How Do We Take Better Care of People With Type 2 Diabetes?
Women leaders in diabetes discussed strategies to address the growing number of people with type 2 diabetes at a recent event in Hamburg, Germany during EASD 2023. Panelists called for more focus on education, access to innovations, and social determinants of health.
As the number of people with type 2 diabetes grows worldwide, new strategies are needed to manage the condition. Increasingly, more people are being diagnosed with type 2 diabetes earlier in life – even below age 40 – with complications already present at diagnosis.
There is also an increasing burden of type 2 diabetes in minority communities and lower- and middle-income countries, which represents a dramatic shift from several decades ago when diabetes was viewed as a disease of “the wealthy.”
The ADA and European Association for the Study of Diabetes (EASD) sought to address these challenges in the 2022 ADA/EASD Consensus Report on the management of hyperglycemia (high blood sugar) in type 2 diabetes. The report includes a focus on addressing obesity, person-centered care, and social determinants of health as important starting points for diabetes care.
During diaTribe’s Solvable Problems in Diabetes event at EASD 2023, experts discussed the consensus report and explored challenges and opportunities to improve care for people with type 2 diabetes. The panel was moderated by Professor Melanie Davies, CBE, professor of diabetes medicine at the Leicester Diabetes Centre and director of the NIHR Leicester Biomedical Research Centre, U.K., and included:
Dr. Roberta Lamptey, consultant family physician and diabetologist at the Korle Bu Teaching Hospital in Ghana, Africa.
Dr. Claire Meek, senior clinical research associate at the Institute of Metabolic Science, University of Cambridge, and honorary consultant chemical pathologist and metabolic physician at Addenbrooke’s Hospital in Cambridge, U.K.
Dr. Nisa Maruthur, associate professor of medicine, epidemiology, and nursing at Johns Hopkins University in Maryland, U.S.
Dr. Athena Philis-Tsimikas, corporate vice president of the Scripps Whittier Diabetes Institute and director of community engagement at Scripps Research Translational Institute in San Diego, U.S.
Dr. Tsvetalina Tankova, head of the department of endocrinology and head of the division of diabetology at the University Hospital of Endocrinology, Medical University Sofia in Bulgaria.
Diabetes education is the first step towards optimizing care
New medications and technologies for diabetes can only go so far – patients must be able to understand the benefits of these innovations and how to use them. In this way, Dr. Roberta Lamptey said that structured education is “low-hanging fruit” for improving diabetes outcomes, as it helps patients understand and navigate lifestyle changes and treatment options.
For instance, continuous glucose monitoring (CGM) is most helpful if patients understand what time in range means and how their behaviors affect glucose control. Dr. Nisa Maruthur said that introducing technology is the “perfect time” to consider DSMES again, in addition to these four critical periods when DSMES is recommended:
At the time of diagnosis
Once a year (or more often) if someone is not meeting their treatment goals
If health complications arise
When transitions in life and care occur
For patients hesitant to use diabetes technology, Dr. Clare Meek said that education can help them better understand the benefits of these devices for their health.
“We’ve found when people are offered the opportunity for structured DSMES, they actually take it and run with it,” said Lamptey of her experiences working in Accra, Ghana.
While people with diabetes in Ghana often receive mixed messages from healthcare providers, nurses, and church leaders, Lamptey said that “when the education is structured, then it doesn’t matter who is delivering DSMES, the message is consistent. Inconsistent messaging contributes to poor self-care behaviors.”
Above all, it’s crucial to put the patient at the center of diabetes care.
“Everything else will fall in place if we focus on that patient, their journey, and their outcomes,” Lamptey said. “At the end of the day, type 2 diabetes requires making lifestyle changes for a lifetime, and we need to find a way to get that information down to the patient.”
It’s also important to recognize multimorbidities – the presence of multiple conditions in a person with diabetes.
“Many people living with diabetes are also living with a whole constellation of other things, much related to obesity and type 2 diabetes, but also the psychological impact,” said Melanie Davies.
Davies said that diabetes distress and depression in particular can pose barriers to self-management in people with diabetes.
In order to address the psychosocial challenges of diabetes and other conditions, Meek encouraged people with diabetes to practice self-compassion. Healthcare providers can facilitate self-compassion by helping people with diabetes identify their recent successes in diabetes management – whether big or small.
Beyond reducing anxiety and improving mental health, self-care can also help with diet and lifestyle changes, Meek said. In addition, Maruthur encouraged healthcare providers to consider the wide range of lifestyle interventions, like DSMES, before treating diabetes with medication.
New incretin-based therapies for glycemic control, pregnancy and cardiovascular risk reduction
Panelists highlighted the potential of incretin-based therapies for weight loss and glycemic management, as well as their cardiovascular benefits. Dr. Athena Philis-Tsimikas described the recent research on these medications as “incredibly exciting,” in contrast to decades ago when insulin and sulfonylureas were the only medications available to treat diabetes.
While clinical trials of GLP-1 agonists have shown strong risk reduction for cardiovascular complications like heart disease and stroke, Meek emphasized that these trials were conducted in older adults and are not representative of the growing number of people under age 40 being diagnosed with type 2 diabetes. Meek encouraged providers to treat type 2 diabetes “early and aggressively” in younger patients at high cardiovascular risk, given that many effective therapies are now available.
Likewise, Dr. Tsvetalina Tankova encouraged healthcare providers to prioritize people who need newer therapies most when prescribing incretin-based therapies. Tankova said these medications appear to be underutilized even in settings where good access is provided.
For people thinking about having a baby, Meek said it’s important to think about preconception care, too. Meek said that removing cardiovascular medications for a few years while a patient tries for a baby “isn’t a risk of zero” and requires a discussion with patients to address their individual risk.
Access is another key issue, as several countries have experienced shortages of incretin-based therapies. Going forward, panelists said that it will be important to consider the value of newer vs. older medications as well as questions of cost-effectiveness.
The potential of technology, from hospitals to pregnancy to prediabetes
Panelists also discussed the importance of CGM for helping patients understand and manage their glucose levels, in tandem with DSMES.
Although CGM isn’t officially approved for hospital use, Philis-Tsimikas said that her staff took advantage of the FDA granting temporary permission for in-hospital use during the COVID-19 pandemic. For instance, nurses were able to remotely monitor patients from nursing stations and introduced protocols that contacted staff when glucose levels fell below 80 mg/dL.
While remote monitoring and telehealth were especially helpful during the height of the pandemic, these services continue to be valuable today, especially for people in rural areas or others who have a hard time accessing in-person appointments.
Diabetes in pregnancy is another example of an area where CGM can be beneficial. While the severity of early type 2 diabetes is often minimized in the general population, Meek explained that pregnancy outcomes in type 2 diabetes remain suboptimal.
Women with type 2 diabetes who become pregnant suddenly need to follow a much stricter diet, test their blood glucose up to seven times a day, and take insulin up to four times a day. In this case, Meek said that CGM could help people adjust to the demands of diabetes management and reduce the burden of treatment.
While CGM is approved primarily for individuals with diabetes who are on insulin, there is also potential value for people with prediabetes. Tankova described her research on CGM use in prediabetes, explaining that “CGM revealed some problems with glucose variability, things we could not find out without using a CGM.”
The panelists acknowledged that more research is needed to understand how to use CGM as a behavioral intervention tool.
“I see technology as the future of where we’re going in diabetes care,” said Philis-Tsimikas.
Learn more about diabetes education and treatments here: