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Aim: The risk of Type 2 Diabetes is 10 times higher after a pregnancy with Gestational Diabetes. Physical activity can independently reduce this risk, yet engagement with physical activity remains low after Gestational Diabetes. Therefore, the present study aimed to explore the barriers and facilitators to the uptake of physical activity after Gestational Diabetes in the United Kingdom, using a socio‐ecological approach. Methods: The paper was written following the Standards for Reporting Qualitative Research. Patient and Public Involvement contributed to the study's conceptualisation and design. Participants were recruited through an audit of Gestational Diabetes cases at a local Teaching Hospital in 2020. Twelve participants took part in semi‐structured one‐to‐one interviews. Reflexive thematic analysis was used to generate themes in iterative rounds of refinement. The final themes were then organised using the socio‐ecological model. Results: Participants were all over 31 years old, predominantly self‐identified as White British and were all in employment but were evenly spread across UK‐based deprivation deciles. Ten themes were generated and organised according to the four levels of the socio‐ecological model: intrapersonal (beliefs about activity, recovering from birth), social (health care professionals, family and partner, role as a mother), organisational (access and cost, environment, childcare and work) and community (connecting women with recent Gestational Diabetes). Conclusions: Many of the amenable barriers and facilitators to physical activity were beyond the intrapersonal level, based on higher levels of the socio‐ecological model (social, organisational and community). Multi‐level interventions are needed to effectively address all barriers. [ABSTRACT FROM AUTHOR]

Background: People with severe mental illness (SMI), such as schizophrenia, have higher rates of type 2 diabetes and worse outcomes, compared to those without SMI and it is not known whether diabetes self‐management interventions are effective for people who have both conditions. Research in this area has been impeded by a lack of consensus on which outcomes to prioritise in people with co‐existing SMI and diabetes. Aims: To develop a core outcome set (COS) for use in effectiveness trials of diabetes self‐management interventions in adults with both type 2 diabetes and SMI. Methods: The COS was developed in three stages: (i) identification of outcomes from systematic literature review of intervention studies, followed by multi‐stakeholder and service user workshops; (ii) rating of outcomes in a two‐round online Delphi survey; (iii) agreement of final 'core' outcomes through a stakeholder consensus workshop. Results: Seven outcomes were selected: glucose control, blood pressure, body composition (body weight, BMI, body fat), health‐related quality of life, diabetes self‐management, diabetes‐related distress and medication adherence. Conclusions: This COS is recommended for future trials of effectiveness of diabetes self‐management interventions for people with SMI and type 2 diabetes. Its use will ensure trials capture important outcomes and reduce heterogeneity so findings can be readily synthesised to inform practice and policy. [ABSTRACT FROM AUTHOR]

Aims: The objective of this study was to determine whether the use of glucagon‐like peptide‐1 receptor agonists (GLP‐1 RAs) is associated with an increased risk of melanoma and nonmelanoma skin cancer, separately, compared with the use of sulfonylureas among patients with type 2 diabetes. Methods: Using the United Kingdom Clinical Practice Research Datalink (2007–2019), we assembled two new‐user active comparator cohorts. In the first cohort assessing melanoma as the outcome, 11,786 new users of GLP‐1 RAs were compared with 208,519 new users of sulfonylureas. In the second cohort assessing nonmelanoma skin cancer as the outcome, 11,774 new users of GLP‐1 RAs were compared with 207,788 new users of sulfonylureas. Cox proportional hazards models weighted using propensity score fine stratification were fit to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of melanoma and nonmelanoma skin cancer, respectively. Results: Compared with sulfonylureas, GLP‐1 RAs were not associated with an increased risk of either melanoma (42.6 vs. 43.9 per 100,000 person‐years, respectively; HR 0.96, 95% CI 0.53–1.75) or nonmelanoma skin cancer (243.9 vs. 229.9 per 100,000 person‐years, respectively; HR 1.03, 95% CI 0.80–1.33). There was no evidence of an association between cumulative duration of use with either melanoma or nonmelanoma skin cancer. Consistent results were observed in secondary and sensitivity analyses. Conclusions: In this population‐based cohort study, GLP‐1 RAs were not associated with an increased risk of melanoma or nonmelanoma skin cancer, compared with sulfonylureas. [ABSTRACT FROM AUTHOR]

Aim: To identify factors influencing dietary behaviour in shift workers with type 2 diabetes (T2D) working in UK healthcare settings. Methods: Semi‐structured qualitative interviews based on the theoretical domains framework (TDF) were conducted with a convenience sample (n = 15) of shift workers (32–59 years) diagnosed with T2D who worked night shifts as part of a mixed shift schedule. The TDF was applied to analyse transcripts using a combined deductive framework and inductive thematic analysis approach. Identified influences were mapped to the behaviour change technique taxonomy to identify potential strategies to change dietary behaviour in this context. Results: Key barriers to healthy dietary behaviours were access and cost of food available during night work (TDF domain: Environment Context and Resources). Factors identified as both enablers and barriers included: availability of staff facilities and time to take a break, (Environment Context and Resources), the physical impact of night work (Beliefs About Consequences), eating in response to stress or tiredness (Emotion), advance planning of meals/food and taking own food to work (Behavioural Regulation). Potential techniques to address these influences and improve dietary behaviour in this context include: meal planning templates, self‐monitoring and biofeedback, and increasing accessibility and availability of healthier food choices during night shifts. Conclusions: The dietary behaviour of shift workers with T2D is influenced by interacting individual, socio‐cultural and environmental factors. Intervention should focus on environmental restructuring and strategies that enable monitoring and meal planning. [ABSTRACT FROM AUTHOR]

Aims: To determine differences in the management of diabetic kidney disease (DKD) relevant to patient sex, ethnicity and socio‐economic group in UK primary care. Methods: A cross‐sectional analysis as of January 1, 2019 was undertaken using the IQVIA Medical Research Data dataset, to determine the proportion of people with DKD managed in accordance with national guidelines, stratified by demographics. Robust Poisson regression models were used to calculate adjusted risk ratios (aRR) adjusting for age, sex, ethnicity and social deprivation. Results: Of the 2.3 million participants, 161,278 had type 1 or 2 diabetes, of which 32,905 had DKD. Of people with DKD, 60% had albumin creatinine ratio (ACR) measured, 64% achieved blood pressure (BP, <140/90 mmHg) target, 58% achieved glycosylated haemoglobin (HbA1c, <58 mmol/mol) target, 68% prescribed renin–angiotensin–aldosterone system (RAAS) inhibitor in the previous year. Compared to men, women were less likely to have creatinine: aRR 0.99 (95% CI 0.98–0.99), ACR: aRR 0.94 (0.92–0.96), BP: aRR 0.98 (0.97–0.99), HbA1c: aRR 0.99 (0.98–0.99) and serum cholesterol: aRR 0.97 (0.96–0.98) measured; achieve BP: aRR 0.95 (0.94–0.98) or total cholesterol (<5 mmol/L) targets: aRR 0.86 (0.84–0.87); or be prescribed RAAS inhibitors: aRR 0.92 (0.90–0.94) or statins: aRR 0.94 (0.92–0.95). Compared to the least deprived areas, people from the most deprived areas were less likely to have BP measurements: aRR 0.98 (0.96–0.99); achieve BP: aRR 0.91 (0.8–0.95) or HbA1c: aRR 0.88 (0.85–0.92) targets, or be prescribed RAAS inhibitors: aRR 0.91 (0.87–0.95). Compared to people of white ethnicity; those of black ethnicity were less likely to be prescribed statins aRR 0.91 (0.85–0.97). Conclusions: There are unmet needs and inequalities in the management of DKD in the UK. Addressing these could reduce the increasing human and societal cost of managing DKD. [ABSTRACT FROM AUTHOR]

Aims: Identifying children at risk of type 1 diabetes allows education for symptom recognition and monitoring to reduce the risk of diabetic ketoacidosis at presentation. We aimed to explore stakeholder views towards paediatric general population screening for type 1 diabetes in the United Kingdom (UK). Methods: Qualitative interviews were undertaken with 25 stakeholders, including diabetes specialists, policymakers and community stakeholders who could be involved in a future type 1 diabetes screening programme in the UK. A thematic framework analysis was performed using the National Screening Committee's evaluative criteria as the overarching framework. Results: Diabetic ketoacidosis prevention was felt to be a priority and proposed benefits of screening included education, monitoring and helping the family to better prepare for a future with type 1 diabetes. However, diabetes specialists were cautious about general population screening because of lack of evidence for public acceptability. Concerns were raised about the harms of living with risk, provoking health anxiety and threatening the child's right to an 'open future'. Support systems that met the clinical and psychological needs of the family living with risk were considered essential. Stakeholders were supportive of research into general population screening and acknowledged this would be a priority if an immunoprevention agent were licensed in the UK. Conclusions: Although stakeholders suggested the harms of UK paediatric general population screening currently outweigh the benefits, this view would potentially be altered if prevention therapies were licensed. In this case, an evidence‐based screening strategy would need to be formulated and public acceptability explored. [ABSTRACT FROM AUTHOR]

Aims: To describe the process and outputs of a workshop convened to identify key priorities for future research in the area of diabetes and physical activity and provide recommendations to researchers and research funders on how best to address them. Methods: A 1‐day research workshop was conducted, bringing together researchers, people living with diabetes, healthcare professionals, and members of staff from Diabetes UK to identify and prioritise recommendations for future research into physical activity and diabetes. Results: Workshop attendees prioritised four key themes for further research: (i) better understanding of the physiology of exercise in all groups of people: in particular, what patient metabolic characteristics influence or predict the physiological response to physical activity, and the potential role of physical activity in beta cell preservation; (ii) designing physical activity interventions for maximum impact; (iii) promoting sustained physical activity across the life course; (iv) designing physical activity studies for groups with multiple long‐term conditions. Conclusions: This paper outlines recommendations to address the current gaps in knowledge related to diabetes and physical activity and calls on the research community to develop applications in these areas and funders to consider how to stimulate research in these areas. [ABSTRACT FROM AUTHOR]

Aims: The contemporary prescription patterns of antidiabetic drugs following guideline changes recommending metformin as first‐line gestational diabetes (GDM) pharmacotherapy is underexplored. We aimed to examined use of metformin and insulin during pregnancy among women with GDM over 20 years in the United Kingdom. Methods: We conducted a population‐based cohort study using linked data from the Clinical Practice Research Datalink, its pregnancy register and Hospital Episode Statistics from 1998 to 2017. We included pregnancies of women without prior diabetes history who received GDM diagnosis or initiated an antidiabetic drug after 20 weeks gestation. Patient‐level and practice‐level characteristics were compared between metformin initiators and insulin initiators. We described trends of initiating metformin as first‐line treatment and described time to initiation of rescue insulin overall, and by body mass index among metformin initiators. Results: Our cohort included 5633 pregnancies from 5393 women with GDM, of whom 38.9% initiated pharmacotherapy (41% insulin, 59% metformin). Metformin prescriptions (as opposed to insulin) increased substantially, from <5% of pregnancies before 2007 to 42.5% in 2008. Over 85% of pregnancies that were prescribed pharmacotherapy were prescribed metformin as first‐line treatment in 2015. Among metformin initiators, 16% initiated rescue insulin, typically occurring within 40 days of metformin initiation. Choice of GDM pharmacotherapy varied by characteristics, including smoking, obesity, race/ethnicity and general practice regions. Conclusions: Metformin was the most prescribed medication for GDM, with large increases over the past 2 decades. The increasing use of oral‐antidiabetic drugs during pregnancy, consistent with other regions, highlights the need for future studies examining effectiveness and safety of antidiabetic drug use during pregnancy. [ABSTRACT FROM AUTHOR]

Aims: Assess effectiveness of a hybrid intervention targeting physical activity in women with prior gestational diabetes. Methods: Randomised controlled trial with parallel arms. 293 women (35.1 ± 5.1 years; 40% ethnic minority) recruited from two hospitals and randomised to routine care or hybrid lifestyle intervention comprising two group sessions and access to a mobile web app. Primary outcome was a change in objectively measured physical activity at 12 months. Secondary outcomes included self‐efficacy for exercise, quality of life and anxiety and depression. Linear regression compared outcome measures between groups. Results: 83% of intervention participants attended at least one group session, of who 66% registered to use the app. There was a non‐significant increase in physical activity at 12 months (between‐group difference of 0.95 mg [95% CI: −0.46 to 2.37]), equivalent to approximately 500 steps per day. Intervention participants reported higher self‐efficacy for exercise (0.54, 95% CI: 0.05 to 1.102; p = 0.029), lower anxiety (−0.91, 95% CI: −1.74 to −0.09; p = 0.031), and higher quality of life (0.05, 95% CI: 0.004 to 0.09; p = 0.032), compared to controls. Conclusions: The intervention improved confidence in exercise and quality of life. Further research is needed to improve participant engagement with physical activity interventions in multi‐ethnic populations with a history of gestational diabetes. [ABSTRACT FROM AUTHOR]

Aims: Fully closed‐loop insulin delivery has been shown in clinical trials to be safe and improve glucose control compared with standard insulin therapy in the inpatient setting. We investigated the feasibility of implementing the approved CamAPS HX fully closed‐loop system in a hospital setting. Methods: This implementation project was conducted in a large teaching hospital in Cambridge, UK. Healthcare professional training was multimodal including face‐to‐face workshops, online learning modules and supported by standard operating procedures. Set‐up and maintenance of closed‐loop devices were undertaken by the inpatient diabetes team. Selection of suitable patients was multidisciplinary and prioritised those with more challenging diabetes management. Demographic and clinical data were collected from electronic health records and diabetes data management platforms. Results: In the 12 months since the closed‐loop system was implemented, 32 inpatients (mean ± SD age 61 ± 16 years, 8 females, 24 males) used closed‐loop insulin delivery during their admission, across medical and surgical wards in the hospital with a total of 555 days of closed‐loop glucose control (median [IQR]: 14 [6, 22] days per inpatient). The time spent in target glucose range 3.9–10.0 mmol/L was 53.3 ± 18.3%. Mean glucose was 10.7 ± 1.9 mmol/L with 46.0 ± 18.2% of time spent with glucose >10.0 mmol/L. Time spent with sensor glucose below 3.9 mmol/L was low (median [IQR]: 0.38 [0.00, 0.85]). There were no episodes of severe hypoglycaemia or diabetic ketoacidosis during closed‐loop use. Conclusions: We have demonstrated that the fully closed‐loop system can be safely and effectively implemented by a diabetes outreach team in complex medical and surgical inpatients with challenging glycaemic control. [ABSTRACT FROM AUTHOR]

Aims: Facilitated self‐management support programmes have become central to the treatment of chronic diseases including diabetes. For many children and young people with diabetes (CYPD), the impact on glycated haemoglobin (HbA1c) and a range of self‐management behaviours promised by these programmes remain unrealised. This warrants an appraisal of current thinking and the existing evidence to guide the development of programmes better targeted at this age group. Methods: Create a narrative review of systematic reviews produced in the last 3 years that have explored the impact on CYPD of the four key elements of self‐management support programmes: education, instruction and advice including peer support; psychological counselling via a range of therapies; self‐monitoring, including diaries and telemetric devices; and telecare, the technology‐enabled follow‐up and support by healthcare providers. Results: Games and gamification appear to offer a promising means of engaging and educating CYPD. Psychological interventions when delivered by trained practitioners, appear to improve HbA1c and quality of life although effect sizes were small. Technology‐enabled interactive diaries can increase the frequency of self‐monitoring and reduce levels of HbA1c. Telecare provided synchronously via telephone produced significant improvements in HbA1c. Conclusions: The cost‐effective flexibility of increasing the reliance on technology is an attractive proposition; however, there are resource implications for digital connectivity in underserved populations. The need remains to improve the understanding of which elements of each component are most effective in a particular context, and how to optimise the influence and input of families, caregivers and peers. [ABSTRACT FROM AUTHOR]

Aims: People with type 2 diabetes can enter remission but may relapse or develop legacy complications. This analysis assesses whether people with remission from type 2 diabetes continue receiving annual care processes recommended in national guidelines and the potential impacts of formal recognition of remission. Methods: People with type 2 diabetes with and without formal recognition (diagnostic code) of remission, and with and without evidence of remission (HbA1c < 48 mmol/mol without prescription for glucose‐lowering drugs in preceding 26 weeks), included in the 2018/19 National Diabetes Audit (NDA) for England and Wales were followed up to identify care processes received between 1 January 2019 and 31 March 2020. Results: Of the 2,822,145 people with type 2 diabetes in the cohort, 16,460 (0.58%) were coded with remission in the 2018/19 NDA. After adjustment for age, sex, socioeconomic deprivation and ethnicity, people coded with remission were less likely to receive each care process than those without such coding irrespective of HbA1c measurements (relative risk (RR) of receiving all 8 care processes 0.70 (95% CI 0.69–0.72)). For the 339,235 people with evidence of remission, irrespective of diagnostic coding compared to those without such evidence, the RR for receiving all 8 care processes was 0.94 (95% CI 0.93–0.94). Conclusions: People coded with remission of type 2 diabetes were less likely to receive diabetes care processes than those without such coding. People with evidence of remission had only a slightly reduced likelihood of receiving care processes. Formal recognition of remission may affect the provision or uptake of care processes. [ABSTRACT FROM AUTHOR]

Aim: To understand the health needs, experiences, and views of women with type 2 diabetes in relation to diabetes, reproductive health experiences, and general wellbeing. Method: A qualitative study using semi‐structured interviews. Thirty‐six women with type 2 diabetes (median age 37 years; age ranges 20–45 years; median diabetes duration 4.5 years), recruited through social media and charities in the UK (n = 23) and Turkey (n = 13). Video interviews (n = 28) were audio recorded and transcribed verbatim. Email interviews (n = 8) and transcribed video interviews were analysed using Framework Analysis. Results: Two overarching themes were identified: (1) Perception of self and identity, (2) type 2 diabetes care is not orientated to women's needs. These themes highlight that living with type 2 diabetes was negatively perceived by the women in terms of their self‐identity and reproductive health. Women reported that the diabetes care provided was often not appropriate or relevant to their health needs, and neglected issues of relevance to them. The women voiced ideas for enhancing current care to reflect their health needs, in particular the need for more emotional and peer‐based support. Conclusion: Living with type 2 diabetes may negatively impact how women view themselves and how they relate to the roles they identify with such as, as a partner, mother, colleague. Current healthcare systems are not orientated to the specific needs of younger women with type 2 diabetes with limited opportunities to target their diabetes care around their health and wellbeing concerns and interests. [ABSTRACT FROM AUTHOR]

Aims: People with pre‐diabetes are at high risk of progressing to type 2 diabetes. This progression is not well characterised by ethnicity, deprivation and age, which we describe in a large cohort of individuals with pre‐diabetes. Methods: A retrospective cohort study with The Health Improvement Network (THIN) database was conducted. Patients aged 18 years and over and diagnosed with pre‐diabetes [HbA1c 42 mmol/mol (6.0%) to 48 mmol/mol (6.5%) were included]. Cox proportional hazards regression was used to calculate adjusted hazard rate ratios (aHR) for the risk of progression from pre‐diabetes to type 2 diabetes for each of the exposure categories [ethnicity, deprivation (Townsend), age and body mass index (BMI)] separately. Results: Of the baseline population with pre‐diabetes (n = 397,853), South Asian (aHR 1.31; 95% CI 1.26–1.37) or Mixed‐Race individuals (aHR 1.22; 95% CI 1.11–1.33) had an increased risk of progression to type 2 diabetes compared with those of white European ethnicity. Likewise, deprivation (aHR 1.17; 95% CI 1.14–1.20; most vs. least deprived) was associated with an increased risk of progression. Both younger (aHR 0.63; 95% CI 0.58–0.69; 18 to <30 years) and older individuals (aHR 0.85; 95% CI 0.84–0.87; ≥65 years) had a slower risk of progression from pre‐diabetes to type 2 diabetes, than middle‐aged (40 to <65 years) individuals. Conclusions: South Asian or Mixed‐Race individuals and people with social deprivation had an increased risk of progression from pre‐diabetes to type 2 diabetes. Clinicians need to recognise the differing risk across their patient populations to implement appropriate prevention strategies. [ABSTRACT FROM AUTHOR]

Aims: Regional variations in the adoption of diabetes technology may be reflected in population‐level metrics of glycaemic control. In this observational study, we aimed to assess the glycaemic impacts of transitioning from the Dexcom G5 Real‐Time Continuous Glucose Monitoring (RT‐CGM) System to the Dexcom G6 in three European countries. Methods: Anonymised RT‐CGM data (uploaded to the Dexcom Clarity app) were from users in Germany, Sweden, and the United Kingdom (UK) who transitioned from G5 to G6 between 9‐12 months after G6 launched in 2018. Primary endpoints were percent time in hypoglycaemia, percent time in range (TIR), user retention rates, device utilisation, and urgent low soon (ULS) alert utilisation. Metrics were computed for 3‐month intervals in the 2‐year study window. Results: In all three countries, the transition from G5 to G6 was associated with a clear decrease in hypoglycaemia. In months 0‐3 after transitioning, the median percent time 〈3 mmol/L (54 mg/dL) and 〈3.9 mmol/L (70 mg/dL) decreased by [0.12‐0.28] and [0.40‐0.43] percentage points, respectively, with another [0.11‐0.21] and [0.34‐0.65] percentage point decrease in months 3‐6 in the three countries analysed. TIR and CGM utilisation were sustained or improved slightly across all countries. At the end of the study window, the retention rate was [88.8‐94.8%] and ULS utilization was [83.9‐86.9%] in the three countries analysed. Conclusions: Similar RT‐CGM trends were observed across Germany, Sweden, and the UK. Improvements in hypoglycaemia occurred in all countries. The high retention of users may lead to sustained glycaemic benefits associated with RT‐CGM use. [ABSTRACT FROM AUTHOR]

Background: Many people with undiagnosed diabetes have hyperglycaemia when admitted to hospital. Inpatient hyperglycaemia can be an indication of diabetes mellitus but can also indicate a stress response. This study reports the extent to which an in‐hospital maximum observed random glucose measurement is an indicator of the need for in‐hospital (or subsequent) HbA1c measurement to look for undiagnosed diabetes. Methods: Blood glucose, HbA1c, age and sex were collected for all adults following admission to a UK NHS trust hospital from 1 January 2019 to 31 December 2020. We restricted the analysis to those participants who were registered with a GP practice that uses the trust laboratory and who had at least some tests requested by those practices since 2008. We stratified individuals according to their maximum in‐hospital glucose measurement and report the number of these with HbA1c measurement ≥48 mmol/mol (6.5%) prior to the index admission, and during and after admission. We calculated an estimated proportion of individuals in each blood glucose stratum without a follow‐up HbA1c who could have undiagnosed diabetes. Results: In toal, 764,241 glucose measurements were recorded for 81,763 individuals who were admitted to the Oxford University Hospitals Trust. The median (Q1, Q3) age was 70 (56, 81) years, and 53% were males. Of the population, 70.7% of individuals declared themselves to be of White ethnicity, 3.1% of Asian background, and 1.1% of Black background, with 23.1% unstated. Of those individuals, 22,375 (27.4%) had no previous HbA1c measurement recorded. A total of 1689 individuals had a diabetes‐range HbA1c during or after their hospital admission (2.5%) while we estimate an additional 1496 (2.2%) may have undiagnosed diabetes, with the greatest proportion of these having an in‐hospital glucose of ≥15 mmol/L. We estimate that the number needed to detect a possible new case of diabetes falls from 16 (in‐hospital glucose 8 mmol/L to <9 mmol/L) to 4 (14 mmol/L to <15 mmol/L). Conclusion: The number of people who need to be tested to identify an individual who may have diabetes decreases as a testing threshold based on maximum in‐hospital glucose concentration increases. Among those with hyperglycaemia and no previous HbA1c measurement in the diabetes range, there appears to be a lack of subsequent HbA1c measurement. This work identifies the potential for integrating the testing and follow‐up of people, with apparently unrecognised hospital hyperglycaemia across primary and secondary care. [ABSTRACT FROM AUTHOR]

Aims To identify factors that influence lack of engagement of young adults with Type 1 diabetes (aged 13-21 years) with structured diabetes education ( SDE) to inform and broaden the reach of future SDE. Methods A quantitative, cross-sectional survey was undertaken of 227 young people with Type 1 diabetes drawn from 11 health trusts across Northern Ireland and England, deemed to be representative of the wider population. Participants were asked to complete a questionnaire exploring non-attendance, along with the Diabetes Care Profile, the Diabetes Empowerment Scale (Short Form), the Diabetes Knowledge Test and the 12-item General Health Questionnaire. Demographic, health and diabetes-specific variables including HbA1c were also collected. Results The five most commonly cited reasons for non-attendance were 'Had other things to do' (68.3%), 'No time' (62.2%), 'Could not get time off school/college or work' (60.8%), 'Learnt about diabetes from other sources' (55.5%) and 'Feel able to cope on own' (52.9%). Conclusions Greater emphasis is required on communication with young people about the benefits of SDE. In addition, efforts need to be directed to making diabetes education more accessible without losing the quality of structured programmes. [ABSTRACT FROM AUTHOR]

Aims To quantify the extent to which ethnic differences in muscular strength might account for the substantially higher prevalence of diabetes in black and South-Asian compared with white European adults. Methods This cross-sectional study used baseline data from the UK Biobank study on 418 656 white European, black and South-Asian participants, aged 40-69 years, who had complete data on diabetes status and hand-grip strength. Associations between hand-grip strength and diabetes were assessed using logistic regression and were adjusted for potential confounding factors. Results Lower grip strength was associated with higher prevalence of diabetes, independent of confounding factors, across all ethnicities in both men and women. Diabetes prevalence was approximately three- to fourfold higher in South-Asian and two- to threefold higher in black participants compared with white European participants across all levels of grip strength, but grip strength in South-Asian men and women was ~ 5-6 kg lower than in the other ethnic groups. Thus, the attributable risk for diabetes associated with low grip strength was substantially higher in South-Asian participants (3.9 and 4.2 cases per 100 men and women, respectively) than in white participants (2.0 and 0.6 cases per 100 men and women, respectively). Attributable risk associated with low grip strength was also high in black men (4.3 cases) but not in black women (0.4 cases). Conclusions Low strength is associated with a disproportionately large number of diabetes cases in South-Asian men and women and in black men. Trials are needed to determine whether interventions to improve strength in these groups could help reduce ethnic inequalities in diabetes prevalence. [ABSTRACT FROM AUTHOR]

Aim To analyse the cost-effectiveness of different interventions for Type 2 diabetes prevention within a common framework. Methods A micro-simulation model was developed to evaluate the cost-effectiveness of a range of diabetes prevention interventions including: (1) soft drinks taxation; (2) retail policy in socially deprived areas; (3) workplace intervention; (4) community-based intervention; and (5) screening and intensive lifestyle intervention in individuals with high diabetes risk. Within the model, individuals follow metabolic trajectories (for BMI, cholesterol, systolic blood pressure and glycaemia); individuals may develop diabetes, and some may exhibit complications of diabetes and related disorders, including cardiovascular disease, and eventually die. Lifetime healthcare costs, employment costs and quality-adjusted life-years are collected for each person. Results All interventions generate more life-years and lifetime quality-adjusted life-years and reduce healthcare spending compared with doing nothing. Screening and intensive lifestyle intervention generates greatest lifetime net benefit (£37) but is costly to implement. In comparison, soft drinks taxation or retail policy generate lower net benefit (£11 and £11) but are cost-saving in a shorter time period, preferentially benefit individuals from deprived backgrounds and reduce employer costs. Conclusion The model enables a wide range of diabetes prevention interventions to be evaluated according to cost-effectiveness, employment and equity impacts over the short and long term, allowing decision-makers to prioritize policies that maximize the expected benefits, as well as fulfilling other policy targets, such as addressing social inequalities. [ABSTRACT FROM AUTHOR]

Aims To assess risk of lactic acidosis among metformin users compared with other glucose-lowering agent users, according to renal function. Methods Using routine registries and databases, we conducted a cohort study. Of 43 580 metformin and 37 788 other glucose-lowering agent users in northern Denmark and 102 688 metformin and 28 788 other glucose-lowering agent users in the UK during 2001-2011, we identified lactic acidosis using diagnostic codes. We calculated the incidence rates of lactic acidosis in metformin and other glucose-lowering agent users overall and according to baseline estimated GFR ( eGFR) levels. Results In Denmark, the incidence rates of lactic acidosis were 11.6 (95% CI 7.0-18.1) and 1.8 (95% CI 0.4-5.4) per 100 000 person-years of metformin use and of other glucose-lowering agent use, respectively. In the UK, the corresponding lactic acidosis incidence rates were 6.8 (95% CI 4.6-9.6) and 1.0 (95% CI 0.01-5.7) per 100 000 person-years of metformin use and of other glucose-lowering agent use. The incidence rates increased with decreasing baseline eGFR in both countries. Of the metformin-exposed people with lactic acidosis, 37% in Denmark and 34% in the UK experienced a decline in renal function in the year before the diagnosis. Conclusions Risk of lactic acidosis was higher in metformin users than in other glucose-lowering agent users, and increased with decreasing eGFR, although this could be attributable to surveillance bias; however, diagnosed lactic acidosis was rare and can occur regardless of renal function. [ABSTRACT FROM AUTHOR]

Aims To report contemporary regression rates from impaired glucose regulation to normal glucose tolerance, identify modifiable factors associated with early regression, and establish whether it affects subsequent diabetes risk in a population-based cohort. Methods Participants with impaired glucose regulation (impaired fasting glucose and/or impaired glucose tolerance on a 75-g oral glucose tolerance test) at baseline in the UK-based ADDITION-Leicester study had annual Type 2 diabetes re-screens for 5 years or until diabetes diagnosis. Logistic regression models investigated modifiable risk factors for regression to normal glucose tolerance at 1 year ( n = 817). Cox regression models estimated subsequent diabetes risk ( n = 630). Results At 1 year, 54% of participants had regressed to normal glucose tolerance, and 6% had progressed to diabetes. Regression to normal glucose tolerance was associated with weight loss of 0.1-3% [adjusted odds ratio 1.81 (95% CI 1.08, 3.03) compared with maintaining or gaining weight] and a waist circumference reduction of > 3 cm [adjusted odds ratio 1.78 (95% CI 1.03, 3.06) compared with maintaining or increasing waist circumference]. Those with normal glucose tolerance at 1 year subsequently had lower diabetes risk than those who remained with impaired glucose regulation [adjusted hazard ratio 0.19 (95% CI 0.10, 0.37)]. Conclusions Early regression to normal glucose tolerance was associated with reduced diabetes incidence, and might be induced by small reductions in weight or waist circumference. If confirmed in experimental research, this could be a clear and achievable target for individuals diagnosed with impaired glucose regulation. [ABSTRACT FROM AUTHOR]

Aims Our aim was to investigate the proportional representation of people of South Asian origin in cardiovascular outcome trials of glucose-lowering drugs or strategies in Type 2 diabetes, noting that these are among the most significant pieces of evidence used to formulate the guidelines on which clinical practice is largely based. Methods We searched for cardiovascular outcome trials in Type 2 diabetes published before January 2015, and extracted data on the ethnicity of participants. These were compared against expected values for proportional representation of South Asian individuals, based on population data from the USA, from the UK, and globally. Results Twelve studies met our inclusion criteria and, of these, eight presented a sufficiently detailed breakdown of participant ethnicity to permit numerical analysis. In general, people of South Asian origin were found to be under-represented in trials compared with UK and global expectations and over-represented compared with US expectations. Among the eight trials for which South Asian representation could be reliably estimated, seven under-represented this group relative to the 11.2% of the UK diabetes population estimated to be South Asian, with the representation in these trials ranging from 0.0% to 10.0%. Conclusions Clinicians should exercise caution when generalizing the results of trials to their own practice, with regard to the ethnicity of individuals. Efforts should be made to improve reporting of ethnicity and improve diversity in trial recruitment, although we acknowledge that there are challenges that must be overcome to make this a reality. [ABSTRACT FROM AUTHOR]

Aims To investigate the relationships between age at diagnosis of diabetes, age at diabetic eye screening and severity of diabetic retinopathy at first and subsequent screenings in children aged 12 or 13 years. Methods Data were extracted from four English screening programmes and from the Scottish, Welsh and Northern Irish programmes on all children with diabetes invited for their first and subsequent screening episodes from the age of 12 years. Retinopathy levels at first and subsequent screens, time from diagnosis of diabetes to first screening and age at diagnosis in years were calculated. Results Data were available for 2125 children with diabetes screened for the first time at age 12 or 13 years. In those diagnosed with diabetes at 2 years of age or less, the proportion with retinopathy in one or both eyes was 20% and 11%, respectively, decreasing to 8% and 2% in those diagnosed between 2 and 12 years ( P < 0.0001). Only three children (aged 8, 10 and 11 years at diagnosis of diabetes) had images graded with referable retinopathy and, of these, two had non-referable diabetic retinopathy at all subsequent screenings. Of 1703 children with subsequent images, 25 were graded with referable diabetic retinopathy over a mean follow-up of 3.1 years, an incidence rate of 4.7 (95% confidence interval, 3.1-7.0) per 1000 per year. Conclusions In this large cohort of children, the low prevalence and incidence rates of referable diabetic retinopathy suggest that screening earlier than age 12 is not necessary. [ABSTRACT FROM AUTHOR]

Aims To demonstrate that analysis of urinary C-peptide across multiple study sites in the context of an intervention trial ( DEFEND-2) is a viable alternative to mixed meal testing and delivers results that correlate to mixed meal testing estimation of endogenous insulin production. Methods Second morning void urine was collected for analysis and was available from 161 subjects at baseline (55 placebo, 106 otelixizumab), and 146 subjects (47 placebo, 99 otelixizumab) at month 12. Urinary C-peptide concentration was corrected for urinary creatinine [urinary C-peptide/creatinine ratio ( UCPCR)] and serum C-peptide from the mixed meal tolerance test was calculated using area under the plasma concentration-time curve ( AUC) normalized over 120 min. The correlation between mixed meal stimulated C-peptide AUC (mmol/l/min) and UCPCR (nmol/mmol), as well as the correlation between insulin use ( IU/kg), and HbA1c (%) with UCPCR, was determined. Results UCPCR and mixed meal testing C-peptide AUC were correlated, with a correlation coefficient of 0.4172. UCPCR was not correlated with exogenous insulin use ( r = -0.089) or with HbA1c ( r = -0.032). Conclusions Urinary C-peptide estimation should be considered as a measure of endogenous insulin production in future Type 1 diabetes mellitus outcome trials. A change in the timing for urine collection (to 120 min post standard meal) may provide a tighter correlation to C-peptide measured via a traditional mixed meal test. [ABSTRACT FROM AUTHOR]

Aims To determine if urine C-peptide/creatinine ratio is a useful tool for monitoring β-cell function in new-onset Type 1 diabetes. Methods Data were obtained from a prospective immunomodulation study in people with Type 1 diabetes ≤ 3 months from diagnosis, with a standard mixed-meal tolerance test and measurement of urine C-peptide/creatinine ratio carried out at 0, 3, 6, 9 and 12 months. The change in the insulin-dose-adjusted HbA1c level was also correlated with the change in serum/urine C-peptide level during the 12-month follow-up period. Results A significant reduction in urine C-peptide/creatinine ratio, measured after a mixed-meal, was reached at 9 months (−45.4%), whilst the reduction in stimulated serum C-peptide level reached significance after 3 months (−54.7%) in placebo-treated participants. Neither change in stimulated serum C-peptide nor change in urine C-peptide level correlated with each other, and nor did change in insulin-dose-adjusted HbA1c level in the first 6 months, but all measures correlated significantly in the second half of the 12-month follow-up period. Conclusion Mixed-meal-stimulated urine C-peptide/creatinine ratio was similar to, although less sensitive than, stimulated serum C-peptide level in monitoring β-cell function during the first year after diagnosis. Because the former is significantly less invasive, it warrants inclusion in further studies in Type 1 diabetes and may represent an attractive alternative outcome measure in cohort studies and in children. [ABSTRACT FROM AUTHOR]

Aims Childhood cancer survivors treated with haematopoietic stem cell transplantation ( HSCT) and total body irradiation are at an increased risk of developing diabetes early in life due to insulin resistance and β-cell dysfunction, but the optimal screening method is unknown. The National Institute for Health and Care Excellence guidelines for community diabetes screening recommend using fasting glucose ≥ 7 mmol/l and/or HbA1c ≥ 48 mmol/mol (6.5%) for diagnosis and, fasting glucose 5.5-6.9 mmol/l or HbA1c 42-47 mmol/mol (6-6.5%) to indicate high risk. This study aimed to evaluate the sensitivities of fasting glucose and HbA1c in the diagnosis of diabetes and impaired glucose tolerance in childhood HSCT survivors. Method The patients were 35 (male = 19) HSCT survivors from a single UK centre under follow-up from 2006 to 2013. Patients had a median age (range) of 19.2 (13.1-26.2) years and had been treated for acute lymphoblastic ( n = 31) or myeloid ( n = 4) leukaemia when aged 7.8 (2.4-16.7) years. The outcome measures were oral glucose tolerance test ( OGTT), fasting glucose and HbA1c. Results OGTT identified 6 patients with diabetes (120-min glucose ≥ 11.1 mmol/l), 12 with impaired glucose tolerance (120-min glucose 7.8-11.0 mmol/l) and 2 with impaired fasting glucose (≥ 7 mmol/l). Fasting glucose ≥ 7 mmol/l or HbA1c ≥ 48 mmol/mol identified two of the six patients with diabetes diagnosed on OGTT. Fasting glucose ≥ 5.5 mmol/l and HbA1c ≥ 42 mmol/mol identified three and two patients, respectively, with diabetes. Only 1 of 12 patients with impaired glucose tolerance had a fasting glucose ≥ 5.5 mmol/l and none had HbA1c ≥ 42 mmol/mol (≥ 6%). Conclusions The fasting glucose and HbA1c cut-offs used in UK population screening only identified one-third of HSCT survivors with diabetes and do not identify those at risk. Diabetes screening in HSCT survivors requires standard OGTTs. [ABSTRACT FROM AUTHOR]

Aim Few real-life studies of non-severe (self-treated) hypoglycaemic events are available. This survey quantified the self-reported frequency of non-severe hypoglycaemia and its effects in adults with insulin-treated diabetes in the UK. Methods Adults aged > 15 years with Type 1 diabetes or insulin-treated Type 2 diabetes completed ≤ 4 weekly questionnaires (7-day recall). Respondents with Type 2 diabetes were grouped by insulin regimen: basal-only, basal-bolus and 'other'. Results Overall, 1038 respondents (466 with Type 1 diabetes, 572 with Type 2 diabetes) completed 3528 questionnaires. Mean numbers of non-severe events per week were 2.4 (Type 1 diabetes; median = 2) and 0.8 (Type 2 diabetes; median = 0); 23% and 26% of non-severe events occurred at night, respectively. Fatigue and reduced alertness were the commonest issues following events (78% and 51% of respondents, respectively). The effects of nocturnal events persisted longer than those of daytime events: Type 1 diabetes = 10.6 vs. 4.9 h ( P = 0.0002); Type 2 diabetes = 15.3 vs. 5.1 h ( P < 0.0001). In the week following an event, respondents' blood glucose measurements increased by 4.3 (Type 1 diabetes; 12% increment) and 4.2 (Type 2 diabetes; 21% increment) tests/week. In employed respondents, 20% of events caused work-time loss, more so following nocturnal (vs. daytime) hypoglycaemia: Type 1 diabetes = 2.7 vs. 1.1 h ( P = 0.0184); Type 2 diabetes = 2.5 vs. 1.6 h ( P = 0.1340). Most respondents rarely/never informed healthcare professionals about events (Type 1 diabetes = 82%, Type 2 diabetes = 69%). Conclusions Non-severe hypoglycaemia is common in adults with insulin-treated diabetes in the UK, with consequent health-related/economic effects. Communication about non-severe hypoglycaemia is limited and the burden of hypoglycaemia may be underestimated. [ABSTRACT FROM AUTHOR]

Aims To determine the cultural competence of diabetes services delivered to minority ethnic groups in a multicultural UK city with a diabetes prevalence of 4.3%. Methods A semi-structured survey comprising 35 questions was carried out across all 66 general practices in Coventry between November 2011 and January 2012. Data were analysed using descriptive statistics. The cultural competence of diabetes services reported in the survey was assessed using a culturally competent assessment tool ( CCAT). Results Thirty-four general practices (52%) responded and six important findings emerged across those practices. (1) Ninety-four per cent of general practices reported the ethnicity of their populations. (2) One in three people with diabetes was from a minority ethnic group. (3) Nine (26.5%) practices reported a diabetes prevalence of between 55% and 96% in minority ethnic groups. (4) The cultural competences of diabetes services were assessed using CCAT; 56% of practices were found to be highly culturally competent and 26% were found to be moderately culturally competent. (5) Ten practices (29%) reported higher proportionate attendance at diabetes annual checks in the majority white British population compared with minority ethnic groups. (6) Cultural diversity in relation to language and strong cultural traditions around food were most commonly reported as barriers to culturally competent service delivery. Conclusions Seven of the eight cultural barriers identified in the global evidence were present in the city. Use of the CCAT to assess existing service provision and the good baseline recording of ethnicity provide a sound basis for commissioning culturally competent interventions in the future. [ABSTRACT FROM AUTHOR]

Aims To develop an algorithm that delivers an individualized dose of rapid-acting insulin after morning resistance exercise to counter post-exercise hyperglycaemia in individuals with Type 1 diabetes. Methods Eight people with Type 1 diabetes, aged 34 ± 7 years with HbA1c concentrations 72 ± 12 mmol/mol (8.7 ± 1.1%), attended our laboratory on two separate mornings after fasting, having taken their usual basal insulin the previous evening. These people performed a resistance exercise session comprising six exercises for two sets of 10 repetitions at 60% of the maximum amount of force that was generated in one maximal contraction (60% 1RM). In a randomized and counterbalanced order, the participants were administered an individualized dose of rapid-acting insulin (2 ± 1 units, range 0-4 units) immediately after resistance exercise (insulin session) by means of an algorithm or were not administered this (no-insulin session). Venous blood glucose concentrations were measured for 125 min after resistance exercise. Data (mean ± sem values) were analysed using anova ( P ≤ 0.05). Results Participants had immediate post-resistance exercise hyperglycaemia (insulin session 13.0 ± 1.6 vs. no-insulin session 12.7 ± 1.5 mmol/l; P = 0.834). The decline in blood glucose concentration between peak and 125 min after exercise was greater in the insulin exercise session than in the no-insulin session (3.3 ± 1.0 vs. 1.3 ± 0.4 mmol/l: P = 0.015). There were no episodes of hypoglycaemia (blood glucose <3.9 mmol/l). Conclusions Administration of rapid-acting insulin according to an individualized algorithm reduced the hyperglycaemia associated with morning resistance exercise without causing hypoglycaemia in the 2 h post-exercise period in people with Type 1 diabetes. [ABSTRACT FROM AUTHOR]

Aim To determine changes in glycaemic control and lipids over time since the introduction of the Quality and Outcomes Framework. Methods In adults with diabetes (Hampshire, UK), HbA1c and lipid measurements were retrieved from a regional National Health Service biochemical database in 2006 and 2013 and analysed using anova and logistic regression modelling. Results In 2006, 8568 people with diabetes were identified. In 2013, 5815 had follow-up data, 1207 people were lost to follow-up and 1546 had died. At baseline, HbA1c concentrations were 62.1 ± 16.1, 64.7 ± 16.7 and 64.5 ± 17.6 mmol/mol for those with follow-up data, those lost to follow-up and those who died, respectively. The mean age was 60.2 ± 14.5, 57.6 ± 18.0 and 73.9 ± 10.5 years, respectively, for the three groups. Total cholesterol, HDL cholesterol and triglyceride concentrations were similar between groups. The mean HbA1c concentration for those with complete follow-up data was 62.1 ± 16.1 mmol/mol in 2006 and 61.7 ± 17.3 mmol/mol in 2013. Quality and Outcomes Framework targets for cholesterol (< 5 mmol/l) were achieved by 79% of people in 2006 and 83% in 2013 ( P < 0.001). Baseline age and HbA1c were associated with death at follow-up: the odds ratio per year increase in baseline age was 1.10 (95% CI 1.09-1.10; P < 0.001) and per unit increase in HbA1c it was 1.02 (95% CI 1.02-1.03; P < 0.001). Conclusions Glycaemic control showed remarkable stability over 7 years of follow-up, despite increasing patient age and duration of diabetes. More patients achieved lipid targets in 2013 than in 2006. Although baseline HbA1c was a predictor of death at follow-up, baseline HbA1c differed little between survivors, non-survivors and those lost to follow-up. [ABSTRACT FROM AUTHOR]

Aims To assess whether a programme of nurse education increased the frequency with which nurses conducted foot checks on people with diabetes undergoing haemodialysis and to evaluate whether this influenced self-reported foot care behaviour. Methods A non-randomized stepped-wedge design was used to evaluate a nurse education programme implemented in four UK National Health Service dialysis units. People with diabetes undergoing haemodialysis were invited to complete a questionnaire on the frequency of foot examination by health professionals, on the presence of foot problems and on their own foot care behaviour, using the Nottingham Assessment of Functional Foot-care (NAFF). An education session for nurses, including procedures for foot examination, was conducted sequentially in each of four haemodialysis units. The questionnaire was repeated at 2-monthly intervals. Results The education session resulted in a significant increase in the reported number of foot examinations by nurses ( P = 0.007). There was also a significant improvement in reported foot care behaviour ( P < 0.001), but this occurred between the first and second 2-monthly assessments and was unrelated to the timing of the intervention. Conclusions A single education session can improve the routine checking of the feet of people with diabetes undergoing haemodialysis. The administration of the Nottingham Assessment of Functional Foot-care questionnaire was associated with improved self-reported foot care behaviour, reflecting greater awareness of risk in this population. [ABSTRACT FROM AUTHOR]

Aims To explore health professionals' views about insulin pump therapy [continuous subcutaneous insulin infusion ( CSII)] and the types of individuals they thought would gain greatest clinical benefit from using this treatment. Methods In-depth interviews with staff ( n = 18) who delivered the Relative Effectiveness of Pumps Over MDI and Structured Education ( REPOSE) trial. Data were analysed thematically. Results Staff perceived insulin pumps as offering a better self-management tool to some individuals due to the drip feed of insulin, the ability to alter basal rates and other advanced features. However, staff also noted that, because of the diversity of features on offer, CSII is a more technically complex therapy to execute than multiple daily injections. For this reason, staff described how, alongside clinical criteria, they had tended to select individuals for CSII in routine clinical practice based on their perceptions about whether they possessed the personal and psychological attributes needed to make optimal use of pump technology. Staff also described how their assumptions about personal and psychological suitability had been challenged by working on the REPOSE trial and observing individuals make effective use of CSII who they would not have recommended for this type of therapy in routine clinical practice. Conclusions Our findings add to those studies that highlight the difficulties of using patient characteristics and variables to predict clinical success using CSII. To promote equitable access to CSII, attitudinal barriers and prejudicial assumptions amongst staff about who is able to make effective use of CSII may need to be addressed. [ABSTRACT FROM AUTHOR]

Aims A diagnosis of Type 1 diabetes in childhood can be a difficult life event for children and families. For children who are not severely ill, initial home rather than hospital-based care at diagnosis is an option although there is little research on which is preferable. Practice varies widely, with long hospital stays in some countries and predominantly home-based care in others. This article reports on the comparative acceptability and experience of children with Type 1 diabetes and their parents taking part in the DECIDE study evaluating outcomes of home or hospital-based treatment from diagnosis in the UK. Methods Semi-structured interviews with 11 (pairs of) parents and seven children were conducted between 15 and 20 months post diagnosis. Interviewees were asked about adaptation to, management and impact of the diabetes diagnosis, and their experience of initial post-diagnosis treatment. Results There were no differences between trial arms in adaptation to, management of or impact of diabetes. Most interviewees wanted to be randomized to the 'home' arm initially but expressed a retrospective preference for whichever trial arm they had been in, and cited benefits relating to learning about diabetes management. Conclusions The setting for early treatment did not appear to have a differential impact on families in the long term. However, the data presented here describe different experiences of early treatment settings from the perspective of children and their families, and factors that influenced how families felt initially about treatment setting. Further research could investigate the short-term benefits of both settings. [ABSTRACT FROM AUTHOR]

Aim To conduct an audit of insulin pump therapy in the UK after the issue of guidelines for the use of continuous subcutaneous insulin infusion by NICE in 2008 (Technology Appraisal 151). Methods All centres in theUK, providing pump services tochildren and young peoplewere invited to participate in anonline audit. Audit metrics were aligned to NICE Technology Appraisal 151 and an electronic data collection tool was used. Results Of the 176 UK centres identified as providing pump services, 166 (94.3%) participated in the study. A total of 5094 children and young people were identified as using continuous subcutaneous insulin infusion (19% of all paediatric patients with Type 1 diabetes), with a median (range) of 16.9 (0.67-69.4)% per centre. Units had a median of 0.58 consultant sessions, 0.43 full-time equivalent diabetic specialist nurses, and 0.1 full-time equivalent dieticians delivering the pump service. The majority of this time was not formally funded. Families could access 24-h clinical and technical support (83% units), although the delivery varied between consultant, diabetic specialist nurse and company representatives. Only 53% of units ran, or accessed, structured education programmes for continuous subcutaneous insulin infusion use. Most units (86%) allowed continuous subcutaneous insulin infusion use for paediatric inpatients, but only 56% had written guidelines for this scenario. Nine percent of units had encountered funding refusal for a patient fulfilling NICE (Technology Appraisal 151) criteria. Conclusion The number of children and young people on continuous subcutaneous insulin infusion therapy is consistent with numbers estimated by NICE. There is a worrying lack of funded healthcare professional time. The audit also identified gaps in the provision of structured education and absence of written inpatient guidelines. [ABSTRACT FROM AUTHOR]

Aims To assess the impact of continual major National Health Service reorganization on commissioning, organizational and delivery arrangements for secondary care diabetes services. To explore how consultant diabetologists and diabetes specialist nurses perceive the issues facing diabetes specialist services in 2011 and how these have changed in the preceding decade. Methods We used a longitudinal case study approach that combined quantitative and qualitative methods. Five locations in England were purposively selected to represent the wider diabetes specialist community, and seven semistructured interviews were conducted. Interviews were recorded, transcribed verbatim and analysed using Framework analysis. Findings were compared with and contrasted to results from national quantitative surveys of diabetes specialist services undertaken in 2000 and 2006. Results Clinicians viewed positively the expertise and commitment of multidisciplinary teams and their ability to adapt to new situations. Negative perceptions persisted throughout the decade, relating to the continual change that threatens to dismantle relationships and services which had taken many years to establish. Lack of resources, inadequate manpower planning and poor access to psychological support for people with diabetes remained constant themes from 2000 to 2011. Conclusions A willingness to innovate and work differently to improve services was identified; however, clinicians must be supported through organizational changes to ensure people with diabetes receive high-quality care. The disruptive nature of organizational change was a recurrent theme throughout the decade. Periods of stability must exist within commissioning to allow relationships, which are key to integration, to be maintained and permit service improvements to develop. [ABSTRACT FROM AUTHOR]

Aims Mortality rates for coronary heart disease ( CHD) have declined substantially in developed countries. Diabetes mellitus is an important risk factor for CHD; its prevalence is increasing. We aimed to compare trends in population-based mortality for CHD without diabetes on the death certificate with trends for CHD with diabetes on the same certificate. Methods Analysis of an all-England dataset with multiple-cause coded mortality records from 1995 to 2010. Analysis of a similar dataset for Oxford, because it has the longest run of multiple-cause coded mortality in England, from 1979. Age-specific and age-standardized mortality rates were calculated. Results In the all-England dataset, there were 1 772 760 deaths with CHD and no mention of diabetes; and 173 184 deaths with CHD and diabetes on the same death certificate. Of deaths with CHD without a mention of diabetes, rates per million men fell by more than half from 2843 (95% confidence interval: 2822-2862) in 1995 to 1379 (1366-1391) in 2010; and those in women halved from 1324 (1314-1336) to 628 (621-635). Of deaths with CHD and diabetes, rates per million men increased from 194 (188-200) to 215 (210-220); and those for women fell, but only very slightly, from 114 (111-118) to 101 (98-104). The longer run in Oxford, from 1979, showed that rates in men and women without diabetes had fallen by two-thirds; but that rates for CHD with diabetes had not fallen. Conclusions The fall in mortality from CHD without diabetes has been spectacular. There has been no comparable fall in mortality from CHD with diabetes. [ABSTRACT FROM AUTHOR]

Aims To describe the effect of a combined diabetes specialist/mental health team approach to prevent readmissions for acute glycaemic events among patients with diabetes. Methods Consecutive patients with diabetes, readmitted to a single hospital for an acute glycaemic condition, were offered one or more diabetes (including assessment, education, medication, technology use and intensive support) and mental health (including assessment, training and therapies) interventions. The pilot service took place over 11 months, with the preceding 24 months and subsequent 8 months serving as control periods. Results Of the 58 patients admitted, 50 had Type 1 diabetes and were from within the hospital catchment area, and were discharged home. Of these, 32 (64%) had a pre-existing mental health issue and 14 (28%) had a complex social situation. In all, 96% of patients were met as an inpatient by a team member, and 94% accepted at least one intervention. The mean ± sd number of admissions per patient/month dropped from 0.12 ± 0.10 to 0.05 ± 0.10 ( P < 0.001) during the intervention, increasing, once the intervention ended, to 0.16 ± 0.36 ( P = 0.002). The mean ± sd length of stay similarly decreased and increased (0.6 ± 0.9 to 0.2 ± 0.7 days; P < 0.001 to 0.006) to 0.6 ± 1.4 days ( P = 0.003) per patient/month) across the three periods, as did the mean ± sd tariff paid per patient/month (₤258.0 ± 374.0 vs ₤92.1 ± 245.0 vs ₤287.3 ± 563.8; P < 0.001 and P = 0.018, respectively). The mean ± sd HbA1c level dropped from 99 ± 22 to 92 ± 24 mmol/mol (11.2 ± 4.2% vs 10.6 ± 4.3%; P = 0.014) but did not increase after the intervention [89 ± 26 mmol/mol (10.4 ± 4.5%)]. Conclusions The cost and long-term risks of hospitalization among patients with Type 1 diabetes and recurrent admissions can be reduced by a combined specialist diabetes/mental health team approach. [ABSTRACT FROM AUTHOR]

Aims To establish whether an 8-week very-low-calorie diet could improve glycaemic control in Type 2 diabetes of long duration. Methods A total of 29 people with Type 2 diabetes [short-duration group (diabetes duration < 4 years), n = 15; long-duration group (diabetes duration > 8 years), n = 14] completed an 8-week very-low-calorie diet, with assessments of fasting anthropometry, blood tests and blood pressure at baseline and weeks 1, 4 and 8 of the diet. Results Similar weight loss was achieved in the short- and long-duration groups (14.8 ± 0.8% and 14.4 ± 0.7% respectively; P = 0.662). The glucose response to acute calorie restriction was heterogeneous in the long-duration group with some responding similarly to those in the short-duration group, some responding, but only slowly, and others not responding at all. Overall, HbA1c concentration in the short- vs. long-duration groups fell to 44 ± 2 vs. 64 ± 6 mmol/l (6.2 ± 0.2 vs. 8.0 ± 0.5%; P = 0.002). Fasting plasma glucose levels decreased to 5.8 ± 0.2 vs. 8.4 ± 1.1 mmol/l ( P = 0.024) respectively. A total of 87% of the short-duration group and 50% of the long-duration group achieved non-diabetic fasting plasma glucose levels at week 8. Clinically significant improvements in blood pressure and lipid profile were seen regardless of diabetes duration. Conclusion In people with Type 2 diabetes of > 8 years' duration, a therapeutic trial of a very-low-calorie diet may be undertaken with a 50% chance of achieving non-diabetic fasting glucose levels off all antidiabetic therapies. [ABSTRACT FROM AUTHOR]

Aim To provide estimates of the costs of severe and non-severe insulin-related hypoglycaemia in the UK using the Local Impact of Hypoglycaemia Tool. Methods Rates of hypoglycaemia were extracted from the UK Hypoglycaemia Study Group observational study. The costs of severe and non-severe hypoglycaemic episodes in insulin-treated adults with Type 1 and Type 2 diabetes were estimated from UK data sources. The rates and costs were then applied to specific populations to give an estimate of the cost of insulin-related hypoglycaemia for the UK, a specific locality, or a user-defined population. User-specific rates and costs could also be applied. Results The estimated cost of a hypoglycaemic episode can range from as much as £2,152 for severe episodes (for which the patient is admitted to hospital) to as little as £1.67 for non-severe episodes. With a UK population of 64.1 million, the total estimated cost of managing insulin-related hypoglycaemia is £468.0 m per year (£295.9 m for severe episodes, £172.1 m for non-severe episodes). On a local health economy level, using a hypothetical general population of 100 000, the total cost of managing insulin-related hypoglycaemia is estimated to be £730,052 per year (£461,658 for severe and £268,394 for non-severe episodes). Conclusions The Local Impact of Hypoglycaemia Tool highlights the economic burden of insulin-related hypoglycaemia. Non-severe episodes are often overlooked because of their low individual cost, but their high frequency makes the cumulative cost substantial. The Local Impact of Hypoglycaemia Tool also shows clinicians and budget-holders the economic impact of lower rates of hypoglycaemia. [ABSTRACT FROM AUTHOR]

Aim To investigate the association between pulse pressure and risk of hospitalization for cardiovascular events among people with Type 2 diabetes. Methods A population-based case-control study was carried out using data from medical databases. A total of 588 people with Type 2 diabetes from 18 general practices in Cambridgeshire recorded a first hospitalization for a cardiovascular event between 2009 and 2011, and a total of 2920 age-matched, gender-matched and practice-matched control subjects with Type 2 diabetes were selected based on risk-set sampling. Pulse pressure was assessed before admission in 2008-2009. Further dose-response relationships between pulse pressure and risks were explored using spline models. Results There was a non-linear relationship between pulse pressure and the risk of hospitalization for a cardiovascular event ( P < 0.001 for linearity test). The pulse pressure associated with the lowest risk of hospitalization for a cardiovascular event was 61 (95% CI 57-63) mmHg. Conclusion In people with Type 2 diabetes, pulse pressure is a good predictor of risk of hospitalization for cardiovascular events. The risk is lowest with a pulse pressure of 57-63 mmHg. [ABSTRACT FROM AUTHOR]