From the desk of the Chairman, Dinesh Nagi

I attended the All-Party Parliamentary Group (APPG) meeting at the Houses of Parliament on 31 October, which was to raise the awareness and profile of diabetes among the parliamentarians, an event organised and sponsored by Novo Nordisk, one of our corporate sponsors. It was an interesting meeting and attended by 25 MPs who were also provided with health checks as well as relevant information on their localities in terms of their performance in delivering the eight healthcare checks for diabetes. I was able to interact with many of the MPs and found their enthusiasm very infectious. We hope that the MPs will go to their constituencies and take an active role in local discussions as to how care processes in their localities can be improved.

The first round table meeting of diabetes technologies took place on 1 November and was attended by experts who are enthusiastic to improve access to technologies and how we can break the barriers which have created a post code lottery system. This was jointly organised by medical management and ABCD, with the hope that output from the meeting and further work can influence the decision makers as to how NHS monies can be spent to help access to technologies in diabetes. We were fortunate to have Sir Muir Gray, who requires no introduction, and talked about Triple Value Healthcare, which may be the way forward in the NHS. While we continue to focus on FreeStyle Libre, continuous glucose monitoring and insulin pumps, we must not forget that there are simple technologies which cost far less but can have a significant impact on patient care – for example, the use of Apps to increase engagement and improvement in self-care.

The autumn meeting of ABCD took place at BMA House on 8/9 November with an extended one and a half day programme. The programme was of excellent quality throughout, but I particularly enjoyed the excellent “Niru Goenka Memorial Lecture” by Dr Emma Wilmot, our current DTN chair, focusing on the first insulin pump audit in 2012 and exploring the issues related to managing a large insulin pump service. I was particularly impressed by a very practical talk by Dr Shivani Mishra from Imperial College London exploring the utility of antibody measurement in the classification of diabetes entitled “So what's the diagnosis? How can genetic and immunology tests help?”.

November has been a busy month, and a week after the ABCD meeting I was invited to attend the Industry Awards during the 5th Diabetes Professional Care (DPC) meeting at Olympia in London. Such meetings, which offer free entry for healthcare professionals in diabetes, have grown over the last five years and this meeting attracted a huge number of delegates, mostly from primary care, and provided a plethora of talks and educational opportunities for those delivering diabetes care in the community. I was lucky to meet Maggie Meer, the founder of these meetings, who exudes enthusiasm and is passionate about improving outcomes for people with diabetes. ABCD is exploring with the DPC organisers as to how the two organisations can work together to improve the content and quality of these meetings. The meeting next year is set for 29/30 October and I am keen that ABCD is represented at this important event.

Having worked on the new website for the ABCD which went live in October, we are currently in the planning phase of getting a fortnightly news to members about topical issues related to diabetes to keep you all updated in a timely manner. Currently we are working on our Charity DCT (Diabetes Care Trust) website which will be launched shortly. The new website will have facilities for anybody to make online donations to the charity.

I am delighted that, finally, common sense has prevailed and the Government has announced that FreeStyle Libre will be available to all localities form April 2019 and, although details are yet to be sorted out, we hope that it will end the post code lottery I talked about earlier.

Please come and join us at the regional ABCD meeting at York racecourse on 6 February 2019, which is a free event and intended for all members of the multidisciplinary team delivering diabetes care. The ABCD-Renal Association meeting is in Birmingham on 13 February 2019. These meetings offer excellent value for money in terms of CPD. I cannot wait for the next DTN-ABCD meeting at the Enterprise Park in Loughborough on 15/16 May 2019.

ABCD executives are currently engaged in an options appraisal to see how we can improve the programme and the attendance at both our meetings which are held in Spring and Autumn each year. I will be very keen to hear any suggestions or ideas in that regard. Please do write to me or email me at

This year has been an interesting year for me as Chair of the ABCD. We approach the end of 2018 with calls for a new General Secretary to replace Dr Russell Drummond and my sincere thanks to him for his support for the ABCD. My job is made much more enjoyable with support from the executive team, trustees of the DCT, our secretariat team at Red Hot Irons and my senior colleagues for their wise counsel.

It is my pleasure to wish you all a very happy Christmas and a very successful start to 2019.

Good bye for now.


From the desk of Umesh Dashora

Rowan Hillson Inpatients Safety Award 2018

The Rowan Hillson Award 2018 will be for the best diabetes education initiative in the UK. The judges will be Rowan Hillson, Ann Kilvert, Clare Crawley, Emma Green and Sarah Gregory. Please look out for the announcement and enter the competition with your educational initiative, with evidence of its positive impact on the lives of people with diabetes. Please contact for details if needed.

News from ABCD audits (by Bob Ryder)

Two posters from the ABCD nationwide audit programme were presented at the EASD in Berlin between 2 and 5 October 2018. Dr Amar Puttanna presented data from the canagliflozin audit looking at the impact of canagliflozin on the first return to clinic after its commencement and then second return. A notable finding was that HbA1c, weight, alanine aminotransferase and systolic blood pressure all continued to fall by significant amounts between the first and second return to clinic, such that by the time of the second return to clinic the mean HbA1c had fallen from 76.3 to 65.3 mmol/mol and it was noteworthy that, by the time of the second return to clinic at 55 weeks, the weight had fallen by a mean of 4 kg from 101 to 97 kg. The poster can be viewed at!resources/2-year-metabolic-outcomes-in-the-abcd-nationwide-canagliflozin-audit

Dr Chris Walton presented data from the liraglutide audit, using the UKPDS risk engine to assess cardiovascular risk in patients receiving liraglutide in routine clinical practice. Whilst we know from the LEADER study that, in patients with high cardiovascular risk there is an impact on vascular outcomes, this was an attempt to gain insight into the potential benefit on ordinary patients in the clinic. The findings were that, between three and nine months after starting liraglutide, there were highly significant falls in all parameters involved in cardiovascular disease risk assessment other than HDL cholesterol which was unchanged. Overall, the data suggested that the use of liraglutide in 100 patients could prevent three events of coronary heart disease or stroke and save two or more lives over the next 10 years. The poster can be viewed at!resources/early-impact-of-liraglutide-in-routine-clinical-use-abcd-nationwide-liraglutide-audit-on-cardiovascular-risk-ukpds-risk-engine and there is also an interview with Dr Walton at the EASD which can be viewed at

Endobarrier results (by Chris Walton)

In the wake of the two studies with EndoBarrier sponsored by ABCD (, Dr Bob Ryder established an NHS service to offer EndoBarrier treatment in 2014 and 62 EndoBarriers were implanted as part of this. At the EASD in Berlin (2–5 October 2018), Dr Ryder presented data on the first 46 patients who received EndoBarrier treatment up to removal. These were patients with long-standing diabetes (duration 13.7 years) and morbid obesity (BMI 41.9) and poor glycaemic control (HbA1c 84.3 mmol/mol); 59% were taking insulin. Following EndoBarrier treatment, weight fell by 15.7 kg and HbA1c fell to 58 mmol/mol. There were significant falls in systolic blood pressure and cholesterol and in the poster the data was fed into the UKPDS risk engine to assess the potential impact on cardiovascular risk of these metabolic improvements. According to the UKPDS risk engine there was a significant fall in the risk of coronary heart disease, fatal coronary heart disease, stroke and fatal stroke such that, according to this assessment, between 8 and 9 patients out of 100 will not have a coronary heart disease or stroke event during the next 10 years. It was concluded that between 6 and 7 lives will be saved with EndoBarrier treatment. The poster can be seen at!resources/impact-of-proximal-intestinal-exclusion-with-endobarrier-on-key-metabolic-parameters-and-cardiovascular-risk-ukpds-risk-engine-in-the-first-nhs-uk-endobarrier-service. Dr Ryder was also interviewed at the EASD and this can be viewed at The latest information on EndoBarrier worldwide is that the company who make it, GI Dynamics in Boston, USA, have appointed a body to administrate the regaining of its CE mark (see and they have also set up a new trial with the FDA to assess its safety and efficacy in the USA (see

NICE impact report on diabetes (by Dinesh Nagi)

NICE has published a new impact report on diabetes ( This explores how NICE guidance has been implemented by the healthcare system and what progress has been made to improve outcomes for those with diabetes or at risk of developing diabetes.

This is the fifth in a series of impact reports which review how NICE recommendations have been used in priority areas of the healthcare system. The impact reports are based on data from national audits, reports, survey and indicator frameworks that show the uptake of the NICE guidance and quality statement measures.

NICE guidance on Neuropad (by Dinesh Nagi)

The final NICE medical technologies guidance on Neuropad for detecting preclinical diabetic peripheral neuropathy has been published. You can find the guidance on the NICE website at


From the desk of Rebecca Reeve

DHSC to publish a clear set of IT and digital standards

The Department for Health and Social Care (DHSC) has published a new strategy, illustrating its vision for the use of digital, data and technology in health and care. The strategy highlights four key priorities for action: Infrastructure, Digital Services, Innovation and Skills and Culture. In particular, the strategy sets out a plan to establish national open standards for data, interoperability, privacy and confidentiality, real-time data access, cyber security and access rules – set out through NHS Digital’s new standards framework. The strategy also formalises DHSC’s duty to deliver the artificial intelligence (AI) and Data Grand Challenge mission to use data, AI and innovation to transform the prevention, early diagnosis and treatment of disease.

DIT publishes guidance on the UK research infrastructure

The Department for International Trade (DIT) and its executive agency, UK Life Sciences Organisation (LSO), have published a series of short guidance notes illustrating the benefits of the UK research infrastructure to attract inward investment. The series includes guidance on developing treatments for diabetes, which highlighted that in 2015–16 there were 560 active NHS clinical trials covering both type 1 and type 2 diabetes, with 27,534 UK participants recruited.

Diabetes UK publishes new recommendations for improving inpatient diabetes care

Following the publication of the National Diabetes Inpatient Audit, Diabetes UK has proposed new recommendations to improve inpatient care for people with diabetes. Currently, one in six hospital beds is occupied by someone with diabetes, and by 2030 it is predicted that this will rise to one in four. Inpatient care for diabetes also costs the NHS £2.5 billion, 11% of the total cost of inpatient care. A key recommendation from the report included ensuring that there are multidisciplinary diabetes inpatient teams in all hospitals. Diabetes UK estimated that an investment of £5 million on new diabetes inpatient specialist nursing services in 54 trusts would yield approximately £14 million savings per year, resulting in net savings of £9 million. Further recommendations included improving the knowledge of other healthcare professionals in diabetes, better support in hospital for people to take care of their own diabetes, enhancing access to systems and technology and more support for hospitals to learn from mistakes.

Public Health England unveils priorities for prevention in the NHS Long-Term Plan

Chief Executive of Public Health England (PHE), Duncan Selbie, unveiled his three priorities for improving prevention in the NHS Long-Term Plan: smoking, cardiovascular disease (CVD) and obesity. In particular, he said that around 250–500 lives each year across England could be saved by prioritising the identification of people at risk of developing CVD – calling for continued uptake and a follow-up to the NHS Health Check. On obesity, he claimed that there should be a renewed commitment and expansion of the NHS Diabetes Prevention Programme (NDDP), with type 2 diabetes costing the NHS £8.8 billion every year. PHE also called for more adults to take the free online Heart Age Test to improve self-awareness and detection of cardiac risk. According to initial results from the test, 78% of people had a heart age over 5 years and 14% at least 10 years over their actual age.

British Heart Foundation warns of cardiovascular risk for a grow-ing population with diabetes

The British Health Foundation (BHF) has published a new forecast highlighting that the growing number of people with diabetes could result in nearly 39,000 people living with diabetes suffering a heart attack in 2035, a rise of 9,000 compared with 2015. In addition, over 50,000 people with diabetes will also suffer a stroke in 2035 – a rise of 11,000. BHF expects the number of people with diabetes in England to rise by over 1 million over the next 20 years, estimating that the yearly cost of treating people with diabetes will be £16.9 billion by 2035, up from £9.8 billion in 2012.

Survey on the management of 16–18-year-olds with diabetic ketoacidosis

Dr Ketan Dhatariya and Andy Raffles are leading on collecting information on the care of 16–18-year-old young people with diabetic ketoacidosis. The questionnaire can be found by clicking on


Interesting recent research

(Umesh Dashora)

A rapid-fire collection of interesting recent developments in diabetes

Authors, Journal Type of study Main results
Cheng et al, Diabetes Care National Health Interview Survey Reduction in cardiovascular mortality in people with diabetes
Over a period of 11.8 years up to 2015 there was a significant reduction in major CVD death in adults with and without diabetes. 10-year relative improvement in mortality was significant for major CVD (−32.7%), IHD (−40%) and stroke (−29.2%) but not heart failure and arrhythmia. People with diabetes showed more reduction than people without diabetes. Men with diabetes had larger decreases in CVD deaths than women with diabetes.
Feig et al, Diabetes Care Pre-specified analysis of CONCEPT T trial MDI users have better outcome than pump users in type 1 diabetes with pregnancy
Pump and MDI users had comparable first trimester HbA1c and CGM time in target. At 34 weeks, MDI users had a greater decrease in HbA1c. At 24 and 34 weeks, MDI users were more likely to achieve target HbA1c. Pump users had higher frequency of hypertension (14.4% vs. 5.2%) and neonatal hypoglycaemia (31.2% vs. 19.1%).
Brown et al, Diabetes Care Pilot study New insulin delivery system
This new type of closed loop insulin pump with Control-IQ technology consists of a Dexcom G6 sensor and a closed-loop algorithm that automates insulin correction boluses, has a dedicated hypoglycaemia safety system and gradually intensifies control overnight aiming for morning blood glucose levels of approximately 5–6.2 mmol/L. The pilot study results are encouraging.
Davies et al, Diabetes Care ADA/EASD position statement on the management of type 2 diabetes Consensus statement on the management of type 2 diabetes
The recommendations include additional focus on life style management and self-management education and support. For overweight people, recommendations include specific focus on weight loss including lifestyle, medications and surgical intervention. For patients with cardiovascular disease, an SGLT-2 inhibitor or a GLP-1 receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic disease, an SGLT-2 inhibitor with proven benefits is recommended.
Rosenstock et al, Diabetes Care Placebo-controlled RCT Empagliflozin as an adjunct to insulin in type 1 diabetes
Placebo subtracted HbA1c reduction was −0.28%, −0.54% and −0.53%, weight loss was −1.8, −3.0 and −3.4 kg and insulin dose reduction was −6.4%, −13.3% and −12.7% in the empagliflozin 2.5 mg, 10 mg and 25 mg groups, respectively. Adjudicated diabetic ketoacidosis occurred more frequently with empagliflozin 10 mg (4.3%) and 25 mg (3.3%) but not with 2.5 mg compared with placebo.
Rosenstock et al, Diabetes Care RCT Insulin glargine 300 U/mL vs. degludec 100 U/mL – head to head study
The RCT showed similar improvement in HbA1c (1.6%) but hypoglycaemia rate was lower with IGlar U300 in the titration period but similar over 24 weeks.
Klubo-Gwiezdzinska et al, Diabetes Care Prospective cohort study Immunosuppressive therapy induces remission of severe insulin resistance
Twenty-two patients with confirmed insulin receptor antibodies and mean insulin requirement of 1775 units daily were treated with rituximab, high-dose pulsed steroids and cyclophosphamide until remission. After 5 months, 86.4% of patients achieved remission, documented by discontinuation of insulin in all patients, normal fasting glucose and HbA1c of 5.5%. During follow-up of 72 months, 13.6% of patients developed recurrence.
Pitchika et al, Diabetologia Prospective cohort study Association of maternal type 1 diabetes and obesity in the offspring
Children of mothers with type 1 diabetes were at increased risk of being overweight (OR 2.40) than the offspring of non-diabetic mothers. Waist circumference, fasting glucose, insulin, C-peptide, insulin resistance and abdominal obesity were all significantly increased in the offspring of mothers with type 1 diabetes, even after adjustments for potential confounders like birth weight
Ohkuma et al, Diabetologia Systematic review and meta-analysis of 121 cohorts Association of diabetes and cancer
The pooled adjusted RR for all-site cancer associated with diabetes was 1.27 in women and 1.19 in men. Women had 6% higher risk particularly for oral, stomach, kidney cancer and leukaemia but a lower RR for liver cancer.
Zong et al, Diabetologia Large-scale analysis of three long running cohorts Gluten intake is inversely associated with the risk of type 2 diabetes
Gluten intake of 12 g a day is inversely associated with the risk of type 2 diabetes. The association was slightly reduced after adjustment for cereal fibre and increased with added intake of bran.
Hayashino et al, Diabetologia Cohort study Diabetes distress is associated with higher mortality is Japanese men
The hazard ratio for mortality can go as high as 1.6 with diabetes distress in men but not in women.
Chen et al, Diabetes Care Systemic review and meta-analysis Poor health literacy might increase the risk of foot ulcers in diabetes
People with inadequate health literacy have double the odds of having diabetic foot disease compared to people with adequate health literacy, but this was not statistically significant. Odds of having diabetic neuropathy were not different in the two groups. Specific studies are needed.
Xu et al, Diabetes Care Retrospective cohort study BMI and mortality in Chinese people with diabetes
Over an average of 6-year follow-up, an L-shaped association was observed between BMI and all-cause mortality in men while a U-shaped association was observed in women with type 2 diabetes. In men, no significant association was observed for BMI and cancer-specific and CVD-specific mortality whereas in women an increased risk of cancer-specific mortality was observed with increasing BMI. In women, increased CVD-specific mortality was associated with decreasing BMI.
Isaken et al, Diabetes Care Case-control study Abnormalities of cardiac repolarisation and depolarisation in type 1 diabetes
Young people with type 1 diabetes had high QTc (by a mean of 13.8 ms at age 20 and 3.4 ms at age 40) compared with control. The rate-corrected QRS was increased in people with type 1 diabetes. Some of these repolarisation abnormalities might explain incidents of dead-in-bed syndrome.
Cusi et al, Diabetes Care Post-hoc analysis of AWARD programme Dulaglutide reduced ALT and γGT in people with type 2 diabetes
Dulaglutide once weekly reduced ALT, AST and liver fat in patients with type 2 diabetes. More pronounced reduction was noted in patients with NASH.
Viljoen et al, Diabetes Obesity and Metabolism Analysis of head-to-head SUSTAIN 7 trial Cost-effectiveness of once weekly semaglutide vs. dulaglutide in patients with type 2 diabetes
Semaglutide 0.5 mg and 1 mg was associated with improvement in quality-adjusted life expectancy of 0.04 and 0.10 years respectively compared to dulaglutide 1.5 mg. Clinical benefits were achieved at reduced cost with life time cost savings of GBP 35 with once weekly semaglutide 0.5 mg dose and 106 with the once-weekly semaglutide 1 mg, resulting from fewer diabetes- related complications due to better glycaemic control.
Brandon et al, Cell Metabolism Animal studies An enzyme from fat tissue might be responsible for the development of diabetes. Protein kinase C epsilon in fatty tissue all over the body might be responsible for inducing insulin resistance that leads to type 2 diabetes. Deletion of this gene in animal models prevents diabetes. This enzyme could be a novel therapeutic target for new drugs.
Udler et al, PLOS Medicine Soft clustering analysis Five types of diabetes
The authors show that it is possible to differentiate five different types of diabetes with genetic clustering and typical phenotype. Two groups show features of insulin deficiency (differentiated by high or low pro-insulin levels) whereas three are associated with insulin resistance (differentiated by obesity, lipodystrophy or disrupted liver lipids).
Kyro et al, Journal of Nutrition Cohort study Whole grain intake is associated with a reduced risk of developing diabetes
Intake of whole grain was associated with 11% and 7% lower risk of developing type 2 diabetes per whole grain serving of 16 g for men and women, respectively. For men, wheat, rye and oats were found to be beneficial but, for women, only wheat and oat showed significant results.
Marnix et al, Diabetes Care Population-based cohort study Prediabetes is associated with structural brain abnormalities
Both prediabetes and type 2 diabetes was associated with the presence of lacunar infarcts, larger white matter intensities and smaller white matter volumes. Early control of dysglycaemia might help prevent brain abnormalities.


YDEF NEWS Young Diabetologists logo

Diabetes and endocrinology is an incredible speciality in which to train and practise. Few specialties offer such a direct link between basic science and clinical therapies that can make such a meaningful difference to patients’ lives. This is a fast-paced, research- active speciality, with an increasing number of therapeutic options available. We work across diverse multidisciplinary teams. We build long-term relationships with the patients we support, we promote shared decision-making and shared learning.

Despite such opportunities, recruitment into the speciality is under threat. In the 2018 Round 1 recruitment, just 39% of the 100 National Training Numbers (NTN) available were filled. There has been a steady decline in the percentage of posts filled with a 70% fill rate in 2017, 73% fill rate in 2016 and 86% fill rate in 2015. There has been variation in the available post numbers (range 74–100), but much of this reflects underlying vacancy rates. A full breakdown of the data is available at

The forthcoming introduction of the Internal Medicine programme adds further uncertainty to speciality recruitment. With potentially fewer years in speciality training, there may be less opportunity to gain exposure to some of the specialist clinics, which are often an attractor to many.

The Young Diabetologist & Endocrinologist Forum (YDEF) is the trainee and young consultants’ wing of Diabetes UK and is supported by the Association of British Clinical Diabetologists (ABCD) and Society for Endo-crinology (SfE). We serve three core functions for our members – education, advocacy and support. We are therefore passionate advocates for recruitment into the speciality, yet equally anxious regarding the recruitment trends we have seen. Frequently, discussions on speciality recruitment focus around ‘mitigating’ the consequences of the medical registrar role, which by some is seen as onerous. Indeed, as trainees or consultants, we may all reflect that after a busy night shift or post take ward round, our positive energy may be limited with a tendency – dare I say – to moan! The impact of this should not be underestimated to both medical students and junior doctors considering their future career choices.

To improve recruitment into our wonderful speciality, we need to share our passion and excitement in our daily practice. There are undoubtedly pressures on overstretched services, but we have the privilege of using our skills to make a real difference to patients’ lives. For YDEF to achieve this, we have rekindled the speciality taster days, with two successful national events already held and a third planned in Northern England. We have free places available for trainees to attend the Diabetes UK Professional Conference and an exciting pre- conference YDEF Day. Our committee members are actively researching drivers to recruitment and retention into the speciality, both looking at variations in training1 and the work-related well-being of trainees.

At the recent SfE BES Conference, Dr Helen Simpson (@hormone_doc) organised a conference fringe meeting to consider the challenges of recruitment and retention, which attracted a passionate and motivated range of trainees and consultants. It was evident that both SfE and YDEF members are jointly committed, and the overall feeling from the meeting was one of excitement, with attendees highlighting the importance of sharing the love of our speciality, be that through journal clubs, society meetings or policy advocacy.

In summary, it may well be a challenging time for recruitment into our speciality, but this only provides more reason to get out and share our passions with medical students and trainees. Ours is a wonderful speciality, and now is an exciting time where, as individuals supported by YDEF, SfE and ABCD, we can work together to change the tune!


1.    Agha A, Singh B, Hanif W. The balancing act: the variation among deaneries across Great Britain regarding provision of focus on diabetes and endocrinology training. British Journal of Diabetes 2018;18(1): p. 22-24.


YDEF Annual Day

5th March, 2019 Liverpool

YDEF Annual Day brings over a hundred specialist registrars and young consultants from across the UK on the eve of Diabetes UK Annual Processional Conference to attend an excellent, free day of lectures and workshops

Dr Tim Robbins
A speciality trainee in the West Midlands Region, a member of the YDEF Committee and trainee representative to the Health Education West Midlands Specialist Training Committee. He is organising the next YDEF Training Day in Northern England.

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 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! @youngdiab on twitter



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