Can Education Save Us From Type 2 Diabetes

In 1982 Diabetes UK announced weight loss was the most effective treatment for Type 2 Diabetes (T2D) . Since then, several national programs have been developed to reduce both the prevalence and incidence of this disease. Despite this, most adults in the UK are now either overweight or obese (NHS Digital, 2020).

In 2006 the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) program was rolled out nationally. This was the first program of its kind in the UK. Pilot data showed positive changes to the quality of life and metabolic control three months following intervention (Skinner et al., (2006). Two years later, a paper examining the effectiveness of DESMOND found program participants did not see a reduction in HbA1c (Davies et al., 2008). Dinneen (2008) defended the program in a BMJ editorial. The author noted DESMOND participants could choose personal goals, such as quality of life measures, that may have been better captured via qualitative analysis.

2006 also saw the launch of the X-PERT structured diabetes education program. This offered participants a weekly 2.5-hour session for six weeks. In an RCT conducted by the program developer, participants saw a reduction in HbA1c (Deakin et al., 2006). To date, there appears to be little independent analysis of the effectiveness of this program. However, internal audit data suggests the program is effective (X-Pert Health, 2020).

Until now, T2D had generally been considered a progressive condition requiring management through reduced carbohydrate intake. The landmark Counterpoint Study by Lim et al. (2011) showed that energy restriction alone could normalise both beta-cell function and hepatic insulin sensitivity. This was associated with decreased pancreatic and liver triacylglycerol stores.

The number of people receiving incomplete diabetes care was highlighted in NHS England's 2014 Action on Diabetes. The report noted there was significant geographical variation in the percentage of people receiving recommended care processes. Although the report highlighted some successes, such as the UK having the lowest early death rates.

In 2015 Public Health England and NHS England announced the National NHS Diabetes Prevention Programme (DPP). It aimed to identify those at high risk of developing T2D and offer them a lifestyle intervention. In 2016 NHS England released an impact analysis of implementing the NHS DPP over the next 5 years. Based on medium-end average costs, the programme is estimated to yield net positive economic returns from year 8 and financially break even in year 14. That same year Diabetes UK (2016) summarised the uptake of diabetes education sessions across the UK, entitling the document 'The Big Missed Opportunity in Diabetes Care'. According to the charity patients only spent 3 hours, on average, per year with a health care professional. They noted all four nations had pledged to improve access to education courses, yet data suggested attendance remained poor. Wales fared worst with only 1% of people with T2D attending classes in 2014.

Following the Counterpoint Study's success, Steven et al. (2016) now looked to test blood glucose normalisation's durability. This was analysed in the Counterbalance study. The authors were able to define the underlying mechanisms for T2D. The twin cycles hypothesis argues that substantial (10%) weight loss in people with T2D improves insulin action and insulin response. That same year the DiRECT Trial (Leslie et al., 2016) sought to establish whether a structured weight management programme, used in the study above, could be rolled out on a national level as a viable treatment for T2D. Results from year 1 and 2 of the study appeared promising.

In 2017 NHS England announced 44 million in funding to increase structured education and meet treatment targets. To support this, Public Health England (2018) created a professional resource that outlined how to best implement the NHS DPP for clinical commissioning groups. The publication describes how the population find themselves in an increasingly obesogenic environment, which it considers to be the primary cause of escalating T2D rates.

The following year the National Diabetes Audit 2016-17 was released (NHS Digital, 2018). The report noted concerns over apparent low rates of attendance at structured education sessions due to poor recording. GPs and specialists were encouraged to enthusiastically advocate programs to their patients. They were also asked to check attendance had occurred and was recorded. In response to this report, the National Institute for Health and Care Excellence (NICE) (2018) released its own summary of diabetes care. The report highlighted the importance of individuals being given the knowledge to manage their condition, ideally through structured education programmes. NICE recognised that implementing structured education has been one of the hardest parts of their guidance for the NHS to put into practice. This was used as justification for making structured education the largest recipient of the diabetes transformation fund.

To date, the majority of T2D care focused on preventing or reversing obesity. However, there now exists a substantial population of non-obese individuals with T2D. In light of this, the University of Oxford's Diabetes Trials Unit (2018) set out to investigate whether weight loss can reverse T2D in non-obese people. The investigators hope to shed further light on the concept of a 'Personal Fat Threshold' through their research.

In 2019 Diabetes UK released a report drawing attention to figures that indicate cases of T2D have almost doubled in the last 20 years, from 6.9 to 13 million. In response to this, the charity calls for new treatments that cure or prevent the condition to be implemented. They hope to reduce the number of people living with diabetes by 2025. That same year analysis concluded the DiRECT trial was viable on a national level and clearly saved the NHS costs (Diabetes Remission Clinical Trial, 2020). In 2019 all Scottish Health Boards received training to deliver the intervention, now called Counterweight-Plus. In 2020 the program was rolled out nationally, both in trials and the diabetes care framework. Patients can enrol on the program privately if it is not available to them through the NHS (Robinson, 2020). Many service providers are now looking to follow this example and digitise their diabetes education service. As T2D significantly increases the risks posed by Covid-19, Quinn et al. (2020) believe technology is essential to ensure care continuation. The authors conclude that the pandemic will have a lasting effect on how diabetes care is delivered in the future.

References

Davies, M.J. et al., (2008) ‘Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial’. BMJ, 336 (7642), pp. 491–495.

Deakin, T.A. et al., (2006) ‘Structured patient education: the Diabetes X‐PERT Programme makes a difference’. Diabetic medicine, 23(9), pp. 944–954.

DESMOND (2020) About us. Available at: https://www.desmond.nhs.uk/about-us (Accessed: 2 December 2020).

Diabetes Remission Clinical Trial (2020) ‘DiRECT 2020 Update’. Available at: https://www.directclinicaltrial.org.uk (Accessed: 3 December 2020).

Diabetes Trials Unit (2018) ‘Reversal of Type 2 diabetes Upon Normalisation of Energy intake in the non-obese’. Available at: https://www.dtu.ox.ac.uk/OurTrials/ReTune.php (Accessed: 3 December 2020).

Diabetes UK (2016) Diabetes education: the big missed opportunity in diabetes care. Available at: https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/diabetes-storage/migration/pdf/Diabetes%2520UK_Diabetes%2520education%2520-%2520the%2520big%2520missed%2520opportunity_updated%2520June%25202016.pdf (Accessed: 2 December 2020).

Diabetes UK (2019) ‘Number of people with obesity almost doubles in 20 years’. Available at: https://www.diabetes.org.uk/about_us/news/number-obesity-doubles-twenty-years (Accessed: 3 December 2020).

Dinneen, S.F. (2008) ‘Structured education for people with type 2 diabetes’. BMJ, 336 (7642), pp. 459-460.

Leslie, W. et al. (2016) ‘The Diabetes Remission Clinical Trial (DiRECT): protocol for a cluster randomised trial’. BMC family practice, 17(1), p. 20.

Lim, E.L. et al., (2011) ‘Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol’. Diabetologia, 54 (10), pp. 2506–2514.

National Institute for Health and Care Excellence (NICE) (2018) ‘Niceimpact Diabetes’. Available at: https://www.nice.org.uk/Media/Default/About/what-we-do/Into-practice/measuring-uptake/impact-diabetes.pdf (Accessed: 3 December 2020).

NHS Digital (2018) ‘National Diabetes Audit 2016-17’. Available at: https://files.digital.nhs.uk/pdf/s/k/national_diabetes_audit_2016-17_report_1__care_processes_and_treatment_targets.pdf (Accessed: 3 December 2020).

NHS Digital (2020) Statistics on Obesity, Physical Activity and Diet, England, 2020. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/england-2020 (Accessed: 2 December 2020).

NHS England (2014) Action on Diabetes. Available at: https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2016/08/act-for-diabetes-31-01.pdf (Accessed: 2 December 2020).

NHS England (2016) NHS England Impact Analysis of implementing NHS Diabetes Prevention Programme, 2016 to 2021. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/08/impact-assessment-ndpp.pdf (Accessed: 3 December 2020).

NHS England (2017) ‘Diabetes transformation fund’. Available at: https://www.england.nhs.uk/diabetes/diabetes-prevention/diabetes-transformation-fund/ (Accessed: 3 December 2020).

Nutrition Subcommittee of the British Diabetic Association's Professional Advisory Committee (1992) ‘Dietary recommendations for people with diabetes: an update for the 1990s’, Diabetes Medicine, 9(2), pp. 189-202.

Public Health England (2018) ‘Health matters: preventing Type 2 Diabetes’. Available at: https://www.gov.uk/government/publications/health-matters-preventing-type-2-diabetes/health-matters-preventing-type-2-diabetes (Accessed: 3 December 2020).

Public Health England and NHS England (2015) National NHS Diabetes initiative launched in major bid to prevent illness. Available at: https://www.gov.uk/government/news/national-nhs-diabetes-initiative-launched-in-major-bid-to-prevent-illness (Accessed: 2 December 2020).

Quinn, L.M. et al. (2020) Virtual Consultations and the Role of Technology During the COVID-19 Pandemic for People With Type 2 Diabetes: The UK Perspective. Journal of Medical Internet Research, 22(8), p.N.PAG.

Robinson, R. (2020) Email to Robert McNally, 1 December.

Skinner, T.C. et al., (2006) ‘Diabetes education and self-management for ongoing and newly diagnosed (DESMOND): Process modelling of pilot study’. Patient education and counseling, 64(1), pp. 369–377.

Steven, S et al. (2016) ‘Very Low-Calorie Diet and 6 Months of Weight Stability in Type 2 Diabetes: Pathophysiological Changes in Responders and Nonresponders’. Diabetes care, 39(5), pp. 808–815.

X-Pert Health (2020) ‘Expert Audit Results 2020’. Available at: https://www.xperthealth.org.uk/wp-content/uploads/2020/11/X-PERT-Audit-Award-Report-November-2020-1.pdf (Accessed: 4 December 2020).