1. Changing trends in Diabetes in a GP Practice Tim Walter

2. Background Falkland Surgery population of 14,500 in Newbury Market Town Main practice demographic is of an average age split but higher than average elderly population c.f. locally (75yrs+) Some pockets of deprivation High level of employment

3. Trends 2000 Type 1 DM = 44 Type 2 DM = 150 (194) 2005 Type 1 DM = 56 Type 2 DM = 250 (306) 2008 Type 1 DM = 66 Type 2 DM = 369 (435) 2012 Type 1 DM = 73 Type 2 DM = 399 (472) Therefore the massive increase in DM is predominantly in the Type 2 group About 3.5% of population

4. Why diagnose early? At diagnosis UKPDS showed 39% H/tension 24% microalbuminuria 24% ECG changes of Ischaemia 50% had some sort of complication

5. “Pre-diabetes” IGT, IFG, Gestational DM, metabolic syndrome etc Now also looking to include a “Risk Assessed” group Conversion Rates Not clear what conversion rate of risk scored pts might be But IGT carries approx. 50% 10yr conversion rate to DM Risk reduction In USA up to 58% reduction in progression to DM with lifestyle intervention (71% in older pts) DPP showed 16% risk reduction per Kg lost

6. QDiabetes at Falkland Surgery In practice we looked at a subgroup of pts age 35+, BMI > 35, excluded other med problems Chose this population to restrict workload Calculated score and selected pts with 10yr risk score of 20% or more (50 pts) i.e. 1 in 5 of these patients predicted to develop DM in the next 10 yrs Most will be “normal”, some have IGT, some have DM

7. Results from Selected Group Average Age 60 Average HbA1c 40 13% pts with HbA1c > 42 (non DM threshold) 16% pts with fasting BS > 5.6 QDiabetes scores 20-49.9% Often large variation in QRisk and QDiabetes scores for an individual eg 8% vs 49%, 10% vs 30% (Ave 15% vs 30%)

8. Project Invitation to participate Baseline blood tests (Renal, Fasting BS, Cholesterol, HbA1c, LFTs etc) Nurse appt to record details of weight, waist, smoking etc Randomly allocated to two intervention groups 10 week Eat4Health vs 10 week Walking4Health Repeat measurements

9. Interventions Eat4Health Established, effective, 10 week group sessions looking at diet, exercise, attitudes to food and diet Walking4Health 1/2hr co-ordinated walking program over same time period Repeat monitoring Rollout to other local practices if successful

10. Eat4Health – Waist Circumference

11. Eat4Health – Weight Loss

12. Eat4Health - Activity

13. Summary Small scale project (approx 25 pts) Workable, practical application of evidence based tools Transferrable Issues Does it work, short-term, long-term? Short term costs, longer term benefits if it does work Costs approx £20 plus bloods, plus admin per pt

14. Proposed plans for the CCG Identify at risk groups Promote the use of QDiabetes across populations Support the workload involved across the CCG However, useless unless action taken as a result Intervention for identified patients Eat4Health Walking4Health Other surgery based initiatives

15. References Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes research and clinical practice 2010;87(1):4-14. Diabetes UK: Diabetes in the UK 2010: Key statistics on diabetes http://www.diabetes.org.uk/Documents/Reports/Diabetes_in_the_UK_2010.pdf, March 2010. Holt TA, Stables D, Hippisley-Cox J, O'Hanlon S, Majeed A. Identifying undiagnosed diabetes: cross-sectional survey of 3.6 million patients' electronic records. Br J Gen Pract 2008;58(548):192-6. Harris MI, Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis. Diabetes Care 1992;15(7):815-9. Yates T, Davies M, Khunti K. Preventing type 2 diabetes: can we make the evidence work? Postgrad Med J 2009;85(1007):475-80. Tuomilehto J, Lindstrom J. The major diabetes prevention trials. Curr.Diab.Rep. 2003;3(2):115-22. Hippisley-Cox J, Coupland C, Robson J, Sheikh A, Brindle P. Predicting risk of type 2 diabetes in England and Wales: prospective derivation and validation of QDScore. BMJ 2009;338:b880.

17. Qdiabetes http://www.bmj.com/content/338/bmj.b880.full Qresearch - 11 million pts Integrated within Emis 25-79yr olds M&F Cohort of 2.5 million pts

18. Other stuff for reference Ignore slides below

19. Early Detection Computer system analyses and flags up patients with previously raised sugar levels. Work done in University of Warwick, published in BMJ and we have been running this for about 2 years Random BSs over 11, fasting over 7 without codes to indicate diagnosed already Looked at 12 patients with potentially missed DM, 9 were subsequently confirmed Ongoing process as new patients arise Second group with random BS over 7

21. National Initiatives We need to see co-ordinated education and action Publicity on healthy living Labelling Role models Newspapers/Magazines/Advertising Prevention better than cure However this costs money now, but won’t show results for many years