What Are the Most Solvable Problems in Diabetes? 2020 Edition
By Emily Fitts
Experts discussed the greatest challenges in diabetes in 2020, including the COVID-19 pandemic, and the most critical changes we need to make to address them during diaTribe’s Solvable Problems event
The diaTribe Foundation’s seventh annual Solvable Problems in Diabetes event, held virtually during the European Association for the Study of Diabetes (EASD) 2020 meeting, brought together people with diabetes, healthcare professionals, researchers, and diabetes leaders from all over the world. The lively conversation focused on diabetes in 2020, during which panelists discussed the interaction between COVID-19 and diabetes, exciting developments in diabetes therapy and technology, and forward-looking solutions for improving diabetes care. The panel, moderated by diaTribe’s Kelly Close, highlighted four leading physician-researchers from the UK:
Professor Pratik Choudhary – Professor of Diabetes at the University of Leicester
Professor Melanie Davies – Professor of Diabetes Medicine at the University of Leicester
Professor Partha Kar – Consultant in Diabetes and NHS England National Specialty Advisor for Diabetes
Professor Kamlesh Khunti – Professor of Primary Care Diabetes and Vascular Medicine at the University of Leicester
Panelists discussed the links between diabetes and COVID-19 and the revelations that the global pandemic has brought. Prof. Davies highlighted the links between COVID-19 and health conditions that are frequently seen in people with diabetes, including obesity and hypertension, and noted that 30% of COVID-19 deaths have occurred in people with type 2 diabetes. Dr. Kar emphasized the difference between modifiable health factors (such as A1C and weight) and unmodifiable health factors (such as age and socioeconomic status), calling for healthcare professionals to focus on the modifiable factors that will help keep people with diabetes healthy during the pandemic and beyond. Prof. Khunti discussed research efforts to understand and address the underrepresentation of racial and ethnic minority groups in clinical research, especially given that these groups have been more affected by COVID-19. Prof. Choudhary and Prof. Davies marveled at the dramatic increase in technology, including telehealth, during COVID-19 that has revolutionized care.
The experts highlighted challenges and opportunities in primary care, especially around technology use. The panelists described a significant gap between technology use in type 1 and type 2 diabetes care, which they attributed to the lack of training, capacity, and collaboration in primary versus specialty care settings. Prof. Khunti argued that primary care physicians need to be educated on diabetes technology, especially CGM, and on interpreting the data. Profs. Davies and Choudhary illustrated the importance of collaboration between primary and specialty care, and Prof. Davies advocated for the entire care team to be engaged with technology.
Leicester, UK, where three of the four panelists work, is part of Cities Changing Diabetes – a program that supports diabetes awareness, care, education, and prevention in twelve partner cities around the world. Profs. Davies and Khunti shared the unique characteristics of Leicester that make the work of the program especially critical – Leicester is a small city that has a minority white population and a much higher percentage of people with diabetes in comparison to the national average. The Cities Changing Diabetes program has focused on addressing racial and ethnic diabetes disparities by connecting with faith centers and counsels, as well as collaborating with major sports clubs to create a prevention program. All panelists emphasized the importance of diabetes prevention, which requires improved access to therapies and technologies, more robust data, and updated practice guidelines for clinicians.
A major theme of the EASD 2020 meeting was new and existing research on therapies with heart and kidney benefits (GLP-1s and SGLT-2s), which the panelists agreed should be more widely used. Prof. Davies highlighted three “scandals” on this topic: 1) despite significant evidence of the benefits of these therapies, the majority of people with established heart disease are still not prescribed these therapies; 2) only 1% of people under age 50 were included in the outcomes trials; and 3) there is a lack of data about long-term outcomes among people with type 1 diabetes. Prof. Khunti argued that access is often limited due to insurance companies that are not accurately weighing the quality of the data and the cost-effectiveness of improving long-term outcomes by reducing complications. Dr. Kar added that the uptake of these new therapies is limited by an outdated way of thinking about diabetes treatment – one that has not “caught up with the new narrative that there is more to it than running more and eating less.”
Finally, throughout the discussion, panelists emphasized the need to change the narrative about diabetes care, especially for those with type 2 diabetes. Prof. Davies and Dr. Kar underscored the importance of centering doctor’s visits on the person’s priorities and goals – beginning by simply asking open-ended questions about what is important to the person in their care. Prof. Choudhary described a demoralizing experience that many people with diabetes face: arriving at the clinic, finding out they are not meeting their A1C target, being scolded by their healthcare professional and being told to make lifestyle changes without clear instructions, leaving, and returning only to repeat the cycle. “That’s the narrative that we as healthcare professionals and people with diabetes really need to change,” he asserted.
Below are some memorable quotable quotes from the expert leaders from Leicester:
“We started using proportion in range, before we started using CGMs. We started talking about proportion in range and it moved seamlessly to time in range, and we found that it is a much more understandable term than A1C (which is a mythical beast that comes out of your finger every three months). I've asked people, how many of your readings do you need to get in range? People think that it has to be 90-100%, and when you say it’s actually 65-70% – there’s a much higher percent allowance for error – people relax. That’s been the effect of TIR for me.” – Prof. Pratik Choudhary
“The person living with diabetes is front and center – we need to keep reminding everyone that we are here to support and work with people who are really making the decisions. The ultimate aim is to optimize people’s quality of life. The decision cycle starts with that conversation. And for people living with diabetes, work to get into the shared decision making where you can articulate what is important to you. I think it’s really interesting when you are in a clinic and you start by saying “hi” and “what issue you would like to discuss today?” – that’s how you start the consultation. We need to get more healthcare professionals to do that.” – Prof. Melanie Davies
“When I was training, the pathway for people with type 2 diabetes was very simplistic, and the problem is that in a lot of people's mind, the pathway is still quite simplistic. It takes a tanker to shift that belief. We now have a situation where the system is still playing catch-up and we haven't quite caught up with the new narrative that there is more to it than running more and eating less. That is a problem.” – Dr. Partha Kar
“One thing that COVID has taught us is that deprivation is the biggest risk factor for morbidity and mortality. We knew about that, but COVID has highlighted it even more, and we know ethnic minority groups more often live in deprived conditions. The only way we can close this gap is first getting the ethnicity data, having that data published on a regular basis, and bringing in interventions to close the gap. We’re not going to get there otherwise.” – Prof. Kamlesh Khunti
“The ecosystem has developed unbelievable tools and resources but we still haven’t yet seen the dramatic changes or improvements that we expect. The main challenge is for all populations to be healthier across the board to make these outcomes the norm. One of the hardest tasks, which has become even more apparent with COVID-19, is that we need to understand the disparities around the world so that we can advocate for change – skin color and neighborhood will no longer be tied to health outcomes.” – diaTribe Founder Kelly Close
Check out the recording of the full panel here.