British Journal of Diabetes

New approaches to weight loss and glycaemic control in T2DM, focusing on tirzepatide and newer agents

Kusuma Boregowda — 2024-06-29

Diabesity and microvascular disease: the impact of weight loss

Siraj Farid — 2024-06-29

There is increasing evidence that obesity is an independent risk factor for the development of microvascular disease. Addressing modifiable risk factors such as obesity may help prevent and even reverse microvascular complications, including neuropathy, nephropathy and retinopathy.

In this review article, we examine the evidence for the impact of obesity on microvascular disease, as well as the effects of weight loss in individuals with and without type 2 diabetes mellitus (T2DM). Numerous studies have shown obesity to be an independent risk factor for neuropathy and nephropathy in patients with and without T2DM but the association between obesity and retinopathy is less clear. Addressing obesity through weight loss strategies can have beneficial outcomes. Although evidence for medical weight management is limited due to the lack of longitudinal data, there is growing recognition of the positive impact of surgical weight management. Recent studies have shown bariatric surgery to be protective against diabetic neuropathy despite previous concerns from older studies. Similarly, several studies have demonstrated improvements in renal measures after bariatric surgery. Improvements in retinopathy, however, have been less encouraging, with further research required to fully understand the impact of obesity. Overall, managing obesity and implementing weight loss through bariatric surgery has positive outcomes for reducing the burden of microvascular disease.

A critique of semaglutide (Wegovy®) for obesity management NICE technology appraisal TA875

Hassan Kahal — 2024-06-29

Wegovy^®, semaglutide 2.4 mg, is a glucagon-like peptide-1 analogue that has been approved by the National Institute for Health and Care Excellence (NICE) for the treatment of adults with obesity in the National Health Service (NHS). In this review, we provide a reflection on NICE TA875 and its implementation in the NHS.

Advances in detection, prevention and treatment of heart failure in type 2 diabetes: part I

Alice Cowley — 2024-06-29

Management of heart failure (HF) in diabetes has previously centred on aggressive control of cardiovascular risk factors. The benefits of this approach are modest. In the past decade, however, there have been numerous advances in our understanding of HF prevention, detection and treatment which are particularly relevant to people with type 2 diabetes. This review is the first of two that summarise these advances, with Part I focusing on HF prevention and detection.

Advances in detection, prevention and treatment of heart failure in type 2 diabetes: part II

Alice Cowley — 2024-06-29

This review is the second of two that aim to cover the advances in heart failure (HF) prevention, detection and treatment relevant to people with type 2 diabetes (T2DM). Part I focuses on HF classification and prevention, specifically lifestyle changes and primary preventative techniques including smoking cessation, physical activity, weight loss, lipid and glucose control. This concluded: 1) intensive blood glucose control is not in itself a necessary or sufficient treatment target for HF prevention, and a multifaceted preventative approach is likely to have a greater effect; 2) the most compelling evidence for HF risk reduction is for sodium glucose co- transporter 2 inhibitors although glucagon-like peptide 1 receptor agonists may also have a role; and 3) patients likely to derive most benefit are those at highest risk of developing overt HF, which probably represent the majority of people with T2DM. Part II of this review will cover early detection of cardiac dysfunction and treatment of established heart failure. Particular emphasis is placed on heart failure with preserved ejection fraction.

Update on recent advances in technology in type 1 diabetes

Aisha Aslam — 2024-06-29

Those living with type 1 diabetes (T1DM) require daily adjustments of exogenous insulin doses and frequent glucose monitoring to optimally manage their condition. Consequently, it is one of the most challenging long-term conditions to live with. Recent years have seen major progress in the management of T1DM, with minimally invasive glucose monitoring technology and glucose-responsive insulin delivery systems, also called hybrid closed-loop systems. This narrative review focuses on three key areas: continuous glucose monitoring (CGM), hybrid closed-loop (HCL) systems, and connected pen devices, sometimes known as smart pens. We describe features of commonly used devices in the UK NHS and summarise their key evidence base. Randomised controlled trials and real-world studies of CGM devices have shown improved haemoglobin A1c (HbA1c) levels, improved sensor-based metrics such as higher time spent in the target glucose range, and reduced rates of hypoglycemia. HCL studies have similarly shown improved HbA1c and other sensor- based glucose outcomes. Further recent innovations for insulin users include connected insulin pens, which allow the display and recording of insulin delivery information. In addition to glycaemic benefits, novel diabetes technology has been shown to improve quality of life and to give higher treatment satisfaction. Some disadvantages of technology include alarm burden, connectivity problems and premature device failure. To get the best from novel diabetes technology, appropriate training and education are required, specifically in identifying and dealing with critical system failures such as cannula failure and the risk of ketoacidosis. Recent recommendations from the National Institute of Health and Care Excellence (NICE) regarding HCL further underscore the growing significance of these advances in diabetes care.

Hepatic abscess secondary to a duodenal- jejunal bypass liner successfully treated with antibiotics without removal of the device

Bob Ryder — 2024-06-29

Mental capacity, declining insulin injections and multidisciplinary team working

Hannah Ellis — 2024-06-30

Co-existence of type 1 diabetes and monogenic diabetes in one family: getting the diagnosis right

Jolyon Dales — 2024-06-30

Abstracts from ABCD Diabetes Update

ABCD Diabetes Update 2024 — 2024-06-30

Is lasting remission feasible in the real-world setting? Yes!

Roy Taylor — 2024-06-29

Is lasting remission feasible in the real-world setting? No!

Kamlesh Khunti — 2024-06-29

Putting EMPA-REG into practice: a data-driven intervention

Ysaline Duvieusart — 2024-06-29

This project aimed to establish community sodium-glucose co- transporter-2 inhibitor (SGLT2i) prescription rates in people with diabetes (PWD) who meet the EMPA-REG trial criteria. We established eligibility of PWD in two GP practices through primary care electronic record searches and a review of their medical notes. A total of 81 PWD were eligible for the EMPA- REG trial (8.2% of PWD); 46 were not prescribed an SGLT2i (56.8%). These individuals were contacted in a standardised way to discuss medication changes or offered a full diabetic review. The prescription rates obtained from review of medical notes were compared to the GP practice’s national therapeutic indicator (NTI) for drugs indicative of cardiovascular disease and an SGLT2i or glucagon-like peptide 1 agonist. SGLT2i prescription rates obtained from this project are similar to NTIs, validating our data extrapolation. If PWD eligible for an SGLT2i, as per EMPA-REG criteria, but not currently prescribed one were commenced on treatment, we calculated that 74 (85.1 – 53.9) all-cause deaths could be prevented over 3.1 years in the Greater Glasgow and Clyde health board.

The rates of SGLT2i prescription in the community are suboptimal. Data-driven targeted reviews of at-risk PWD are a simple, time-efficient way to increase SGLT2i prescription rates, preventing some deaths with minimal additional workload.

Exploratory outcomes of the use of insulin degludec in the real world: data from the Association of British Clinical Diabetologists nationwide degludec audit

Santo Colosimo — 2024-06-29

Insulin degludec is a long-acting basal insulin analog that is used as a single daily injection in people living with type 2 diabetes (T2DM) or in combination with rapid-acting analogs in basal-bolus regimens in people living with T2DM or type 1 diabetes (T1DM). Registration studies showed benefits of reduction of hypoglycaemia rate and severity compared to previously available long-acting insulins.

The Association of British Clinical Diabetologists nationwide clinical audit of insulin degludec is a real-world data program which includes a secondary care prospective data collection and a primary care retrospective data collection. Data were used to investigate the effects of degludec initiation in people living with T1DM or T2DM on hypoglycaemia rate and severity, change in haemoglobin A1c (HbA_1c) and weight change.

From the secondary care prospective and the primary care retrospective data 432 (of whom T1DM=273) and 3,513 (of whom T1DM=2,040) patients, respectively, were included in the analysis. HbA_1c change was non-significant in people with T1DM and T2DM who were switched to insulin degludec due to hypoglycaemia in the secondary care cohort. A significant reduction of 3 and 10 mmol/mol was observed in people with T1DM and T2DM, respectively, when the switch to degludec was prompted by reasons other than hypoglycaemia, and in people with T1DM this was also associated with a 2.5 kg weight gain. There was a clinically significant reduction in minor, severe and nocturnal hypoglycaemia in 62%, 45% and 54% of T1DM and in minor hypoglycaemia in 44% of T2DM in the prospective cohort.

Insulin degludec reduced HbA_1c in people with diabetes who were started for non-hypoglycaemia reasons and in people in the retrospective cohort. The extent of reduction in HbA_1c was similar in both cohorts, even after stratification for T1DM and T2DM. Overall, insulin degludec resulted in lower HbA_1c and modest weight gain in people starting for non- hypoglycaemia reasons and lower hypoglycaemia without any change in HbA_1c or weight in people switching due to hypoglycaemia.

Real-world cross-comparison of metabolic outcomes with different sodium-glucose co-transporter 2 inhibitors agents in adults with type 2 diabetes: results from the Association of British Clinical Diabetologists audit programme

Tom Crabtree — 2024-06-29

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) have demonstrated significant efficacy in improving cardiorenal and metabolic outcomes, However, whether there are differences between agents remain unclear. We therefore assessed changes in haemoglobin A1c (HbA_1c), weight, body mass index (BMI) and systolic blood pressure (SBP) across the class; and between agents.

Methods: Individuals using empagliflozin (E), canagliflozin (C) or dapagliflozin (D) in the ABCD audits were included provided that data were available for the outcomes of interest. Multivariate linear regression analysis was used to assess adjusted change in HbA_1c, weight, BMI and SBP and to compare outcomes between drugs. Analyses were performed in Stata 17.

Results: 21,263 individuals (E=11,231; C=2,257; D=7,775) with mean±SD age 60.0±10.4years, HbA_1c 75.3±17.2 mmol/mol, BMI 33.9±7.1kg/m2 and 61.2% female were included. Over median follow-up of 1.7 years, HbA_1c reduced by 10.0 mmol/mol (95% CI 9.8-10.2; p<0.001); weight reduced by 3.2 kg (95% CI 2.2-4.1; p<0.001); BMI reduced by 1.1 kg/m2 (95% CI 0.8-1.5; p<0.001) and SBP reduced by 0.9 mmHg (95% CI 0.7-1.1; p<0.001). Empagliflozin was associated with larger HbA_1c reduction than dapagliflozin and canagliflozin (-10.6 mmol/mol [E] vs -9.8 mmol/mol [C] vs -9.1 mmol/mol [D]; p<0.001 for both). Canagliflozin was associated with statistically larger SBP reductions compared to dapagliflozin (-1.6 mmHg [C] vs 0.6 mmHg [D]). No differences were noted in weight and BMI change between drugs. Discontinuation of SGLT2i therapy was rare, only occurring in 0.35% (75/21,338). Our cohort has individuals with higher baseline weight and HbA_1c compared to published trial data and may be more generalisable to a UK population.

Conclusion: SGLT2i are very well tolerated and are associated with improvements in multiple metabolic and clinical parameters in UK real-world practice. Relatively small differences were observed between agents for HbA_1c and SBP reduction, but not for weight reduction. Further work should focus on establishing the association between individual SGLT2i agents and hard cardiorenal end points in the real world.

The Re:Mission study. Evaluating the NHS Low Calorie Diet pilot - an overview of service user data collection methods

Catherine Homer — 2024-06-29

Introduction: The National Health Service (NHS) Low Calorie Diet (LCD) pilot programme aimed to support people with type 2 diabetes (T2DM) to lose weight, reduce glycaemia and potentially achieve T2DM remission using total diet replacement alongside behaviour change support. The Re:Mission study seeks to provide an enhanced understanding of the long-term cost-effectiveness of the programme and its implementation, equity, transferability and normalisation across broad and diverse populations. This article presents an overview of the methods used in the Re:Mission study.

Methods and analysis: A mixed method approach was used to draw together service user insights from across longitudinal and cross-sectional online surveys and semi-structured interviews supported by a modified photovoice technique. Insights were captured from active service users across the three phases of the programme (total diet replacement, food reintroduction and maintenance) in addition to those discharged prematurely. Survey data were analysed using descriptive statistics and qualitative data were thematically analysed and interpreted through a realist informed lens to understand which aspects of the service work and do not work, for whom, in what context and why.

Results: Results from the study are presented elsewhere, with recommendations for policy practice and research.

A fresh start with high hopes: a qualitative evaluation of experiences of the Total Diet Replacement phase of the NHS Low Calorie Diet Programme pilot

Catherine Homer — 2024-06-29

Background: The National Health Service (NHS) Low Calorie Diet (LCD) programme in England aims to support people with type 2 diabetes (T2DM) to lose weight, improve glycaemic parameters and potentially achieve diabetes remission. The programme pilot launched in 2020 using three different delivery models: one-to-one, group and digital via an App. Service users begin the programme with 12 weeks of Total Diet Replacement (TDR). This study aims to understand the experience of this TDR phase from the service user perspective.

Methods: This was a co-produced qualitative longitudinal and cross-sectional study, underpinned by a realist informed approach using semi-structured interviews and photovoice techniques. Service users (n=45) from the NHS LCD programme were recruited across the three delivery models and 21 pilot sites in England. Data were analysed using a thematic approach.

Results: Participant demographics were representative of the overall LCD pilot population sample and included experiences from a mix of delivery models and providers. Three themes were presented chronologically. 1) life pre-LCD: the LCD programme was viewed as an opportunity to reset eating behaviours and improve quality of life; 2) experience of TDR: flexibility in allowing supplementary non-starchy vegetables and adapting the flavour and texture of TDR products supported adherence; 3) looking ahead to food reintroduction: at the end of the TDR phase, weight and glycaemia had reduced, while subjective energy levels and mobility improved. Some participants were concerned about progressing to the food reintroduction phase and the possibility of weight regain. Conclusions: The paper reports insight from the TDR phase of the LCD programme. The co-production of this work has resulted in several recommendations for policy and practice which have informed the national roll out of the programme.

“Trying to make healthy choices”: the challenges of the food reintroduction phase of the NHS Low Calorie Diet Programme pilot for type 2 diabetes

Catherine Homer — 2024-06-29

Background: The food reintroduction phase of the NHS Low Calorie Diet (LCD) programme aims to support service users to reintroduce food gradually back into their diet. Understanding experiences of food reintroduction from a broad and diverse range of service users is critical in helping to improve service delivery and commissioning and equity in care.

Methods: This was a co-produced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=43) of the NHS LCD Programme were recruited from three delivery models across 21 pilot sites in England. Data were analysed using a thematic approach.

Results: The food introduction phase required control and planning that challenged the behaviours of participants. Around a third of participants continued use of Total Diet Replacement products, or considered doing so, for convenience and to maintain calorie control. The coach–service user relationship was important to understanding of session content and translation into behaviour change. Physical activity increased during this phase, which contributed to positive health outcomes.

Conclusions: The paper reports insights from the food reintroduction phase of the LCD programme. Key messages include the need for increased frequency of support and the need for tailored and culturally representative education.

‘Life changing or a failure’? Qualitative experiences of service users from the weight maintenance phase of the NHS Low Calorie Diet Programme pilot for type 2 diabetes

Catherine Homer — 2024-06-29

Background: The weight maintenance phase of the NHS Low CalorieaDiet (LCD) programme focuses on embedding long- term dietary and physical activity changes. Understanding individual experiences of this phase is crucial to exploring long- term effectiveness and equity of the intervention approach.

Methods: This was a coproduced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=25) of the NHS LCD programme were recruited from three delivery models, across 21 sites in England. Data were analysed using a thematic approach.

Results: The experiences reported were largely positive, with many participants reporting changes in their diet and physical activity. Some service users expressed a need for additional support and there appeared variation in their experiences of the service providers and the wider available support network. Fear of weight regain and its glycaemic consequences was expressed by many; various mitigations were employed, including participating in other weight loss services and continuing use of Total Diet Replacement products.

Conclusions: The NHS LCD programme has been life-changing for some people. However, service user insights suggest that a stronger person-centred focus might further improve effectiveness and service user experience.

A qualitative study of the experiences of individuals who did not complete the NHS Low Calorie Diet Programme Pilot

Kevin J Drew — 2024-06-29

Background: Attrition remains a significant public health challenge as individuals who do not complete programmes are likely to have poorer programme outcomes. On calorie- restricted diets, including the NHS Low Calorie Diet (LCD) Programme pilot, approximately 50% of people are discharged prematurely, and thus do not complete the programme. Reducing attrition therefore has the potential to improve programme efficacy, impact and cost-effectiveness.

Methods: Ten semi-structured interviews were conducted with purposively sampled individuals who did not complete the NHS LCD programme. Interviews explored service user experiences of the programme and experiences of being discharged. Interview data were analysed thematically.

Results: Four core themes were identified: 1) the pre- programme struggles of service users and their route to LCD; 2) a positive and impactful programme; 3) life gets in the way; and 4) a perceived lack of support from the provider. These findings show that individuals had pre-programme struggles and a series of life events that constrained their good intentions, and whilst they were positive about the programme, they were critical of the support they received from providers to deal with their life circumstances.

Conclusions: Policy makers and providers can act proportionately to ensure that programmes, such as the NHS LCD Programme pilot, recognise the circumstances and context of people’s lives, and take a more person-centred approach.

Participant experiences during the NHS Low Calorie Diet Programme pilot. Findings from an online survey

Duncan Radley — 2024-06-29

Background: In 2020, NHS England commissioned independent commercial service providers to deliver a Low Calorie Diet Programme pilot, offering Total Diet Replacement alongside behavioural support.

Methods: This paper presents participant experiences of the programme using both quantitative and qualitative data derived from four cross-sectional surveys, and examines differences by sociodemographics, delivery model and provider.

Results: The majority of participants reported a positive experience with the referral process, with a small proportion feeling that insufficient information was provided and that they did not feel respected or listened to by their healthcare professional. Participants’ relationship with their coach was generally positive throughout each phase of the programme, and highlights the importance of coach-participant relationships. The relationship with the coach via digital delivery was less favourable compared to other delivery models, as was the perceived adequacy of support provided.

Conclusions: The experience of the referral from general practice and the relationship with the coach are key elements of the participant experience. They demonstrate the importance of, and need for, person-centred care.

Supporting remission of type 2 diabetes in the real world

Jonathan Valabhji — 2024-06-29

ABCD News

Ketan Dhatariya — 2024-06-30