From the desk of the chairman, Ketan Datariya

2024 is already promising to be a fantastic year for ABCD, with new programmes, events and activities. I am delighted to announce that we have extended associate membership to all healthcare professionals who represent the multidisciplinary team which provides care for people with diabetes. Associate members receive all the benefits of membership except voting rights at the AGM, which helps to ensure that our purpose, goals and ambitions remain led by and for consultant diabetologists. This last issue has been debated repeatedly over the years; each time we come back to our core membership – https://abcd.care/join#associate)

In this, my first year as chair of the committee and ABCD Executive, we have strengthened our governance and reporting responsibilities.

We have been working to strengthen and enhance our external relationships with partner organisations such as DUK and YDEF and our representation on national bodies.

In collaboration with our parent charity, Diabetes Care Trust, we have once again been able to successfully award two research grants totalling £50,000. The first grant was awarded to Gordon Sloan at the University of Sheffield, who will be investigating the efficacy of cerebral bioenergetics as a biomarker for neuropathic pain in diabetic peripheral neuropathy. The second grant will be awarded to Lauren Quinn at the University of Birmingham, who will be testing the acceptability of adult screening for T1DM. Look out for announcements on how to apply for this year’s grant.

We also introduced an exciting new “Dragons’ Den” style research grant programme where researchers presented their proposals to a panel of experts. We were delighted to award a total of £20,000 between Emma Johns at NHS Glasgow and Clyde for her project on hybrid closed-loop systems to prevent recurrent DKA in high-risk people with diabetes, and Oluwaseun Anyiam at University Hospitals of Derby and Burton for his project exploring whether high- intensity interval training can improve maintenance of T2DM remission. Please take the time to read about Emma and Oluwaseun’s experience of the Diabetes “Dragons’ Den” in our interviews with the successful applicants – https://abcd.care/dragons-den.

I would like to thank all those who applied for grants and to especially thank all those involved in the review of the applications, which was a huge commitment led by Susan Wong and the research committee. Please feel free to apply when the initiative is launched again later this year.

2024 has kicked off with several events. Our extremely popular and well- respected Diabetes Update programme was held in January. This three-day meeting for SpRs provided a fantastic opportunity for networking and learning. Delegate feedback has again been excellent. I am very grateful to all those who contributed their time and expertise in developing this important programme. Later in the year the dates for 2025 will be announced, so please let your trainees know to look out for them.

We have also delivered an event to support those looking to achieve CESR (Certificate of Eligibility for Specialist Registration, now known as the portfolio pathway) in diabetes and endocrinology and two Diabetes Technology Network educators meetings.

We have a packed programme for the rest of the year, including our Consultant Development Programme (CDP) from the 14th to 18th October 2024 in Birmingham and the annual conference for DTN and ABCD on the 4th and 5th September in Bristol. Featuring inspiring sessions, highly relevant presentations, professional education, expert speakers and networking for clinicians working in diabetes and endocrinology, the ABCD and DTN annual conference is not to be missed and we encourage you to register early. Check out our events pages for more information on regional and national ABCD and DTN meetings – https://abcd.care/events.

In addition to our in-person events we are running a quarterly webinar programme. The first was held in February, covering the topic of Diabetes and Ramadan. The next session in June, on the Re:Mission study, explored learning from staff and service user insights from the NHS Low Calorie Diet pilot. You can watch previous webinars on demand and register for upcoming webinars via the ABCD website - https://abcd.care/abcd-webinars.

I am also delighted to announce that we will shortly be supplementing our webinar programme with a new Podcast channel featuring regular interviews with experts in the field discussing the topics that matter to you.

I am thrilled to let you know that The British Journal of Diabetes has been accepted for membership by the Committee of Publishing Ethics (COPE). This is a big step forward in our preparations for PubMed application. Marie-France Kong and Chris Walton have been working very hard behind the scenes to get this done. From this issue onwards, all journal articles will be published under a Creative Commons licence, ensuring we truly operate an open access Journal.

Our education programme continues, and we are delighted to continue to host the Joint British Diabetes Societies for Inpatient Care Group, the Obesity Management Collaborative and the Diabetes Technology Network.

With membership numbers touching 800 we have a strong, vibrant, and active membership and a powerful voice representing diabetes specialists and the patients for whom we care. There is always room for growth, however, and it is important that we are welcoming and inclusive in our membership. I encourage those who have yet to join ABCD to consider signing up at https://abcd.care/join. There are many benefits of membership, including discounted delegate rates for events and access to mentoring, grant programmes and member-exclusive resources.

We are working with international partner organisations from around the world who have expressed an interest in associating and affiliating with us. If you have links with national organisations in different parts of the world who you think might like to talk to us about how ABCD can help them (or equally how they can help us!), then get in touch.

As chair of the ABCD committee I would like to take this opportunity to thank all our corporate sponsors of both ABCD and DTN, without whom none of these programmes and supporting activities would be possible. Sponsors include: A Menarini Farmaceutica Internazionale SRL, Abbott, Air Liquide Healthcare Ltd, AstraZeneca UK, Boehringer Ingelheim and Lilly Alliance, Dexcom, Eli Lilly and Company, Insulet International, Medtronic Limited, Sanofi, and Ypsomed Ltd.

As always, if you think of something that you feel ABCD should be doing, then please let us know. We are your organisation, and we represent and advocate for you.

I look forward to seeing you all at this year’s conference.

KetanDhatariya, ABCD Chair, Norwich.

From the desk of the News Editor, Umesh Dashora

JBDS-IP news (Omar Mustafa)
The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) group published two new guidelines this month. The first is on using technology to support diabetes care in hospital. The guidelines, produced jointly with Diabetes Technology Network UK (DTN-UK), are the first comprehensive document in the UK to address use of diabetes technology in hospital. The guidelines focus on care in hospital for people wearing diabetes technology (pump, glucose sensors and hybrid closed- loops), networked point of care glucose/ ketones meters, electronic prescribing and medicines administration systems and electronic health records. Also included is a set of audit standards.

The second document addresses glycaemic management during enteral feeding for people with diabetes in hospital. This document expands the scope of the previous document that focused on management of blood glucose in people receiving enteral feeding in the context of stroke care, which has been widely used and adapted. The new document provides advice to the diabetes multidisciplinary team and the non-specialist team on how to manage and when to escalate care. A systematic review of the evidence base is currently under way to inform the update and future directions of research in this field. This document is a collaboration between JBDS-IP, Diabetes UK, the Association of British Clinical Diabetologists (ABCD) and the Diabetes Inpatient Specialist Nurse (DISN) UK Group.

Whilst both documents address gaps in care, there are many unanswered research questions that have been included in the documents. These will hopefully drive groups nationally to collaborate and drive improvements and generation of an evidence base.

Rowan Hillson Award (Umesh Dashora)
The Rowan Hillson Award competition is open for submissions. Please submit your entry if you want to highlight any innovation from your team that improves inpatient diabetes care. The project may cover any or all aspects of empowering people with diabetes, demonstrating value for money, encouraging collaboration, scaleability and sustaina- bility. The winning team will be invited to present their innovation at the next ABCD/DTN conference in Bristol (4-5th September, 2024). ABCD will offer free conference registration, complimentary places at the conference dinner, accommodation for one night and travel expenses for two team members from the winning and runner-up teams. The winning entries will also have the chance to publish their work on our website and in our journal. The project is being led by Prof Umesh Dashora. https://abcd.care/announcement/rowan- hillson-inpatient-diabetes-award-2024

News from ABCD audits (Bob Ryder)
At the Diabetes UK annual professional conference at ExCel London, 17-19th April 2024, Dr Tom Crabtree presented data from the ABCD NHS England pilot audit of hybrid closed-loop therapy (HCL), which was launched in 2021. His examination of factors predicting achievement of recommended time in range (TIR) and HbA1c 12 months following HCL in individuals with elevated baseline HbA1c levels showed that only baseline TIR predicted achievement of either 70% TIR or HbA1c at target after 1.3 years of follow-up in the multivariate model. He concluded that all users in the real world benefit equally, irrespective of ethnicity, gender and deprivation status. His oral presentation of these data was joint winner of the Young Diabetologists and Endocrinologists Forum Travel Award. In a separate poster from the same audit, Dr Emma Wilmot demonstrated that significant HbA1c reductions and improvements in sensor glucometrics are seen with HCL therapy. These occur by six months and are sustained out to 1.3 years’ follow-up.

In his poster EndoBarrier treatment for longstanding type 2 diabetes and obesity: outcomes two years after EndoBarrier in 90 consecutively treated patients from the Birmingham Centre of the ABCD EndoBarrier Worldwide Registry, Dr Bob Ryder demonstrated that in patients with refractory diabesity, EndoBarrier resulted in considerable weight loss, improvement in glycaemic control, reduction in a marker of fatty liver (ALT) and reduction in the need for insulin; and that there continued to be significant improvement two years after removal in 80% of patients. DUK issued a press release about the findings, which led to articles in the Daily Mail and in Medscape Diabetes & Endocrinology.

In a poster looking at predictors of response to injectable once-weekly semaglutide in the ABCD Semaglutide Audit, Dr Ben Field demonstrated in this real-world study that baseline HbA1c and weight are predictors of the respective outcomes following initiation of semaglutide. Individuals who are younger may derive more glycaemic benefit from semaglutide, and individuals switching to semaglutide from alternative GLP1RAs had smaller additional HbA1c and weight reductions. https://abcd.care/announcement/abcd-audits-win-prizes-and-found-newsworthy-recent-duk-meeting-london

The ABCD audit programme featured at the 17th International Conference on Advanced Technologies & Treatments for Diabetes (ATTD 2024), which was held on 6-9 March 2024 in Florence, Italy. In an oral presentation, Dr Tom Crabtree presented data showing that in the ABCD NHS England pilot audit of HCL, which was launched in 2021, the improvements in HbA1c and sensor glucometrics were sustained to 12 months’ follow-up. In a poster presentation he showed that mild weight increases are observed six months following HCL, which then plateau, and that the weight gain correlates with increased total daily insulin dose. In another poster presentation he demonstrated that HCL is associated with reductions in diabetes distress and with positive impacts on quality of life.

In an oral presentation, Dr Bob Ryder presented data from the ABCD world- wide EndoBarrier registry suggesting that the considerable benefits of EndoBarrier on weight and HbA1c are achieved in nine months and that a reduction in the recommended implantation period from 12 to nine months would reduce serious adverse events (SAE). More than 60% of liver abscess SAEs would be avoided if the implantation period was reduced to nine months. https://abcd.care/announcement/abcd- audits-recent-attd-meeting-florence

Update on diabetic renal disease (Andrew Frankel)
There is significant concern that over the next 10 years there will be a dramatic increase in the number of people requiring dialysis in the UK, driven predominantly by the growth in number of people with diabetic kidney disease. Because of this, NHS specialist commissioning services in London have invested £10 million over the next two years on a range of projects across the five Integrated Care Systems to pilot potential solutions to reduce the long-term requirement for in-centre haemodialysis.

In North West London (NWL) several programmes are currently being set up which will have an impact on the care of people with diabetes.

1. Working together teams based in Harrow primary care, together with secondary care nephrology, diabetes and cardiac failure services, are establishing a model of care based around a cardiorenal metabolic hub within the This is aimed at ensuring that all people with early cardiorenal metabolic disease (pre- dominantly individuals with diabetes) are managed according to best practice guidelines by clinicians trained in their care, thus reducing progression of their underlying disorder.
2. The NWL nephrology team have developed a range of utilities in conjunction with partners in primary care and people with lived experience to improve the pathway for people with early kidney disease (again, a significant number of these will be individuals with diabetes). This project aims to increase screening of kidney disease, coding of kidney disease and then clinical In Ealing Borough these utilities are being rolled out in conjunction with a communication and educational programme for both staff and people with the underlying condition, and with financial incentivization.
3. NWL has a high incidence of end-stage kidney failure driven by the large number of people in the region with diabetes. Indeed, more than 50% of people on dialysis in West London have diabetes. These individuals are often isolated and do not receive the quality of care that a person with diabetes should expect. A project is being undertaken to improve the care of people with diabetes on dialysis in NWL built around the 2022 Joint British Diabetes Society guidelines. The aim is to ensure that these individuals are both more likely to receive a kidney transplant and, if they are transplanted, to have better diabetes control and therefore better outcomes.

These programmes will run over the next two years and are being fully evaluated by the NHS specialty commissioning service.

Diabetes in the elderly (Giuseppe Maltese)
These are seven key messages from a talk delivered at the recent Diabetes UK conference.

1. Globally, we are witnessing ageing of the population and a rapid increase in the prevalence of diabetes among older individuals
2. In the UK, as of 2020, nearly three- quarters of individuals registered with a practice and diagnosed with T2DM were aged 60 and above. Just over a quarter of those with T1DM were in the same age group
3. The emerging challenge lies in managing diabetes alongside geriatric syndromes (e.g. cognitive impairment, depression and disability), a group of conditions commonly observed in older adults which can significantly impact diabetes self-management and overall quality of life
4. Community diabetes services, employing a multidisciplinary team (MDT) approach, are increasingly responsible for the care of older individuals with diabetes, regardless of their living situation, and should proactively identify frail older individuals and promptly recognize signs of early cognitive impairment and depression
5. Treatment objectives should be tailored to individual patients based on their level of frailty, number of co- morbidities and life expectancy
6. Hypoglycaemia poses a significant threat to frail older individuals but can be mitigated through the integration of technology (e.g. CGM) into diabetes management strategies
7. Diabetes care in care homes remains a neglected area and needs improvement, especially in several specific areas such as diabetes screening, hypoglycaemia treatment, managing diabetes during illnesses, assessing foot risk and educating care home staff.

Diabetic ketoacidosis (Punith Kempegowda)
The increasing incidence of diabetic ketoacidosis (DKA) in the UK underscores the critical need for interventions to enhance care and lower expenses. Local audits often lack the scope for collaboration among hospitals. The DEKODE (Digital Evaluation of Ketosis and Other Diabetes Emergencies) initiative is designed to standardize DKA management practices with no additional costs.

Participating hospitals stand to gain significantly from DEKODE's approach, receiving regular feedback on key performance indicators of DKA care compared to the median of all participating hospitals. This feedback loop aids in pinpointing areas for improvement, ultimately leading to reduced DKA duration and a more consistent standard of patient care.

Moreover, DEKODE presents an opportunity to involve medical students and junior doctors in its model. By engaging them, the initiative not only taps into fresh perspectives but also nurtures their ability to contribute to research, evidence-based guidelines and leadership development. For more information, please visit the DEKODE website.

From the desk of Rebecca Reeve (Sanofi)

QiC
Quality in Care Diabetes (QiC), now in its 14th year, was launched at the 2024 Diabetes UK professional conference. A new category for 2024 might be evaluating whether you have been using data to improve your diabetes service. You might, for example, have used data- led prioritisation to prioritise your diabetes patients so that you can focus your resources on the patients with a reduced clinical risk to create capacity for a Hybrid Closed-Loop Clinic. Check out the categories you could enter here https://qualityincare.org/diabetes/categories/ and submit your entry by 5th July 2024.

The New Hospital Programme
The New Hospital Programme team has faced issues recruiting to internal roles and recently had a 50 per cent vacancy rate, the government has admitted. Around two-thirds of its workforce were outsourced at the end of last year, according to a letter sent to MPs. This was a similar workforce split to the previous year. Department of Health and Social Care official Shona Dunn said the programme planned to spend more than £800m on “external specialist expertise” in the seven years until 2030- 2031. She said this would be around 4% of total expenditure. The team is responsible for building 40 “new hospitals” by the end of the decade, as well as a promised rolling programme of capital investment beyond this date.

Five hospitals constructed using mostly reinforced autoclaved aerated concrete (RAAC) will be rebuilt by 2030 as part of the New Hospital Programme, a measure expected to be backed by over £20 billion of investment in hospital infrastructure. The five hospitals are Airedale in West Yorkshire, Queen Elizabeth King’s Lynn in Norfolk, Hinchingbrooke in Cambridgeshire, Mid Cheshire Leighton in Cheshire, and Frimley Park in Surrey. This is in addition to two of the worst affected hospitals - West Suffolk Hospital in Bury St Edmunds and James Paget Hospital in Norfolk. The NHS has asked the government to prioritise the rebuilding of these hospitals given the risks they pose to patients and staff: the full extent has come to light since the New Hospital Programme was first announced in 2020. New Hospital Programme – media fact sheet – Department of Health and Social Care Media Centre (blog.gov.uk)

The IRP
Launched in January 2024, the International Recognition Procedure (IRP) aims to help bring life-saving new medicines to UK patients without delay. The IRP allows the Medicines and Healthcare products Regulatory Authority (MHRA) to accelerate the assessment of new medicines by considering the expertise and decision- making of trusted regulatory partners in the authorisation process. As a result, medicines that have been approved in other countries with stringent regulators will reach UK patients without delay, resulting in a more rapid, efficient and cost-effective process. The first product through this process (a formulation of denosumab, a treatment used in adults to prevent serious bone-related complications caused by bone metastases and to treat giant cell tumours of bone in adults and adolescents) was authorised in 30 days, providing UK patients with earlier access to this treatment thanks to international recognition. IRP is open to applicants that have already received an authorisation for the same product from one of MHRA’s specified trusted regulators. These are the regulatory authorities from Australia, Canada, the EU, Japan, Switzerland, Singapore and the US. As a sovereign regulator, the MHRA retains ultimate authority to accept or reject applications submitted under the IRP, ensuring that all products meet safety, quality and effectiveness standards to be licensed in the UK. MHRA grants first approval via the new International Recognition Procedure in 30 days - GOV.UK (www.gov.uk)

Genetic links between diabetes and cancers
The study by the University of Surrey examined the DNA of 36,000 people to see whether genetics could help to explain why some people with T2DM also develop cancer. The research focused on the three cancer types that people with T2DM are at higher risk of developing – post-menopausal breast cancer, colorectal (bowel) cancer and pancreatic cancer. For the first time, two specific genetic variants were pinpointed as key contributors to people developing both T2DM and some cancers. One variant was linked to the risk of developing both breast cancer and T2DM. The other affected T2DM and breast, colorectal and pancreatic cancer risk. A further 17 variants which increase the risk of developing T2DM and change the body in ways which increase the risk of cancer – such as through higher blood sugar and insulin levels, inflammation and hormonal changes – were also identified. The findings of the study, led by Prof Inga Prokopenko, were presented at the Diabetes UK Professional Conference in London.

UK medication shortages
Pharmacists have issued an updated warning over the UK medication shortage as a greater number of drugs become less accessible to patients. A poll of 1,562 UK pharmacists for the Pharmaceutical Journal found that more than half (54%) believed patients have been put at risk in the last six months due to shortages. Unpublished figures reveal that the number of products in short supply has doubled in the past two years. The plummeting value of the pound since the Brexit referendum and government policies such as taxing manufacturers have exacerbated the crisis. Additionally, disruptions in global supply chains due to the war in Ukraine have further impacted medicine availability in the UK and other European countries. Patients’ well-being is at stake, and urgent measures are needed to address this critical issue. The situation affects a wide range of treatments, from controlling epileptic seizures to managing conditions like cancer, schizophrenia and T2DM. Special report: the UK’s medicines shortage crisis The Pharmaceutical Journal (https://pharmaceutical-journal.com/article/feature/special-report-the-uks-medicines-shortage-crisis)

Interesting recent research

Umesh Dashora

A rapid-fire collection (extract) of interesting recent developments in diabetes