IDDT Conference ‘Changing Times’

Ageing with Diabetes

Professor Alan Sinclair of the Foundation for Diabetes Research in Older People

The number of older people with diabetes is rising globally. Currently there are 3.8 million people with diabetes in England. Nearly 1 million have diabetes but are undiagnosed. 90% have Type 2 diabetes. In 2020 the number with Type 1 diabetes in England was 218,670.

• It is now clear that Type 1 can present at any age with an unexplained fall, change in personality, fatigue or with a memory problem.
• People over 70 do not have the same symptoms as younger people and may present with different symptoms.
• Type 2 in older adults is often missed for up to 9 years by which time complications have set in.
• The risk of hypos increases with age – and not just in those aiming for “tight control”.
• In older people it is better to aim for a stable level of blood glucose rather than a lower HbA1c.
• The prevalence of diabetes is even higher in care homes and mental health facilities than in the general population.

Frailty and dementia are complications of diabetes.

• Frailty can be reversed. Diabetes accelerates the loss of muscle tissue. This risk can be lessened with regular exercise and good nutrition.
• Frailty is marked by weight loss, exhaustion, slow walking, low grip strength, and low physical activity.
• Frailty should be screened for in all people over 65 as it is a risk factor for falls, mobility, length of hospital admission and death.

Older people with diabetes + frailty + Covid had very high mortality rates. Unfortunately, European guidelines to administer dexamethasone and oxygen were not picked up in the UK.

Research on diabetes in older people indicates that the way forward is with good screening and individualised diabetes care.

Better Services, Better Care?

Feedback from 2021 – Jenny Hirst

Delegates at last year’s conference asked the Trust if it could lobby to improve postcode lottery in diabetes care. With great regret, Jenny had to report that it had not been possible. Changes in Government and the move from CCGs to Integrated Care Systems/Boards have meant there is no one identifiable national figure and the new local boards have not been in place for long enough to appoint diabetes leads. It could be another two years, based on past experience, until things have settled.

Another issue is that NICE issues guidelines, which are not mandatory, so even if a patient knows what care they are supposed to receive, decisions taken at a local level may be different.

We were advised to familiarise ourselves using the ‘9 Key Checks’ leaflets to request the services we are supposed to be getting. Members of the audience also suggested turning to social media. A local tv or radio station may pick up on social media posts and put pressure on service providers. It was also suggested that delegates might volunteer to be a patient representative on a local Integrated Care Board.

Pros and Cons of technology

Led by Dr Gary Adams

The focus was on continuous glucose monitors and pumps. Positives were identified as no finger pricking, accurate results, improvements in control, quality of life, better health, the reassurance of notifications for hypos and more time spent with blood glucose in range. Some cons were identified as not having enough education to use technology optimally, the risk of losing one’s foundation knowledge about diabetes and its management, being over-reliant on technology, doubtful reliability, anxiety about travel/loss of devices, expense if not NHS funded, risk of infection, and becoming obsessive about blood glucose range at the expense of a relaxed life.

Getting the most from the NHS

Led by Anne Aubin

Attendees bemoaned the breakdown of the health and care system and struggling to get care, from getting past a GP receptionist, to obtaining a preferred pump. With regard to getting and making best use of an appointment, some people said they found it easier to go into the GP surgery and make a booking, as it is so hard to get through by phone, or past telephone triage.

The Expert Patient Programme and Shared Decision-Making guidelines recommend PART.

• • ‘P’ is Preparing for the appointment by identifying what is most important to you, and taking along an advocate or carer if we struggle to get our point across.
  • ‘A’ stands for Ask – it is recommended we ask three questions: What are my treatment options? What are the Pros and Cons of each? Where can I get support with whichever option I choose?
  • ‘R’ is Repeat – telling the professional what you believe the plan to be so there are no misassumptions.
  • ‘T’ is for having a clear Target outcome.

The benefits of complaining in writing if we are unsatisfied were discussed. There is a duty to respond to complaints. If a complaint is not adequately addressed, copying the complaint to the practice Senior Partner, to PALS, to the ICB, the GMC, the CQC, one’s MP, or the press, may bring results. We also looked at how to be an effective presence in groups/on committees, and the benefits of being part of an online support group such as GBDoc – Diabetes, Peer Support, Information Service. One’s personal expertise with diabetes can be shared during an appointment, on social media and working with a patient participation group.

Carers group

Led by John Birkbeck

Those living with someone with Type 1 or Type 2 diabetes attended and found the group a valuable place to freely discuss the impact of living with someone with diabetes and they shared struggles and achievements. It can be easy to feel alone and knowing that other carers can have similar experiences – or worse – makes it easier to keep going.

Three keynote addresses.

The Latest on the Freestyle Libre – Jane Cheetham, Abbott Laboratories

A surprisingly large number of delegates were wearing their Libres! It is possible to get individual tuition from Abbott if you self-fund a Libre. Abbott’s trials have shown that their sensors are accurate with only a marginal difference from finger prick testing (though some in the audience disagreed). Readings from the Libre are acceptable to the DVLA. Libre 1 is being phased out at the end of the year. Libre 3 is coming out – this monitors glucose continuously, rather than at intervals and has an even smaller sensor. The Customer Care Line will answer questions and will replace any sensor that is faulty or falls off before the end of its life. Lots of questions were raised from the floor and the Abbott team did their best to answer as many as possible. When going through airport security it is preferable if a guard uses the wand rather than you going through a whole-body scanner. Spare sensors should be in hand, not the hold baggage. You don’t need a mobile phone – Abbott will supply a scanning device.

Proteins, Fat, Vitamins, Minerals – and Carbs

Dr Mabel Blades

Dr Blades echoed Professor Sinclair’s earlier remarks about protein being important for muscle bulk. She demonstrated the Dynometer to measure grip strength. She referred us to the Eatwell Guide which is now available for cultural sub-groups.

Protein includes cheese, eggs (no longer felt to be a cholesterol risk), meat, fish and pulses. Good quality bread and pasta also contain 8% protein. Adults need 0.8 g /kg body weight/day and protein requirements increase in older age. It is recommended that we eat no more than three portions of red meat a week and we should have two of fish – one oily. Vegans can obtain enough protein but must proceed knowledgeably as only soya contains all of the essential amino acids and other pulses need to be combined with a whole grain. Calcium is important to prevent osteoporosis and may not be present in all plant-based milks. Check that such a milk is fortified with calcium, protein and iodine. Mono-unsaturated oils like rapeseed and olive oils are best for us. Fish oil supplements contain Omega 3.

We should have 400g fruit and vegetables per day, for fibre, vitamins and minerals. Most people manage 3 portions or less, whereas five are recommended. Frozen vegetables are more nutritious than canned. Dr Blades recommends we all take Vitamin D supplements as we don’t absorb calcium without it.

Newer Treatments for Type 1 and Type 2 Diabetes

Dr Gary Adams

Dr Adams delivered a thought-provoking talk asking us to reflect on the following questions:

• How much do you really know about your current insulin(s)?
• Do you want to see new insulins and sensors being developed?
• What impact do you want a new treatment to have?
• Will you accept new insulins despite risk?

Dr Adams pointed out that we are all individuals and will respond differently to different insulins. Ultra long-acting insulins that will stay in the system for a whole week are being delivered. Several amino acids in the insulin chain have to be modified and different preservatives will be needed. People without diabetes metabolise their natural insulin within an hour – will we want to have something that lasts a week? Closed loop systems (sensor communicates with pump) are supposed to respond to your BG levels but the algorithm, or mathematical programme, can be unreliable. This can lead to non-stable BG levels and anxiety. There are also risks from inflammation, infection, and itchiness and insulin sticks to the inside of tubing, so dosing may not be as accurate as we think. Some technology is being developed by the diabetes community which will be unregulated, but may still be very good. One such piece of kit is the K-watch developed by PK Vitality. Online fora can be helpful. Take home message – our bodies, our insulin, our choice?

Close of the Day

Jenny Hirst closed the conference by thanking all our members and supporters for their generous donations of insulin, medication, testing strips and meters and money for our efforts in Ukraine. Everything, including knitted toys, hats, gloves, and scarves, has been much appreciated by those in the warzone. IDDT has used donated funds to purchase necessary supplies and to pay for van deliveries. Every penny is being spent where it is most needed.

The staff and trustees very much look forward to seeing you in 2023.