Diabetes #trends we’d like to see in 2023.

1. Subsidised CGM for T2D

Findings from several large randomised controlled trials have demonstrated the clinical value of improving the overall outcomes and reducing hypoglycaemia risk in individuals with both type 1 diabetes (T1D) and type 2 diabetes (T2D).¹

Prevention is better than a cure, and this is articulated perfectly in the below research highlights:

Approximately 20%–30% of patients with T2D eventually require insulin therapy which leads to substantial reductions in A1C levels, acute diabetes-related adverse events and hospitalizations.¹‍

• In a Canadian chart review of 91 T2D adults managed with basal insulin therapy, there were significant A1C reductions
• A review of 363 T2D adults from three European countries assessed the effectiveness of flash GM use in conjunction with basal–bolus therapy, which showed significantly lower A1C levels after >90 days of flash GM use
• Studies highlight significant decreases in acute diabetes-related adverse events after just 6 months use of a flash GM device
• Findings from two studies, which assessed changes in A1C in T2D adults enrolled in the Onduo Virtual Diabetes Clinic telehealth program, showed that intermittent use of CGM was strongly associated with significant reductions in A1C
• In 55 patients with mean baseline A1C of 8.9%, intermittent use of the Dexcom G5 device resulted in a 1.6% reduction in A1C from baseline

In some cases, in the UK and Nordic countries, people living with T2D are able to access subsidised flash GM (Libre) systems to help them manage their diabetes. These countries can see the savings on offer in healthcare costs. Now it’s time to get it happening in Australia, and expanding the scope of how many people living with T2D are eligible for this access.

Subsidised (free!) CGM for women with T1D planning pregnancy and managing a pregnancy with T1D hit Australian shores in 2019. Women living with T2D are still waiting for this healthcare equality. Additionally, these women now make up 54% of pregnancies, compared to 27% in 2002-03.² What makes their health and the health of their babies any less important? Hyperglycaemia in pregnancy contributes to adverse outcomes for women and their children, regardless of type of diabetes and whether the person living with diabetes has access to subsidised CGM or not. We know this. So why aren't we doing more about it?

2. A focus on mental health from Health Care Providers (HCPs)

Not enough HCPs are asking how’s your mental health, or helping patients access a mental health care plan. Yet:

• 41.6% of adult Australians with diabetes also reporting medium, high or very high levels of psychological distress.³‍
• People living with diabetes are two to three times more likely than the general population to experience depression⁴ ‍
• People with depression are more likely to be diagnosed with type 2 diabetes⁵‍
• Diabetes distress and depression are separate constructs, but they are risk factors for each other⁶

Yes, diabetes is a fairly ‘invisible illness.’ We don’t really look sick. There’s nothing obviously wrong or "broken" about us. However, it’s very real. It’s very demanding and it’s very complex to manage. Cue= diabetes mental load.

A person living with diabetes will make over 100 diabetes-related decisions every day. It is more than a full-time job. It’s 24/7, you can’t take leave and there are certainly no holidays.

We are doing the best we can, but there is always room for support. There is never room for judgement.

There is no quick fix, there is no cure and there’s no way to prevent the disease. So we need more healthcare providers to be proactive in supporting the mental health of all people with diabetes, and ensuring they have access to these supports. Did you know that, currently, mental health assessments are not even part of our recommended annual cycle of care? Or maybe it is? The NDSS annual cycle of care checklist suggests that it is, but I guarantee that not many of us are being asked about our mental health on an annual, let alone regular, basis. Justine Cain, Diabetes Australia, CEO summed it up well:

“Diabetes mental health challenges are widespread, but they are rarely discussed as part of routine diabetes care. They really are a silent diabetes complication.”

There are many resources and guidelines that have been developed for health professionals, but the mental health needs of people with diabetes seems to remain a low priority. Diabetes technology and treatment options, management styles have evolved significantly (and continue to do so!)– but diabetes and mental health keeps slipping behind.

It’s not just about the demands of diabetes (thought his might be the key trigger). There is the constant worry about long-term complications, the stigma associated with diabetes, lack of awareness & understanding from those around us, the financial implications. Even the most care-free among us worry about these things, or are reminded of these by the healthcare professionals we see, our peers, our families, randoms on the street and keyboard warriors etc.

People with diabetes can experience diabetes distress: the emotional distress that can result from having diabetes and the pressure of relentless self-management of the condition, among other mental health conditions including depression and anxiety. 

Ask your patients how they are – how’s your mental health? Are you coping ok? – at every consultation. If you spend the whole time discussing mental wellbeing, and nothing about diabetes – that’s OK. Because that’s obviously what they need. And as I've said in previous blog posts: it’s patient health, not mental health.

3. Build up a stronger T2D community

The T1D community is strong, it’s fierce, it’s loud, it’s supportive. It’s a special club to be a part of, though no one ever really wants the membership they’re given.

The T2D community needs a stronger voice, and we need to support that voice. We know the stigma associated with T2D is real. The diabetes “jokes” are relentless (and not that funny). How can we expect a community to form, for people living with T2D to reach out to others for peer support or to engage in a community that is shamed so often. We want to see that changed. We are here to help make that happen, and we certainly hope to make that happen in 2023, but we need a collective voice to help make that happen. It requires health care professionals, patients, peers, family, friends and everyone else in between to get on board and stamp out the stigma. Let’s make it happen together.

4. More care plan visits

Currently, a care plan from your GP will get you up to 5 subsidised allied health appointments per year. However, those 5 visits can’t be used per allied health provider. Instead, those 5 visits are all you get for one year with all/any allied health providers you wish to see.

Best practice guidelines for diabetes management recommend a visit to see a diabetes educator every 3 months at a minimum. This only covers 4 visits per year, with one allied health provider, and it certainly doesn’t leave us much room for other reasons why you might need to see a CDE more frequently than once every 3 months (which many people will need!). Nor does it leave you with many visits to see other allied health providers such as a podiatrist, physio, exercise physiologist or dietitian.

We are so lucky in Australia that we have ever-changing technology, medication and management/therapy options. However, to hear about and access these new and innovative options, requires regular access to an experienced and knowledgeable healthcare provider.

No one living with a chronic health condition should be punished for it. More care plan visits make accessing the quality health care we have in Australia much more affordable, which has the flow on effect of improved health outcomes for the individual and reduced healthcare costs.

 Sources: 

1 – Diabetes Technology and Therapeutics Journal, vol 23, James R. Gavin and Clifford J. Bailey

2 - The National Pregnancy in Diabetes (NPID) Audit, Professor Helen Murphy at ATTD Conference 2022

3 - https://www.aihw.gov.au/reports/diabetes/diabetes-poor-mental-health-wellbeing-analysis/summary

4, 5 & 6 – Diabetes and Emotional Health, NDSS

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