BJDVD

Update on the NHS Diabetes Prevention Programme (from Jonathan Valabhji, the National Clinical Director for Obesity and Diabetes at NHS England)

The launch of the NHS Diabetes Prevention Programme was announced at The Diabetes UK Professional Conference by Simon Stevens, CEO of NHS England. Evidence-based reviews of real-world translations of randomised, controlled diabetes prevention trials were undertaken by Leicester University, after a competitive tender, and will be published over the course of the summer. The Clinical and Expert Reference Group, which I chair, has adapted the evidence into a service model which will inform an invitation to tender, subject to further input from a User Representation Group, and subject to further modification following testimonials delivered by a number of academic and provider units.

For phase 1 of the Programme (through to March 2016), we will work with seven demonstrator sites, announced at Programme launch, to test the practical application of various aspects of the service model, including case finding. Eligible participants will have already been identified as having non-diabetic hyperglycaemia (the current term for the middle category of glucose tolerance) through the NHS Health Check Programme or through prior opportunistic testing. Up to 10,000 eligible people will be enrolled on the Programme during this current financial year.

An invitation to tender will be issued to identify suitable providers and allow the procurement of the behavioural intervention, based on the service model, for phase 2 of the Programme. Phase 2 will constitute the first stage of a national rollout during the 2016/17 financial year, and will involve 10,000–30,000 behavioural interventions for people with non-diabetic hyperglycaemia. The learning from phases 1 and 2 will inform further adaptations and refinements of the service model, which will be used as we work with providers to achieve full national rollout. The behavioural interventions, focusing on weight loss, physical activity, and diet quality, will be intensive – at least 13 face-to-face interactions over at least 9 months, in group settings of at least 1 hour duration. A formal evaluation to assess that the Programme is indeed preventing type 2 diabetes is being established.

Dinesh Nagi takes over as General Secretary from Patrick Sharp who has kindly agreed to stay on the committee to lead our type 1 diabetes work stream and to assist with ABCD’s contribution to 'Medical Care', RCP London's web-based guide to medical specialities.

Karen Adamson has been co-opted to assist Dev Singh in implementing the ABCD Consultant Mentorship Scheme in Scotland, and contributing to our education and development programme. She will also liaise with the Scottish Colleges. We welcome two new committee members, Marc Atkin and Allison Gallagher, to the executive committee.

ABCD's response to the second consultation on this guideline can be found on the website. The publication date has yet to be announced.

The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) is inviting professionals to submit entries to this competition to find the best UK initiative aimed at preventing severe hypoglycaemia in hospitals. This JBDS-IP project is being led by Umesh Dashora, Debbie Stanisstreet, and Erwin Castro. Please send entries to christine.jones@ nnuh.nhs.uk.

Application deadline: 1 September 2015. See Prof Mike Sampson’s announcement at

The Joint ABCD-WEDS meeting in Cardiff was a successful venture and an enjoyable event. In future the best abstracts will be selected for oral presentation at the meeting instead of the winners of the SpR Training Award, who will still receive a prize for their presentation at the annual SpR Meeting. Our next conference is the autumn meeting at the Royal College of Physicians of London (RCPL) on 5–6th November. Finally, Peter Winocour and I have arranged a joint RCPL meeting “Managing complex long term conditions and multi-morbidity” on 18th February 2016, so put that date in your diary too.

The safe use of insulin training module is now available on payment from Virtual College Healthcare as part of an expanded National Patient Safety Training Suite (http://www.healthcareea.co.uk/patient_safety_training_suite). As another option, Primary Care Diabetes Society and Training, Research and Education for Nurses on Diabetes-UK have collaborated to produce an eLearning module ‘Six Steps to Insulin Safety’ that is free to access at www.cpd.diabetesonthenet.com.

The new Chair of the All Party Parliamentary Group for Diabetes is the Rt Hon Keith Vaz MP. ABCD looks forward to working with him. We gratefully acknowledge the significant contribution made by his predecessor as Chair, Adrian Sanders, who was not re-elected to parliament at the general election.

The Diabetes Think Tank met on 30th June and learned that there is talk of a Diabetes Strategy or Diabetes Action Plan for England. This is an unexpected opportunity to make improvements in diabetes care, and the Think Tank debated what the most important components of the strategy should be. Better integration of services and a national survey of patient experience were high on the list.

Dr Peter Belfield, Medical Director for Royal College of Physicians (RCP) Invited Service Reviews, would be pleased to hear from ABCD members who meet the criteria who might be prepared to assist with such reviews. Please contact Michelle Wong (michelle.wong@ rcplondon.ac.uk) if you are interested. More information can be found at:

The RCPL has launched a guide on making sense of the key to service provision in secondary care. See:

Jyothis George is planning a meeting for new investigators as an ABCD event, as part of our strategy to encourage academic diabetologists. Travel grants of up to £1,000 are available for SpR members of ABCD who have had an abstract accepted for presentation at an overseas meeting. Details are on the ABCD website.

Andy Macklin will be working on modernising ABCD's communication and information systems to support all we do more efficiently and cost-effectively. This will include updating the membership database and website architecture. The ABCD committee approved a modest budget for this.

IDegLira (Xultophy^®) is now licensed for the treatment of adults with type 2 diabetes mellitus in combination with oral glucose-lowering medicinal products when these alone or combined with a GLP-1 receptor agonist or basal insulin do not provide adequate glycaemic control.

Garry Tan from Oxford has been nominated by the Joint Specialty Committee for Endocrinology and Diabetes of the RCP on the Tariff and Commissioning Group, hereafter known as the Expert Advisory Group on Commissioning.

In conjunction with Emma Willmot and Peter Hammond, Rob Gregory has produced a specification for a National Insulin Pump Network to fill the void left by the demise of NHS Diabetes. This is likely to go live in 2016.

In this project a relatively small number of themes have emerged that explained a depressingly large number of harms. ABCD has written to Trusts highlighting the number of insulin prescribing, and administration errors resulting in harm and asked them to review their processes. ABCD recommends the award winning prescription charts on its website http://www.diabetologists-abcd.org.uk/JBDS/insulin_ chart_winners.pdf. The next step is to ask each participating trust to identify a theme to address, decide for themselves how to address it, implement an action plan and evaluate it. There will be a session dedicated to the project at the 2016 Diabetes UK Professional Conference.

A nationwide canagliflozin audit will be launched shortly to accompany the ongoing nationwide dapagliflozin audit. Please start collecting data patient names and data of your patients on canagliflozin in readiness. Forms for data collection can be found at:

The two audits give us a unique opportunity to increase our understanding of the new SGLT2 class of agents in real world use. Bob Ryder gave a demonstration in Cardiff of how to use the online tools to analyse one’s own data and his presentation is available at http://www.diabetologists-abcd.org.uk/HowToABCDAudits.pdf. All members are encouraged to join the audits.

QualityWatch has produced a report of 3rd July comparing health parameters in 27 countries. More positively, the analysis found that the UK performs better than most on diabetes, saying that the numbers of potentially preventable admissions for diabetes and admissions for lower extremity amputations are relatively low.

Partha Kar discusses a model consultant job plan which may satisfy the needs of integrated diabetes care. Please feel free to provide feedback on this proposal.

According to new figures, the number of people with diabetes in the UK is now an all-time high at 3.9 million and 42 per cent of people with type 2 diabetes do not feel empowered to manage their diabetes. Details at:

Sampson Rob Gregory and Daniel Flanagan, from July 2015 all Acute Trusts will be asked to give an overview of inpatient diabetes care at their Trust in the provider information request (PIR). This could include inviting Trusts to make statements on the presence (or absence) of an inpatient diabetes nurse service, the provision of mandatory insulin training, the recording of insulin errors, and on provisions made as an organisation to adapt to the needs of people with diabetes.

It is possible that a CQC inspection that looks specifically at inpatient diabetes might sharpen Trusts’ focus on training issues and inpatient risk for people with diabetes. Alan Sinclair is undertaking a parallel work with CQC on diabetes in care homes.

A local diabetes specialist nurse and dietician designed Skills for Adjusting Diet and Insulin in East Sussex (SADIE) aims to meet the educational needs of people with type 1 diabetes. Attendees show improved quality of life and an average HbA1c reduction of 0.5% (5.5 mmol/mol) at one year.

SADIE has recently been certified by the Quality Institute for Self-Management Education and Training (QISMET). Achieving QISMET certification provides formal recognition and quality assurance for local services, providing a ‘gold standard’ for providers and commissioners.

Afrezza^® (Sanofi) inhaled insulin is now available for use at mealtimes by people with type 1 and type 2 diabetes in the USA. The insulin, delivered as a dry powder by a portable inhaler, is not approved for children, people with chronic lung conditions, DKA and smokers.

Interesting recent research
A rapid-fire collection of interesting recent developments in diabetes

SGLT2 inhibitors and the risk of diabetic ketoacidosis (submitted by Drs Dev Singh and Caroline Day)

Published evidence of varying quality is available on the use of metformin, GLP-1 agonists and SGLT2 inhibitors in type 1 diabetes either used singly or in combination.¹ Ketosis and diabetic ketoacidosis (DKA) may be missed because SGLT2 inhibitor adjunctive therapy may maintain an effective glycaemic state, in the face of insulin deficiency in patients with type 1 diabetes. Peters et al described 13 episodes of euglycaemic DKA or ketosis in nine individuals (seven with type 1 diabetes and two with type 2 diabetes) associated with SGLT2 inhibition in the USA in a presentation at the ADA 2015 meeting, since published in full in Diabetes Care.² The absence of significant hyperglycaemia in these patients delayed recognition of the emergent nature of the problem by patients and providers. According to the European Medicines Agency, a total of 101 cases of DKA in patients treated with SGLT2 inhibitors in both type 2 and type 1 diabetes had been reported worldwide in EudraVigilance as of 19 May 2015. Putting aside the potential for diabetes type misclassification, this clearly extends this concern to type 2 diabetes where DKA may develop in particular circumstances.³ An alert has been issued by MHRA.⁴

Intensive blood glucose control leads to poor outcomes and more hypos in North America (but not in the rest of the world) compared with standard glucose control

A systematic review and meta-analysis of randomised, controlled trials compared the effect of intensive versus standard glucose control on outcomes. Intensive control was associated with more all-cause mortality, cardiovascular mortality and severe hypoglycaemia in North America but not in the rest of the world.
Sardar P et al. J Am Heart Assoc 2015;4. pii: e001577; doi: 10.1161/JAHA.114.001577.

Researchers at Imperial College London identified a genetic defect in making a protein, carboxypeptid-ase-E, in an extremely obese young woman with type 2 diabetes, learning difficulties and reproductive problems.
Alsters SI et al. Plos One 2015; doi: 10.1371/journal.pone.0131417.

Combined use of antidiabetic and antidepressant drugs is associated with higher risk of myocardial infarction

This registry-based study shows that the combined use of these drugs is associated with a higher risk of myocardial infarction compared to either type of drugs used alone.

Markers of low-grade inflammation at diagnosis predict worsening glycaemic control in type 1 and type 2 diabetes

In a recent prospective study, two-year increases of high-sensitivity C-reactive protein, soluble E-selectin (sE-selectin), and soluble intercellular adhesion molecule-1 in type 2 diabetes and IL-18 in type 1 diabetes was associated with worsening of HbA1c. Additionally, 2-year increases of sE-selectin were associated with decreases of prehepatic β-cell function in type 2 diabetes (all p<0.05).

No cognitive impairment with statins in a systematic review and meta-analysis

A systematic review and meta-analysis of 25 RCTs did not show an association of statins with cognitive impairment. The FDA warning about the potential adverse effect of statins on cognition may need to be revisited.

Ott BR et al. J Gen Intern Med 2015;30:348-58; doi: 10.1007/s11606-014-3115-3.

Thyroid antibodies predict gestational diabetes mellitus (GDM) in some patients

A meta-analysis finds a significant association between thyroid antibodies in patients with thyroid dysfunction but not euthyroid state and GDM.

Yang Y et al. Fertil Steril 2015 Jul 4. pii: S0015-0282(15)00425-2; doi:http://dx.doi.org/10.1016/j.fertnstert.2015.06.003

The prevalence of cognitive impairment was five-fold higher in adults with type 1 diabetes with childhood onset disease compared to those without diabetes. A relationship with poor control of diabetes, proliferative retinopathy, higher BMI and peripheral vascular disease is described.

Adelaide researchers are developing a laser system for fast, non-invasive, on-site breath analysis to diagnose diabetes, infections and various cancers. The system senses by–products of metabolic processes in the body that change even before symptoms of disease appear.

OZURDEX^® (dexamethasone 0.7 mg intravitreal implant) provides significant improvements in visual acuity, compared to baseline, in patients affected by diabetic macular oedema in new and refractory patients. NICE has proposed this treatment for patients due for artificial lens implant (due to cataract surgery) and who are considered insufficiently responsive to, or unsuitable for, non-corticosteroid therapy.

Escobar-Barranco JJ et al. Ophthalmologica 2015;233: 176-185; doi:10.1159/000371770.

Eating proteins and vegetables before carbohydrates leads to lower post-meal glucose and insulin levels.

Liraglutide 3 mg induced weight loss in people who were overweight or obese but without diabetes (the majority had prediabetic dysglycaemia); 63% on liraglutide lost 5% of initial weight (vs. 27% on placebo) and 33% lost 10% of initial weight (vs. 11% on placebo).

Pi-Sunyer X et al. N Engl J Med 2015;373:11-22; doi: 10.1056/NEJMoa1411892

Weight loss surgery more effective than banding or lifestyle measures at inducing remission

In a paper published in JAMA Surgery, Roux-en-Y gastric bypass led to more patients with diabetes achieving remission (40%) than gastric banding (29%) or diet and exercise alone (0%).

New data from the Look AHEAD trial show that weight loss in the first two months of intensive life-style intervention is associated with long-term success eight years after the initial treatment.

Umick JL et al. Obesity (Silver Spring) 2015;23:1353-6; doi: 10.1002/oby.21112.

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YDEF are governed by their mantra of education, representation and communication. Some of the ancillary objectives are the cultivation of a healthy interaction between trainees, not just within the UK, but internationally; and the development of research within our specialty. The annual North Europe Young Diabetologists (NEYD) meeting embodies these views and provides a platform for young trainees to share their research amongst their peers. This tri-nation meeting has been going strong for over 30 years (including its previous format as the Anglo-Danish-Dutch club) and continues to be one of the more enjoyable and lighthearted/informal YDEF courses.

This year the NEYD meeting was held in the picturesque city of Bergen in the Netherlands from 27th to 29th May. Over three days and seven themed sessions, attendees were treated to presentations from each of the 28 delegates on topics ranging from physiological to psychosocial and clinical aspects of hypoglycaemia and diabetes. These were interspersed with a plenary lecture on cardiovascular outcome trials in diabetes by Prof Jørgen Rungby; and a lively and entertaining debate between Professors Henk Bilo and Rory McCrimmon on the potential value of newer diabetes therapies in type 1 diabetes.

What also sets NEYD apart from other meetings is the promotion of networking between the attendees, and this was encouraged through evening meals and daily activities outside of the presentations. The meeting closed on Friday lunchtime with the award of a prize for best presentation, which deservedly went to Aleks from Denmark.

YDEF would like to thank our sponsors at Boehringer-Ingelheim for helping organise an exciting and thoroughly enjoyable event.

Keeping with the high calibre meetings organised by YDEF, the Insulin pump course was another highlight of the year. This year we kicked off to a rousing start with Dr Pratik Choudhary challenging trainees on what constituted a good diabetes clinic. Professor Stephanie Amiel laid the groundwork by emphasising the importance of getting insulin management right before reaching for technology.

Then followed excellent talks and hands on experience for the delegates who each spent 24 hours wearing their own pump. New for 2015 was a practical session with sensors – 3 lucky, lucky SpRs got to monitor their (interstitial!) glucose in real time overnight. Running a pump service was also covered as delegates got advice on negotiating with CCGs and procurement from clinical lead consultants Dr David Hopkins and Dr Nick Oliver who have been there and done that. The always popular workshop session on the final day covered pregnancy (Dr Peter Hammond), sport (Dr Alistair Lumb) and download interpretation (Dr Pratik Choudhary).

A great time was had by all and, as always, we extend our thanks to the brilliant faculty and sponsors Roche, Medtronic, Bayer, Abbott and Advanced Therapeutics UK.

Looking forward

Looking ahead to the upcoming events by YDEF, we plan for the European Association for Study of Diabetes (EASD) annual meeting by offering our members an opportunity to apply for the YDEF-Lilly EASD scholarships. This initiative is supported by the team at Lilly diabetes and is aimed at providing support to 10 applicants to attend the EASD meeting to present their research or to experience the wonders of an international meeting. The deadline for applications has passed and once again proved to be very popular. The selected applicants will shortly be informed of their success.

Continuing our tradition of providing novel and essential events dedicated to developing our members, we are proud to announce our new venture with ABCD. The YDEF-ABCD Consultant Development Programme is a comprehensive leadership and management course specifically tailored for final year registrars and new consultants in our specialty. Set for November this year, it promises to be another unique meeting in the armoury of YDEF (and ABCD).

Dr Ali Chakera
Email: Ali.chakera@nhs.net

YDEF is dedicated to all diabetes and endocrine trainees and is open for new members to register on our website. Take advantage of our regular newsletters and up to date advertising of a wide variety of courses, jobs and meetings to complement your training.

As always, we are continuously looking to develop and propagate our specialty so do not hesitate to contact us if you have any suggestions or questions! www.youngdiabetologists.org

Interesting recent research A rapid-fire collection of interesting recent developments in diabetes

Looking forward

Interesting recent research
A rapid-fire collection of interesting recent developments in diabetes