • 1: Face to face appointments which are as brief as possible and prioritised for those where it is vital to collect data such as cholesterol and kidney function. However, it should be acknowledged that during the outbreak, a lot of healthcare professionals will have made decisions around postponing these face to face visits to lower the number of people coming into practices
  • 2: Virtual follow-ups which are longer and allow for more of a consultation and interaction. To support these, patients are encouraged to keep on top of self-management of blood pressure and HbA1c.

Here are a few of my top tips to navigate a consultation:

Signpost

My advice to nurses is to signpost the individual to support groups that will build on the initial discussions. Where I practise, we often direct people to local groups to discuss lifestyle, smoking cessation and weight management and to third-party organisations such as Diabetes UK, Heart UK and the British Heart Foundation all of which are informative resources. Additionally, I have been involved in developing a factsheet outlining resources for people, especially important at this time of remote consulting: “At a glance factsheet: Sources of information and education for people with diabetes to support remote consulting.” It includes advice around topics such as lifestyle, monitoring, preparing for a review, as well as some useful information relating to COVID-19. It is available at: https://www.diabetesonthenet.com/journal/diabetes-primary-care.

Useful resources

Note: The Boehringer Ingelheim and Lilly Diabetes Alliance is not responsible for the content on these external sources of information

Tailor your approach

While it is important to bring to life the seriousness of CV-related risks, this does need to be done in a sensitive way. Receiving a type 2 diabetes diagnosis can be devastating for a person, they can often blame themselves or feel a stigma attached to this diagnosis. In the early conversations as there is a lot of information to take on board and reactions to this may vary. It is important that healthcare professionals approach with empathy first and education thereafter. Using negative and stigmatising language is rarely motivating. The role of the nurse is sensitively to encourage and positively reinforce the importance of making changes that will lead to CV risk reduction.

Tailoring treatment conversations around the individual needs of the person is key, especially in light of the newer options available. Now we have evidence of the cardiovascular and renal benefits of certain diabetes drugs over and above their blood glucose lowering capability it is important we consider this when deciding on a therapy. Important factors to consider include whether a person has established atherosclerotic CV disease, heart failure or CKD. CV risk is another important factor and QRisk 3 is a useful tool that may be used to calculate CV risk in those without established CVD.

The significantly improved understanding of type 2 diabetes treatments and the growing evidence from larger cardiovascular outcome trials (CVOTs) is leading to changes in guidelines, both in the UK and internationally. Discussing treatments that have proven cardiovascular benefit with appropriate individuals will further help people to understand the importance of addressing CV-related risks in type 2 diabetes. Some guidelines have been updated already to include recommendations on early CV interventions for those with established CVD and other co-morbidities. As nurses we have a role to play in helping people choose the treatment that is right for them. Ensuring these conversations centre around a person’s individual CV risk is important because it relates to them and this is more powerful than relying solely on national or population statistics. Using tools such as QRisk3 to illustrate how stopping smoking will reduce an individual’s personal CV risk score can be very impactful.

Primary care nurses are key to supporting patients in making lifestyle choices

Sometimes we struggle to know what to say and how to say it

Sometimes we struggle for time – we can’t work harder but we can work differently

Risk factors for CV include: 8,14,15

Non-modifiable:

  • Age
  • Ethnicity
  • Gender

Modifiable:

  • Weight
  • Smoking
  • Increased blood pressure
  • Cholesterol
  • Lipids
  • Increased albumin-creatinine ratio
  • Coronary heart disease
  • Chronic kidney disease

Follow the process

Every person with diabetes should receive eight key checks: HbA1c, blood pressure, cholesterol, foot examination, kidney function, urinary albumin, BMI and smoking review. However, figures from the latest National Diabetes Audit (2017/18) revealed that only six people in 10 with type 2 diabetes received all eight healthcare checks,16 even though these are the essentials of diabetes management. Additionally, we need to be mindful that when these checks are carried out, that they are acted upon appropriately – if abnormal findings are identified they need to be optimally managed.

We know that targeting HbA1c should not remain the only focus in reducing diabetes complications. Targeting HbA1c reduces the risk of diabetes complications including eye, kidney and nerve damage and reduces cardiovascular risk but so does addressing high blood pressure and raised cholesterol and this is an important message to get across in the consultation as many individuals don’t know this. All three treatment targets (for HbA1c, blood pressure and cholesterol) need to be considered if we are to effectively lower CV risk and reduce the devastating CV complications of type 2 diabetes yet the 2017/18 audit revealed that only two in five people with type 2 diabetes achieve all three of these treatment targets.16

Stay positive and encourage small (yet important) actions

Giving advice on small, incremental changes a person can make is important. Changing behaviours on a large scale overnight is difficult and rarely lasts. Understanding what motivates a person and what they see as a tangible/manageable change is important and should be encouraged.

Since the COVID-19 outbreak and not being able to see people face to face, some practices have stepped up their contact with people via text messages. By doing so, they can “drip feed” information and links to resources to people on how to manage their condition and make lifestyle choices in an encouraging, positive way.

We know from the DiRECT study that with sufficient weight loss, remission of type 2 diabetes can be achieved in some individuals and this is an important message to convey to people with type 2 diabetes because it offers them hope.17  Diet and lifestyle have a centrally important role in achieving this goal and their impact should not be underestimated.

Don’t assume that dietary interventions will fail or that patients will not be willing to make or maintain dietary changes.18,29,20

  • Emphasise non-starchy vegetables
  • Minimise added sugars and refined grains
  • Choose whole foods over highly processed foods to the extent possible (eat ‘real’ food)
  • Low calorie diets/intermittent fasting/ time-restricted eating can all help with weight loss but special care must be taken if the individual is taking medications, especially blood glucose lowering drugs associated with hypoglycaemia

Empower with shared decision making

We must involve those living with the condition in the decision making process. Typically, in a year a person will have around two hours of clinical interaction with an HCP compared to 8,575 hours self- managing their condition. It is the individual who decides whether they feel ready and able to make healthy lifestyle choices and whether or not to take the medications we prescribe.

It is important we share results but that we translate these into language that is understandable. By doing this, people will feel encouraged to have more control and ownership over their health and lifestyle choices.

A person’s ability and willingness to self-manage their condition is a crucial factor in determining outcomes

Our role is to work in partnership with people and equip them with the knowledge, skills, resources and confidence to succeed outside the healthcare setting

How should healthcare professionals deal with the backlog of appointments after the COVID-19 outbreak?

There is going to be a balancing act when it comes to resuming business as usual at practices after the initial COVID-19 outbreak and teams will need to assess how to prioritise appointments. Things to consider include:

  • If someone was recently diagnosed, ensuring that they get access to information and a follow up as it is likely that an early intervention could help with ongoing management
  • Check in on whether some people’s lifestyle choices have been impacted by the stress of the COVID-19 lockdown, e.g. have they taken up smoking, drinking or eating the wrong foods
  • Ask whether people have been able to exercise during the COVID-19 lockdown and if that has impacted on their diabetes management
  • Has someone had COVID-19 (confirmed by a test) and/or do they suspect they may have had it?
  • Has someone’s mental health been affected by the outbreak and has this impacted on their self-management?
  • Is someone known to have poor glycaemic control?
  • Has someone been able to monitor their blood pressure while it home during lockdown? Has this changed over time?

In summary

Overall, I am optimistic that we can help people better understand the true impact of type 2 diabetes and take the associated CVD risks seriously. We have already made great improvements in terms of screening to identify type 2 diabetes earlier but having identified it the focus has to be on more proactively tackling risk factors. We must be sensitive to the needs and preferences of every individual and tailor our approach appropriately. Effective management of type 2 diabetes requires a multifactorial approach and should not focus exclusively on glycaemic management. All primary care healthcare professionals – nurses, GPs, healthcare assistants, pharmacists, dieticians, social prescribers/community groups and health coaches – need to work together and support individuals to make positive health choices which will ultimately impact on their CV health.

In light of the COVID-19 outbreak, it is even more important for us to connect with people around their diabetes management. This is to ensure that they are following appropriate advice on not just staying safe and managing their risk of contracting COVID-19, but also following advice on managing their condition if they are unable to see their healthcare teams in person in the same ways as previously.

Finally, as well as providing lifestyle advice, we need to work together to follow the most appropriate and up-to-date guidance. In relation to blood glucose management there are a number of options now available, which not only lower blood glucose but also have been shown to have proven cardiovascular benefit.

If we get it right at the start – intervene earlier, provide the right education and support and raise awareness around the link between type 2 diabetes and CVD this can lead to better outcomes.

 

References

  1. Einarson TR, et al., Cardiovasc. Diabetol; 2018;17:83
  2. NHS Digital (2017) National Diabetes Audit Report 2A: Complications and Mortality Royal College of Physicians Sentinel Stroke National Audit programme (SSNAP). National clinical audit annual results portfolio March 2015–April 2016. Available: https://www.strokeaudit.org/results/Clinical-audit/National-Results.aspx [Accessed August 2020]
  3. Booth G et al. Lancet 2006; 368; 29-36
  4. Diabetes UK ‘The Future of Diabetes’ https://www.diabetes.org.uk/resources-s3/2017-11/1111B The future of diabetes report_FINAL_.pdf [Accessed August 2020]
  5. Diabetes UK, ’39 Million People now Living with Diabetes.’ Available: https://www.diabetes.org.uk/About_us/News/39-million-people-now-living-with-diabetes [Accessed August 2020]
  6. Appicella M et al. The Lancet. 2020 Available: https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30238-2/fulltext [Accessed August 2020]
  7. Holman N et.al The Lancet. Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort study.https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30271-0/fulltext [Accessed August 2020]
  8. The 2019 ESC guidelines . Available: https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines [Accessed August 2020]
  9. Diabetes UK Facts and Stats. 2017. Available https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/diabetes-storage/migration/pdf/DiabetesUK_Facts_Stats_Oct16.pdf [Accessed August 2020]
  10. Diabetes UK, ‘Updates: Coronavirus and diabetes’ Available: https://www.diabetes.org.uk/about_us/news/coronavirus. [Accessed August 2020]
  11. American Heart Association ‘Understanding the risky combination of diabetes and coronavirus’. Available: https://www.heart.org/en/news/2020/04/13/understanding-the-risky-combination-of-diabetes-and-the-coronavirus [Accessed July 2020]
  12. European Society of Cardiology ‘ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic’. Available: https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance [Accessed August 2020]
  13. How to undertake a remote diabetes review – a PCDS quick guide. Diabetes & Primary Care. Vol 22 No 3 2020
  14. Arnett DK et al. J Am Coll Cardiol. 2019. pii: S0735-1097(19)33876-8
  15. Bertoluci MC & Rocha VZ. Diabetol Metab Syndr. 2017;9:25
  16. NHS, ‘National Diabetes Audit – Report 1 Care Processes and Treatment Targets 2017-18, Full Report.’ Available: https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-audit/report-1-care-processes-and-treatment-targets-2017-18-full-report
  17. Direct Clinical Trial. Available: https://www.directclinicaltrial.org.uk/ [Accessed August 2020]
  18. How to improve carbohydrate awareness. Diabetes & Primary Care. Vol 21 No 3 2019.
  19. There is no such thing as a diet for type 2 diabetes… or is there? Part 1. Diabetes & Primary Care Vol 21 No 3 2019
  20. There is no such thing as a diet for type 2 diabetes… or is there? Part 2. Diabetes & Primary Care Vol 21 No 4 2019

Job code: NP-GB-100445
Date of preparation: September 2020