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diabetes

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In the UK, more than 3.2 million live with diabetes, up from 2.1 million in 2005. The majority (90%) have type-2 diabetes, which is linked to poor diet and obesity.

Diabetes arises when the body loses its ability to use or make insulin, a hormone that helps regulate the amount of sugar in the blood, causing uncontrolled blood sugar levels. Patients with diabetes are at risk for macrovascular complications such as myocardial infarction and stroke, and microvascular complications such as nephropathy, retinopathy, and neuropathy. It can lead to devastating complications such as blindness, and was the cause of 22,000 early deaths last year.

Many diabetics experience peripheral neuropathy (nerve damage), which can result in a loss of sensation or persistent, nagging pain. The loss of sensation can lead to sores or infection in the feet, which, if left undetected necessitate lower limb amputation (135 per week across the UK); diabetic peripheral neuropathy can also cause gnawing, tingling, shock-like, or shooting pain in the extremities, which causes great distress and has no cure.

The spiralling numbers of diabetes patients, following the trend of obesity, shows that the public may still be unaware of the severity of these conditions.

Human cost aside, what about the NHS?

The dramatic growth in the numbers of people with diabetes underlines the urgent need for prevention, before the disease burden overwhelms the NHS.

  • The NHS spends 10% of its entire budget managing diabetes
  • Diabetes already costs the NHS nearly £10bn a year, and 80% of this is spent on managing avoidable complications
  • In 2014-15, there were 47.2 million items prescribed in England for diabetes
  • Diabetes prescription accounted for 4.5% of the total number of items prescribed and 10% of the total cost of all prescribing
  • Since 2005-6, prescribing of antidiabetic drugs has risen by 107%, with the net ingredient cost increasing by 138.6%

Despite this exorbitant spending, the charity Diabetes UK has warned that only 60% of patients receive all the care processes they require for effective monitoring and treatment. There is huge potential to save money and reduce pressure on NHS hospitals and services, but without successful diabetes prevention, this figure will unquestionably rise to unsustainable levels.

If nothing changes then what will happen?

The shocking recent headline that ‘Diabetes cases soar by 60% in past decade’ (1) is likely to have worried many, because – as with obesity – it is not an easily reversible trend. Many believe that obesity causes prediabetes (non-diabetic hyperglycaemia), a metabolic condition that almost always develops into type-2 diabetes

According to data from Public Health England, five million adults in England are pre-diabetic; using much broader criteria, Diabetes UK actually estimates a UK-wide figure of around 18 million people as being risk of developing diabetes; and the British Medical Journal suggests a staggering third of all adults in England are already pre-diabetic (2). However, some doctors have questioned the value of the pre-diabetic diagnosis (3), arguing that only a small number – perhaps one in 10 – will go on to develop diabetes.

Despite these widely variable outcome predictors for diabetes, the fact that diabetes prevalence has soared, and obesity – the greatest risk factor for developing DM – continues to “spread”, it is highly likely that diabetes prevalence will continue to grow.

Cause of diabetes: unhealthy lifestyle, genes or gut microbiota?

Diagnoses are not always clear-cut: obesity and diabetes result from complex interactions between environmental and genetic factors. However, with 80% of people with type-2 diabetes being overweight or obese at the time of diagnosis (according to the International Diabetes Federation), the explanation for the recent exponential increases in numbers of type 2 is being placed on the expanding waistlines of the nation. Excess abdominal fat is an especially high-risk form of obesity: abdominal fat causes pro-inflammatory mediators to be released from fat cells, which effectively reduce insulin responsivity, a major trigger for type-2 diabetes.

Recently gut microbiota has shown to be involved too. Using mice genetically predisposed to obesity and metabolic disorders Ussar and co-workers showed that this phenotype is the result of interactions between gut microbiota, host genetics, and diet (4). This is somewhat encouraging: individuals may be amenable “reprogramming” of microbiota for ameliorating the development of metabolic disorders and may offer hope for faecal transplants in the future.

So what’s new? Is it as simple as healthy eating and more exercise?

Although diabetes medication is routine treatment, it basically helps to control the condition and is not preventative. These drugs fall into many categories, such as alpha glucosidase Inhibitors (slow carbohydrate digestion), incretin mimetics, and thiazolidinediones (reduce insulin resistance), to name but a few. With diabetes, the old adage – that prevention is better than cure – is a huge understatement.

Although to many, healthy lifestyle choices are common sense and almost intuitive, the NHS is preparing to roll out a diet, weight loss and exercise programme that has been shown to reduce the diabetes risk for a quarter of those who take it up. However implementing these recommendations into real world settings is a challenge for many.

Most people understand that in order to reduce risk of developing diabetes or reduce complications associated with diabetes they need to lose weight, exercise and eat healthily, but can find it difficult to maintain, so therefore patient support is critical. Mobile applications and web-based technology can be useful in self-management, and particularly for lifestyle changes in patients with diabetes.

A review of internet-based interventions highlighted that they were focused on management of glycaemic controls and drug titrations and rather than lifestyle changes, and that in this respect they lacked behaviour theory and educational components (5). This comes as a surprise as the lifestyle choices could be both cause and cure for the disorder. Promisingly, they found the tools available demonstrated improvements in behavioural, physiological outcomes as well as improved knowledge and self-efficacy. This suggests that utilisation of the almost ubiquitous smartphone as a motivational and educational tool may hold promise for managing type-2 diabetes for individual and peer-to-peer support using social media.

Another school of thought believes that a more drastic method is required: bariatric surgery. A recent study demonstrated that half of the type-2 diabetes patients who had weight loss surgery were cured for at least two years (6). Overall they were less likely to have heart problems (a common side-effect of uncontrolled diabetes), and reported improved quality of life and even those who weren’t cured were able to better manage their symptoms. In fact, so effective is this approach that NICE guidelines have reduced the threshold for consideration for surgery from a BMI of 35 with concurrent health to a BMI of 30-35 (7).

Clearly, in order to slow this wave of diabetes something must change, whether it is a more aggressive pre-symptomatic diagnostic phase with education and behavioural therapy, or decisive action regarding surgery at early stage or more effective symptomatic treatment. Technology must be embraced, so that patients can self-manage, self-motivate and prevent diabetes and its deleterious complications before NHS resources are overwhelmed with what is largely a preventable disease.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. http://www.bbc.co.uk/news/health-33932930.
  2. Wise J. A third of adults in England have “prediabetes,” study says. BMJ. 2014;348:g3791. Epub 2014/06/12.
  3. Yudkin JS, Montori VM. The epidemic of pre-diabetes: the medicine and the politics. BMJ. 2014;349:g4485. Epub 2014/07/17.
  4. Ussar S, Griffin NW, Bezy O, Fujisaka S, Vienberg S, Softic S, et al. Interactions between Gut Microbiota, Host Genetics and Diet Modulate the Predisposition to Obesity and Metabolic Syndrome. Cell metabolism. 2015;22(3):516-30. Epub 2015/08/25.
  5. Cotter AP, Durant N, Agne AA, Cherrington AL. Internet interventions to support lifestyle modification for diabetes management: a systematic review of the evidence. Journal of diabetes and its complications. 2014;28(2):243-51. Epub 2013/12/18.
  6. Arora T, Velagapudi V, Pournaras DJ, Welbourn R, le Roux CW, Oresic M, et al. Roux-en-Y Gastric Bypass Surgery Induces Early Plasma Metabolomic and Lipidomic Alterations in Humans Associated with Diabetes Remission. PloS one. 2015;10(5):e0126401. Epub 2015/05/07.
  7. http://pathways.nice.org.uk/pathways/obesity – path=view%3A/pathways/obesity/surgery-for-obese-adults.xml&content=view-node%3Anodes-people-with-recent-onset-type-2-diabetes.

 

Image: ©Yuganov Konstantin/Shutterstock #95643241

Developments in both the sophistication and affordability of mobile technologies using custom-designed hardware and software are changing how healthcare is delivered, received and researched. Healthcare workers and pioneers alike are embracing mobile technology, including social media educational tools, mobile apps, wearables and other digital tools.

Ambulatory monitoring or telemonitoring has been routine practice for preventing heart failure for many years (1). However, recent advances in smartphone and tablet technology have allowed the development of highly integrated and complex information systems. Mobile technology removes geographical and temporal boundaries by remotely communicating and monitoring real-time physiological information guaranteeing user interoperability, and importantly– connectivity. These functions, including more basic features (such as automatic reminders for medication or therapy) could hugely benefit the efficiency and quality of healthcare.

How does this influence healthcare systems and how it is likely to evolve in the future?

The potential for doctors and nurses to monitor patients remotely through internet-connected devices could streamline healthcare systems. On-duty doctors could receive the required data such as blood glucose levels, ECG data or mood ratings; then diagnose, prescribe treatment as well as monitor therapeutic effects via remote monitoring; and share this patient data on a centralised system.

Mobile technology could vastly reduce administration times, permitting knowledge transfer and faster decision-making and delegation of tasks – compared with the current system of handwritten notes, fixed terminals and pagers – drawing nurses away from their patients. Mobile and digital technology could allow nurses be at their patients’ bedsides whenever required ultimately improving the quality of care.

Outpatients and caring at home

There is also a desire to shift the point of care to the outpatient setting and the patient’s home, and this necessitates innovations in technology. Mobile technology is already popular in several specialist medical fields, including oncology, cardiology, diabetes and mental health.

Currently available mobile technology allows earlier diagnosis as well as both long-term and long-distance monitoring of patients with cardiovascular diseases(2). Healthcare costs and hospital admission can be reduced by remotely monitoring cardiac patients using implantable devices (3). Post-hospital patients can benefit from routine ECG measurement and data transmission from home to hospital; data captured by ECG devices at home by patients are transmitted to the hospital using wireless networks and the internet (4). Likewise, the field of oncology has many relevant apps at its disposal (5)and a recent pilot study of these shows great promise in monitoring in-hospital chemotherapy as well as management and treatment of cancer at home (6).

Application of mobile technology in diabetes mellitus care is making rapid strides and could transform how this condition is managed for both patient and practitioner: self-reported glucose data can transmitted, amassed with relevant physiological data, and analysed (7); data-support apps can assist with decision smaking, and in some cases direct patients to make decisions without their clinician’s input (8). Facilitating a holistic approach, patients with diabetes can use the information presented by apps to help guide their choices of medication doses, foods, or exercises.

Currently, diagnosis of mental states has been based on subjective self-reporting by patients. However, although a relatively new application in psychiatry, using mobile technology the emerging data is very encouraging with respect to both assessment (9) and intervention (10).  Mobile technology can be used for measurements (e.g., functional behaviours, mood states, and psychotic symptoms), and providing unique information concerning relationships between daily life contexts, behaviours, and experiences.

Mobile technology in research

Underlying mechanisms of disease can only be understood by measurements of physiological parameters. The generalisability of these measurements to real-life settings can be limited when using questionnaires or tests performed in practices or hospitals. The ultimate goal for clinical researchers is to be able to provide biological markers (biomarkers)of disease, in order to assess and diagnose patients on a very individual basis. By utilising these novel technological tools – including mobile applications and handheld microcomputers like smartphones and tablets, there is an opportunity to measure physiology, cognition and other behaviours and to proactively treat conditions in patients before complications have progressed.

Considerations, limitations and future refinements

The torrential amount of data streaming from such devices must be managed efficiently, as doctors will not have time to analyse this information unless it leads to improved patient outcomes, time-saving, or economic benefit. Therefore mobile app software for decision support must be developed to deal with interpretation of this physiological data. According to an Ipsos report, the future application of mobile technology in healthcare must be clarified. Although its use in monitoring was the top function identified, most new doctors (73%) couldn’t say exactly what they wanted it to do (11).Other challenges with mobile technology usage include the appropriate maintenance of professional relationships between colleagues, and between doctors and patients as well as patient privacy. As with all healthcare interventions, high quality adequately powered trials are required to evaluate effects on objective outcomes.

Mobile technology has great translational capacity and is a powerful tool for facilitating the personalised care that is very much needed across healthcare, although its full potential remains to be realised. As digital-native, younger generations move through the ranks of healthcare, mobile innovations will be increasingly embraced and become commonplace.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. Roglieri JL, Futterman R, McDonough KL, Malya G, Karwath KR, Bowman D, et al. (1997): Disease management interventions to improve outcomes in congestive heart failure. The American journal of managed care. 3:1831-1839.
  2. Neubeck L, Lowres N, Benjamin EJ, Freedman SB, Coorey G, Redfern J (2015): The mobile revolution–using smartphone apps to prevent cardiovascular disease. Nature reviews Cardiology. 12:350-360.
  3. Banchs JE, Scher DL (2015): Emerging role of digital technology and remote monitoring in the care of cardiac patients. The Medical clinics of North America. 99:877-896.
  4. Brunetti ND, Amodio G, De Gennaro L, Dellegrottaglie G, Pellegrino PL, Di Biase M, et al. (2009): Telecardiology applied to a region-wide public emergency health-care service. Journal of thrombosis and thrombolysis. 28:23-30.
  5. McCann L, Maguire R, Miller M, Kearney N (2009): Patients’ perceptions and experiences of using a mobile phone-based advanced symptom management system (ASyMS) to monitor and manage chemotherapy related toxicity. European journal of cancer care. 18:156-164.
  6. Doyle-Lindrud S (2014): Mobile health technology and the use of health-related mobile applications. Clinical journal of oncology nursing. 18:634-636.
  7. Klonoff DC (2013): The current status of mHealth for diabetes: will it be the next big thing? Journal of diabetes science and technology. 7:749-758.
  8. Rao A, Hou P, Golnik T, Flaherty J, Vu S (2010): Evolution of data management tools for managing self-monitoring of blood glucose results: a survey of iPhone applications. Journal of diabetes science and technology. 4:949-957.
  9. Granholm E, Loh C, Swendsen J (2008): Feasibility and validity of computerized ecological momentary assessment in schizophrenia. Schizophrenia bulletin. 34:507-514.
  10. Spaniel F, Vohlidka P, Kozeny J, Novak T, Hrdlicka J, Motlova L, et al. (2008): The Information Technology Aided Relapse Prevention Programme in Schizophrenia: an extension of a mirror-design follow-up. International journal of clinical practice. 62:1943-1946.
  11. http://www.emarketer.com/Article/Europes-Doctors-Embrace-Digital-HelpersUp-Point/1012837?ecid=NL1002

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