Falkland Surgery PPG Open Evening on Diabetes

1. Falkland Surgery PPG Open Evening on Diabetes Tim Walter - GP Jackie Winterbourne - Practice Nurse - Falkland Surgery Janet Grimes – Diabetes Educator/Specialist Nurse – NHS Berkshire West

2. Agenda • TW - Introduction to Diabetes at Falkland Surgery – diagnosis, prevalence, risk factors • JG - Education programmes after diagnosis etc. • JW- Conversion from oral treatment to insulin

3. Earlier Intervention in Diabetes Tim Walter

4. Background • Falkland Surgery population of 14,400 • Main demographic is of an average age split but higher than average elderly population c.f. locally (75yrs+) • Some pockets of deprivation • High level of employment

5. Diagnosis Trends • 2000 = 194 patients registered with DM • 2005 = 306 patients registered • 2008 = 435 patients registered • 1.3% / 2.1% / 3.0% of population • National prediction 3.6% in 2007 – still a way to go

6. Trends in detail • 2000 Type 1 DM = 44 Type 2 DM = 150 • 2005 Type 1 DM = 56 Type 2 DM = 250 • 2008 Type 1 DM = 66 Type 2 DM = 369 • Therefore the massive increase in DM is predominantly in the Type 2 group • NB Caveats, re recording etc

7. Why? • Demographics • Ageing population • Trend nationally towards obesity • Clinical • Better detection • Lower thresholds Fasting BS of 7.8 down to 7 Type 2 DM is associated with age, ethnicity, family history, weight/obesity and sedentary lifestyle

8. Actions we are taking to prevent epidemic • Weight clinics • Exercise referrals • Earlier screening and detection • Public education and involvement

9. Weight Clinic • Currently piloting a weight clinic – Julie • Weekly clinic with interventions, advice, encouragement, medication if appropriate • Part of the Greenham project • However we need to audit results to prove its effectiveness, September 08 and review

10. Exercise referrals • Ongoing work done via Northcroft Centre with April Peberdy for any patient with a need • Exercise “on prescription” • Something like 70% of “early detected raised BS/DM” can be managed by diet and exercise (but it takes effort)

11. Early Detection • Computer system analyses and flags up patients with previously raised sugar levels. Work done in University of Warwick, published in BMJ and we have been running this for about 2 years • Random BSs over 11, fasting over 7 without codes to indicate diagnosed already • Retest to assess risk • Looked at 12 patients with potentially missed DM, 9 were subsequently confirmed • Ongoing process as new patients arise • Second group with random BS over 7

13. National Initiatives • We need to see co-ordinated education and action • Publicity on healthy living • Labelling • Role models • Newspapers/Magazines/Advertising • Prevention better than cure • However this costs money now, but won’t show results for many years

14. Further interventions • We are starting people on medication earlier and more aggressively – not only for the DM but also statins, aspirin, antihypertensive medication • Converting to Insulin earlier and more frequently (see later) as patients with Type 2 live longer

15. Recent NICE guidelines - 1 • Patient education • Offer structured education to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review. Inform people and their carers that structured education is an integral part of diabetes care.

16. Recent NICE Guidelines - 2 • Setting a target HbA1c When setting a target HbA1c: – involve the person in decisions about their individual HbA1c target level, which may be above that of 6.5% set for people with type 2 diabetes in general – encourage the person to maintain their individual target unless the resulting side effects (including hypoglycaemia) or their efforts to achieve this impair their quality of life – offer therapy (lifestyle and medication) to help achieve and maintain the HbA1c target level – inform a person with a higher HbA1c that any reduction in HbA1c towards the agreed target is advantageous to future health – avoid pursuing highly intensive management to levels of less than 6.5%.

17. Recent NICE Guidelines - 3 • Self-monitoring Offer self-monitoring of plasma glucose to a person newly diagnosed with type 2 diabetes only as an integral part of his or her self-management education. Discuss its purpose and agree how it should be interpreted and acted upon.

18. Recent NICE guidelines - 4 • Starting insulin therapy • When starting insulin therapy, use a structured programme employing active insulin dose titration that encompasses: • structured education • continuing telephone support • frequent self-monitoring • dose titration to target • dietary understanding • management of hypoglycaemia • management of acute changes in plasma glucose control • support from an appropriately trained and experienced healthcare professional.

19. Conclusion • Massive rise in Diabetes diagnosed through better detection but unfortunately also through higher incidence. • Provision of lifestyle interventions (weight / diet / exercise) • Still a way to go but somehow we need to prevent problems arising • Please put us out of a job!