British Journal of Diabetes

Implementation of hybrid closed loop therapy in the NHS: experiences from the adult diabetes centre in Derby and Burton

Alexandros L. Liarakos — 2024-12-18

Exploring the value of peer support for people living with type 1 diabetes

Shaun Carpenter — 2024-12-18

DAFNE is agile and responsive—a beacon of best practice

Jackie Elliott — 2024-12-18

The original Dose Adjustment For Normal Eating (DAFNE) randomised controlled trial (RCT) was conducted nearly 25 years ago.¹ It has transformed structured education for type 1 diabetes (T1DM) across the UK and is still evolving through its evidence base of further RCTs,^2-3 and routine collection of real-world evidence (RWE),⁴ thereby proving that what works in a research setting, also benefits people with T1DM in the large number (more than half) of the hospital Trusts that have adopted DAFNE countrywide.

This review summarises the latest national audit data, and describes future work responding to the rapid changes in technology used in T1DM, how we are evolving to support people living with type 2 diabetes (T2DM), and adapting our learning materials in the digital age. Through the strength and depth of committed multidisciplinary healthcare professionals (HCPs) we have been able to expand our portfolio of learning materials available to DAFNE centres, who pay a nominal annual fee of ~£5,000. By partnering with the Open University we now offer free accredited online learning to a wide range of HCPs, thereby helping to upskill the diabetes workforce at no extra cost to the NHS.

Finally, in a new and exciting collaboration with the Diabetes Technology Network (DTN) and industry colleagues, DAFNE offers free online training to all people living with T1DM to prepare them for closed-loop therapy.

Is a low-calorie diet (LCD) key to treating type 2 diabetes holistically?

Louisa Ells — 2024-12-18

Managing menopause in women with diabetes

Annice Mukherjee — 2024-12-18

The impact of the current diabetes pandemic on the menopause experiences and health outcomes of women with diabetes is under-researched and poorly understood.

Type 2 diabetes mellitus (T2DM) often emerges during midlife and, in women, frequently presents synchronously with menopause, which independently increases the cardiometabolic risk.

Recent interest in menopause has highlighted the lack of clinical evidence upon which to base menopause management recommendations for women with diabetes. Most evidence relating to safety and efficacy of menopause hormone therapy (MHT), the first-line treatment for menopause symptoms, is based mainly on Caucasian, socially advantaged women with low rates of co-morbidity. The dearth of data relating to MHT in women with diabetes means that much evidence for women with diabetes relies on extrapolation.

A nuanced and judicious approach to the management of menopause in women with diabetes and associated co-morbidities is, therefore, crucial.

This review focuses on the postmenopausal health risks in women with diabetes and the impact of different types of MHT. It highlights areas of uncertainties and unmet need in menopause care for this cohort of women.

Viewing the doctor-patient relationship through an educational lens: a reflection on running a diabetes clinic

Vaios Koutroukas — 2024-12-18

Diabetes as a disease is characterised by a significant focus on patient training. This article explores the relationship between the diabetologist and the patient as a teacher-student relationship, and how the consultation setting can be modified to facilitate patient learning based on individual need.

Sustainability in diabetes care: building an environment for change

Amar Puttanna — 2024-12-18

Sustainability is increasing with regard to its recognition and consideration in healthcare – from a policy level through to clinical practice. The implications for the environment and the healthcare system make the understanding of what sustainability means and how best to achieve it all the more important. The healthcare considerations have generally been broad, covering healthcare as a whole, but more interest in grassroots change and specialty-specific understanding is developing. This article aims to highlight some of the key concepts when discussing sustainability, with a specific focus on the field of diabetes and clinical care. It additionally provides possible considerations about how to develop sustainable practice and diabetes care-specific considerations.

ABCD News

Ketan Dhatariya — 2024-12-18

Time to act? Is the new era of gut hormone-based pharmacotherapy an opportunity to rethink the tier-based UK obesity care model?

Ehtasham Ahmad — 2024-12-18

Obesity, like type 2 diabetes, is a complex, often life limiting disease influenced by genetics and modern environment. However, unlike diabetes, the provision of integrated, holistic care for people with obesity in the UK remains underdeveloped, despite the growing prevalence of obesity and increasing availability of effective treatments for weight loss. The current tier-based approach to obesity management, although based around a multidisciplinary model, can be fragmented with significant geographical variations in care. The recent approval of new pharmacotherapies by the National Institute for Health and Care Excellence offers an opportunity to rethink and reshape the approach to obesity management. This article provides a review of the current tier-based system for obesity care in UK and proposes alternative models aimed at improving efficiency, promoting equity, and enhancing person-centred outcomes.

ABCD 2024 winning posters

British Journal of Diabetes — 2024-12-18

Abstracts from ABCD Conference

British Journal of Diabetes — 2024-12-18

A brief review of the 60th Annual Meeting of the EASD 2024

British Journal of Diabetes — 2024-12-18

Null variant homozygous familial hypercholesterolaemia: genetic analysis and 34 years follow-up

Charles Van Heyningen — 2024-12-18

A seven-year-old girl presented with lack of energy, a systolic heart murmur, total cholesterol of 18.7 mmol/L and skin xanthomas. During aortic valve surgery, atheroma was found in the ascending aorta. Initial treatments were diet, lipid-regulating medication and lipoprotein apharesis followed by aortic valve replacement and coronary artery bypass grafting.

At age 17 years she had a combined heart and liver transplant. Thirteen years later she developed a recurrence of ischaemic heart disease symptoms and autoimmune chronic liver disease and hence was given a second liver transplant. She died from a cardiac arrest at the age of 41 years caused by cardiac allograft immune vasculopathy.

Genome analysis showed two mutations in the LDL receptor gene, confirming a diagnosis of homozygous familial hypercholesterolaemia. Complete loss of LDL receptor function was demonstrated on fibroblast bioassay. New LDL receptor- independent therapies for homozygous familial hyper- cholesterolaemia have recently become available.

Severe DKA at presentation in young people - is it always type 1 diabetes?

Rijas Keethadath — 2024-12-18

Benefits of reducing duration of endoscopic duodenal-jejunal bypass liner implantation to nine months in treatment of diabesity

Robert E J Ryder — 2024-12-18

Aims: To assess the safety and efficacy of duodenal-jejunal bypass liner (DJBL) implantation for 9 months or 12 months in patients with obesity and sub-optomally controlled type 2 diabetes (T2DM).

Methods: Over 4.25 years DJBLs were implanted in 90 adult patients with obesity and sub-optimally controlled T2DM at a single centre in England. The liners remained in situ for up to 12 months and outcomes were monitored in a registry.

Results: Of the 90 patients (BMI 41.5±7.1kg/m2, HbA1c 79.3±20 mmol/mol), 53% were insulin-treated. During DJBL treatment, there was no difference between the mean±SD fall in HbA1c at 9 months (20.5±18.8mmol/mol) vs. 12 months (20.5±19.4mmol/mol) (p=0.95). The mean±SD weight loss at

9 months (13.8±7.7kg) was 1.6±3.6kg less than that at 12 months (15.4±8.4kg) (p<0.001). By 12 months, 15.6% of patients had had early DJBL removal due to serious adverse events (SAEs), from which they all recovered. Of these SAEs, 43% would have been avoided by DJBL removal at 9 months. Conclusion: DJBL is effective in people with intractable diabesity. To reduce the incidence of SAEs, our data support reducing the recommended/conventional implantation period for DJBL from 12 months to 9 months.

What does current diabetes and endocrine speciality outpatient training look like and what will change? Observations from a single training region in England

Jolyon Dales — 2024-12-18

Introduction: Diabetes and endocrine speciality training in the UK has traditionally been lasted five years but moved to a four- year model in 2021 with the introduction of the Internal Medical Training (IMT)3 year programme. Here we aim to review the case mix of outpatients seen by a single diabetes and endocrinology Specialty Registrar (SpR) during clinical training and offer insights into the range of patients seen. We will also review the NHS ePortfolio entries for Diabetes and Endocrinology and for General Internal Medicine to establish how many self-entered forms, assessments (completed and expired) and summary assessments are typically undertaken before certification of completion of training (CCT).

Methods: A diabetes and endocrinology registrar (JD) kept an anonymised log of all outpatient consultations from starting speciality training as an ST3 in August 2017 up until his CCT was awarded in May 2023. Duration of training was extended because JD was a less than full time trainee (LFTT), with a period of shared parental leave. Non-patient-identifiable data included diagnosis or presenting complaint of patient seen, type of clinic and date of clinic between August 2017 and May 2023. Following CCT, NHS ePortfolio data were reviewed to establish NHS ePortfolio entries, including the number of requested assessments and number of completions.

Results: For the last 18 months of training, approximately 40% of JD’s working time was spent on general medicine and 60% on diabetes and endocrinology. Over the total time of training from 2017 to 2023 JD had a total of 4,150 consultations in outpatient clinics. There were 1,347 consultations in the endocrine clinic and 2,803 consultations in the diabetes clinic. There were 472 ePortfolio entries: 158 of these were self-entered, 284 requested assessments completed and 30 summary or progression assessments. 130 requested assessments expired before completion, giving a response rate of 68.5%.

Conclusion: Observations from a single training region in England show that five years of diabetes and endocrinology registrar training provided a broad mix and depth of outpatient experience. The greater number of patients seen in diabetes clinic represents the requirement for service delivery in the area and subspecialist interest being developed. The change to four years’ speciality training is likely to represent around 800 fewer consultations as a speciality trainee in diabetes and endocrinology. The reduction in training opportunities could be addressed through having more protected time for specialist teaching clinics, particularly pump and technology clinics. A large amount of evidence from both the trainee and assessors is required in NHS ePortfolio to achieve CCT in diabetes and endocrinology and general internal medicine. Although the data come only from one trainee and one region, they can provide a point of reference for future analysis of the effect of four years’ speciality specific training on the breadth of training and a stimulus for other trainees and other region to reflect and analyse their rota and data.

Acknowledgement to BJD 2024 reviewers

2024-12-18