Diabetes foot ulcer service digital imaging in the community


Diabetes Distilled: March 2018

The March edition of ‘Diabetes Distilled‘ has selected the following articles for further discussion:

Diabetes distilled | March 2018 | Primary Care Diabetes Society

NHS Diabetes Programme

NHS England has published the following factsheets relating to the NHS Diabetes Programme:

NHS Diabetes Programme: Improving outcomes in diabetes
This fact sheet shows how the Diabetes Treatment and Care Programme is aiming to improve outcomes for those with diabetes.

NHS Diabetes Programme: Digital innovations in diabetes
This fact sheet shows how NHS England’s digital work supports both the diabetes prevention and treatment and care agendas.

Healthier You: NHS Diabetes Prevention Programme fact sheet
This fact sheet gives more detail about the Healthier You: NHS Diabetes Prevention Programme and how it supports patients identified at high risk of developing Type 2 diabetes.

Multimorbidity: a priority for global health research

This report was undertaken to summarise the existing research evidence about the burden, determinants, prevention, and treatment of multimorbidity | The Academy of Medical Sciences

Image source: acmedsci.ac.uk

The term multimorbidity  refers to the existence of multiple medical conditions in a single individual. For many regions of the world, there is evidence that a substantial, and likely growing, proportion of the adult population is affected by more than one chronic condition.

Health conditions that frequently group together include heart disease, high blood pressure, diabetes, cancer, depression, anxiety, chronic obstructive pulmonary disease (COPD) and chronic kidney disease.  Why this happens is poorly understood, making it difficult to predict which patients may be most in need of preventive or increased care.

The report also highlights how physical conditions, such as type 2 diabetes, can affect mental health, and vice versa. But the division between health services treating mental and physical health often means that patients with physical and mental conditions are at particular risk of poor care.

Full report: Multimorbidity: a priority for global health research | The Academy of Medical Sciences.

See also:

Avoiding type 2 diabetes – there is more than one diet to choose from

In this article, Nicola Guess of King’s College London asks what diets could be equally or more effective than a low-fat, high-fibre diet in avoiding Type 2 Diabetes? 

nuts-1327434_1920The article suggest that if weight loss is the primary driver of type 2 diabetes prevention, then a well-formulated low-carbohydrate diet (high in non-starch vegetables, fruits, nuts and seeds) would probably be as effective as the current standard advice of a low-fat, high-fibre diet.

The author also looks at the growing evidence that adding protein to the diet may help control blood glucose levels, lower liver fat (strongly linked to insulin resistance) and even help the pancreas produce insulin. Also discussed are the findings of a  recent large study from Spain (PREDIMED) which showed that a Mediterranean diet with extra virgin olive oil and added nuts helped prevent type 2 diabetes even though people did not lose weight.

Full article: Avoiding type 2 diabetes – there is more than one diet to choose from | The Conversation

Potential cost savings for early detection and treatment of type 2 diabetes

Large study finds that for individuals diagnosed with diabetes, screening is associated with a reduction in healthcare costs due to fewer admissions and doctor’s visits and a reduction in prescribed medicationDiabetologia | via ScienceDaily

Between 2001 and 2006, a population-based cardiovascular and diabetes screening programme was introduced in five out of sixteen Danish counties. Over 150,000 individuals registered with 181 practices participating in the ADDITION-Denmark study were sent a diabetes risk score questionnaire, and if their score indicated moderate to high risk they were invited to attend for a diabetes test and cardiovascular risk assessment with their family doctor.

More than 27,000 attended for screening, and 1533 were diagnosed with diabetes during screening. A further 1,760,000 individuals were identified for a matched no-screening control group. Participants were followed for approximately six years following diagnosis until 31 December 2012, when national registers were searched for healthcare usage and healthcare cost.

The researchers found that those individuals with clinically-diagnosed diabetes were identified on average 2.2 years later than individuals whose diabetes was detected in the screening practices. Healthcare costs were significantly lower in the screening group compared with the no-screening control group, with an average annual difference in healthcare costs of €889 per individual with diabetes. The results have just been published in the scientific journal Diabetologia.

Full article:  Sortsø C et al |  Effect of screening for type 2 diabetes on healthcare costs: a register-based study among 139,075 individuals diagnosed with diabetes in Denmark between 2001 and 2009 | Diabetologia |  March 2018

Web-based self-management support for people with type 2 diabetes

In this UK-based trial of a web-based self-management programme for people with T2DM, participants randomised to HeLP-Diabetes Healthy Living for People with Diabetes, an interactive, theoretically informed, web-based self-management programme, demonstrated improved glycaemic control at 12 months compared with those randomised to a simple information website.


Objective:  To determine the effectiveness of a web-based self-management programme for people with type 2 diabetes in improving glycaemic control and reducing diabetes-related distress.

Methods and design: Individually randomised two-arm controlled trial.

Setting: 21 general practices in England.

Participants: Adults aged 18 or over with a diagnosis of type 2 diabetes registered with participating general practices.

Intervention and comparator:  Usual care plus either Healthy Living for People with Diabetes (HeLP-Diabetes), an interactive, theoretically informed, web-based self-management programme or a simple, text-based website containing basic information only.

Outcomes and data collection: Joint primary outcomes were glycated haemoglobin (HbA1c) and diabetes-related distress, measured by the Problem Areas in Diabetes (PAID) scale, collected at 3 and 12 months after randomisation, with 12 months the primary outcome point. Research nurses, blind to allocation collected clinical data; participants completed self-report questionnaires online.

Analysis: The analysis compared groups as randomised (intention to treat) using a linear mixed effects model, adjusted for baseline data with multiple imputation of missing values.

Results: Of the 374 participants randomised between September 2013 and December 2014, 185 were allocated to the intervention and 189 to the control. Final (12 month) follow-up data for HbA1c were available for 318 (85%) and for PAID 337 (90%) of participants. Of these, 291 (78%) and 321 (86%) responses were recorded within the predefined window of 10–14 months. Participants in the intervention group had lower HbA1c than those in the control (mean difference −0.24%; 95% CI −0.44 to −0.049; p=0.014). There was no significant overall difference between groups in the mean PAID score (p=0.21), but prespecified subgroup analysis of participants who had been more recently diagnosed with diabetes showed a beneficial impact of the intervention in this group (p = 0.004). There were no reported harms.

Conclusions:  Access to HeLP-Diabetes improved glycaemic control over 12 months.

Full article: Murray E, Sweeting M, Dack C, et al | Web-based self-management support for people with type 2 diabetes (HeLP-Diabetes): randomised controlled trial in English primary care |  BMJ Open | 2017; 7:e016009

Common diabetes drug may not reduce risk of death, according to new research

Imperial College London | April 2018 | Diabetes drug may not reduce risk of death

A new paper published in the Journal of the American Medical Association (JAMA),   studied three types of diabetes treatment to compare hwo they reduced mortality for people with type 2 diabetes.  These are sodium-glucose cotransporter 2 (SGLT-2) inhibitors, glucagon-like peptide 1 (GLP-1) agonists, and dipeptidyl peptidase 4 (DPP-4) inhibitors. Previous research findings indicate these treatments are currently prescribed to at least one in three people with type 2 diabetes (via Imperial College London).

Question  How do sodium-glucose cotransporter 2 (SGLT-2) inhibitors, glucagon-like peptide 1 (GLP-1) agonists, and dipeptidyl peptidase 4 (DPP-4) inhibitors compare in reducing mortality and cardiovascular events in patients with type 2 diabetes?

Findings  In this network meta-analysis that includes 236 trials with 176 310 participants, the use of SGLT-2 inhibitors or GLP-1 agonists was significantly associated with lower all-cause mortality compared with the control groups (placebo or no treatment) (hazard ratio [HR], 0.80, and HR, 0.88, respectively) and with DPP-4 inhibitors (HR, 0.78, and HR, 0.86, respectively).

Meaning  In patients with type 2 diabetes, the use of SGLT-2 inhibitors or GLP-1 agonists was associated with better mortality outcomes than DPP-4 inhibitors



Importance  The comparative clinical efficacy of sodium-glucose cotransporter 2 (SGLT-2) inhibitors, glucagon-like peptide 1 (GLP-1) agonists, and dipeptidyl peptidase 4 (DPP-4) inhibitors for treatment of type 2 diabetes is unknown.

Objective  To compare the efficacies of SGLT-2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors on mortality and cardiovascular end points using network meta-analysis.

Data Sources  MEDLINE, Embase, Cochrane Library Central Register of Controlled Trials, and published meta-analyses from inception through October 11, 2017.

Study Selection  Randomized clinical trials enrolling participants with type 2 diabetes and a follow-up of at least 12 weeks were included, for which SGLT-2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors were compared with either each other or placebo or no treatment.

Data Extraction and Synthesis  Data were screened by 1 investigator and extracted in duplicate by 2 investigators. A Bayesian hierarchical network meta-analysis was performed.

Main Outcomes and Measures  The primary outcome: all-cause mortality; secondary outcomes: cardiovascular (CV) mortality, heart failure (HF) events, myocardial infarction (MI), unstable angina, and stroke; safety end points: adverse events and hypoglycemia.

Results  This network meta-analysis of 236 trials randomizing 176 310 participants found SGLT-2 inhibitors (absolute risk difference [RD], −1.0%; hazard ratio [HR], 0.80 [95% credible interval {CrI}, 0.71 to 0.89]) and GLP-1 agonists (absolute RD, −0.6%; HR, 0.88 [95% CrI, 0.81 to 0.94]) were associated with significantly lower all-cause mortality than the control groups. SGLT-2 inhibitors (absolute RD, −0.9%; HR, 0.78 [95% CrI, 0.68 to 0.90]) and GLP-1 agonists (absolute RD, −0.5%; HR, 0.86 [95% CrI, 0.77 to 0.96]) were associated with lower mortality than were DPP-4 inhibitors. DPP-4 inhibitors were not significantly associated with lower all-cause mortality (absolute RD, 0.1%; HR, 1.02 [95% CrI, 0.94 to 1.11]) than were the control groups. SGLT-2 inhibitors (absolute RD, −0.8%; HR, 0.79 [95% CrI, 0.69 to 0.91]) and GLP-1 agonists (absolute RD, −0.5%; HR, 0.85 [95% CrI, 0.77 to 0.94]) were significantly associated with lower CV mortality than were the control groups. SGLT-2 inhibitors were significantly associated with lower rates of HF events (absolute RD, −1.1%; HR, 0.62 [95% CrI, 0.54 to 0.72]) and MI (absolute RD, −0.6%; HR, 0.86 [95% CrI, 0.77 to 0.97]) than were the control groups. GLP-1 agonists were associated with a higher risk of adverse events leading to trial withdrawal than were SGLT-2 inhibitors (absolute RD, 5.8%; HR, 1.80 [95% CrI, 1.44 to 2.25]) and DPP-4 inhibitors (absolute RD, 3.1%; HR, 1.93 [95% CrI, 1.59 to 2.35]).

Conclusions and Relevance  In this network meta-analysis, the use of SGLT-2 inhibitors or GLP-1 agonists was associated with lower mortality than DPP-4 inhibitors or placebo or no treatment. Use of DPP-4 inhibitors was not associated with lower mortality than placebo or no treatment.
Full reference: Zheng,  S.L., et al |2018 | Association Between Use of Sodium-Glucose Cotransporter 2 Inhibitors, Glucagon-like Peptide 1 Agonists, and Dipeptidyl Peptidase 4 Inhibitors With All-Cause Mortality in Patients With Type 2 Diabetes A Systematic Review and Meta-analysis| JAMA | 319 |Vol. 15 | p. 1580–1591. doi:10.1001/jama.2018.3024

The full article is available here from JAMA

Imperial College’s news feature is here 

New method to monitor blood sugar developed for diabetics

 Science Daily | April 2018 | Bloodless revolution in diabetes monitoring

A non-invasive patch which can measure blood glucose levels without the need for finger prick test has been developed at the University of Bath. The multi-disciplinary research team behind this innovation  included Scientists from the Departments of Physics, Pharmacy & Pharmacology, and Chemistry, hopes that it can eventually become a low-cost, wearable capable of  sending regular  glucose measurements to the wearer’s smartphone or smartwatch, in order to alert them when they may need to take action (via Science Daily).

adhesive-bandages-155776_1280The team tested the patch on pig skin,  and on healthy human volunteers,  in both tests the patch was able to track blood sugar variations throughout the day.   The researchers will now develop the patch by improving its design and optimising its sensors, so that it is effective for 24 hours wear, before undertaking  key clinical trials.  


Currently, there is no available needle-free approach for diabetics to monitor glucose levels in the interstitial fluid. Here, we report a path-selective, non-invasive, transdermal glucose monitoring system based on a miniaturized pixel array platform (realized either by graphene-based thin-film technology, or screen-printing). The system samples glucose from the interstitial fluid via electroosmotic extraction through individual, privileged, follicular pathways in the skin, accessible via the pixels of the array. A proof of principle using mammalian skin ex vivo is demonstrated for specific and ‘quantized’ glucose extraction/detection via follicular pathways, and across the hypo- to hyper-glycaemic range in humans. Furthermore, the quantification of follicular and non-follicular glucose extraction fluxes is clearly shown. In vivo continuous monitoring of interstitial fluid-borne glucose with the pixel array was able to track blood sugar in healthy human subjects. This approach paves the way to clinically relevant glucose detection in diabetics without the need for invasive, finger-stick blood sampling.

Full reference:
Lipani, L.,  Dupont, B. G. R., Doungmene,  F., Marken, F., Tyrrell, R.M, Guy, R.H. &  Ilie, A. | Non-invasive, transdermal, path-selective and specific glucose monitoring via a graphene-based platformNature Nanotechnology, 2018 DOI: 10.1038/s41565-018-0112-4

Rotherham NHS staff can request the article here