New NICE guidelines; what do they mean for T2 PWD?

This month saw NICE (The National Institute for Health and Care Excellence) publish new guidelines on the treatment of Type 2 (T2) diabetes. Although not mandatory, this document will have a profound impact on the way T2 people with diabetes (PWD) like myself receive treatment.

The recommendations represent an important watershed in T2 treatment, being the first update in 6 years, and are likely to be influential far beyond the intended scope of England and Wales.

What’s the good news?

Taking a non-technical look at the document itself, there are a number of things that I am happy to see. For me the most important is that the guidelines call for a more patient-centric style of treatment; an individually tailored approach to care that takes into account a person’s personal preferences, ability to benefit from long-term interventions, other medical conditions and risk from other medications. I never ceased to be amazed by what a varied bunch of humans we PWD are; each of us on a unique and complex journey that bears little resemblance to the thoughtless and cruel media stereotyping we see so often. Want to hear about my journey? Well you better pull up a comfortable chair and make a fresh pot of tea because it is a long story, and I wouldn’t expect yours to be any less complex either. So it is good to hear that we are going to be treated more individually; to what extent this happens when the guidelines collide with real life remains to be seen, but it seems a worthy starting point to me.

The guidelines also call for monitoring of blood pressure every 1-2 months, and intensifying therapy if the PWD is already receiving treatment for high blood pressure. As diabetics we are more likely than the general population to have high blood pressure issues, and it is well established that these can increase the risk of diabetes complications such as diabetic eye and kidney problems. Like the development of a more personalised treatment plan, a more active approach to monitoring and treatment seems like a good approach.

Another feature of the new guidelines is measuring HbA1c at 3 to 6 monthly intervals until their HbA1c is stable, and then every 6 months thereafter. As someone who has struggled to get his blood tested once a year, this sounds great to me

It is also great to hear a strong recommendation that structure education should be offered to patients and their family around the time of diagnosis. I have spoken to plenty of people who have received structured education, and it has been described to me as everything from “very helpful” to “a life changing experience”. Unfortunately as few as 16%[i] of newly diagnosed patients currently receive an offer of education, so the opportunity for more people to not only understand more about the condition, but to learn the skills needed to self‑manage diabetes is great news.

So it’s all good news?

Unfortunately no, it’s not all good news. My first concern is with the recommendation that adults are reminded about the importance of diet & lifestyle. Although this promises access to ongoing nutritional advice, this is unchanged since 2009 and centred on generic NHS recommendations for losing weight. The provision of this is already very spotty, and the report seems to have no recognition that the diets that work best for us vary a lot from person to person.

For most of us that have had success in managing our T2D, we have needed to make difficult and substantial changes in lifelong habits. If it were easy for people to change their lifestyle, the vast majority would have done so already, and to assume that PWD just needed to be better educated about lifestyle choices is to perpetrate unhelpful and often cruel stereotypes about those with T2D. The truth is, as ever, much more complex; if we are serious about helping people make significant changes in their lifestyles, they need to be provided with encouragement and practical support.

And the bad news?

The really bad news for me, and it is a big disappointment, is that not only is there no provision for self-testing of Blood Glucose outside a few exceptions[ii] , the recommendations seek to further restrict those that have access to self-testing already.

Critics say that there is no cost effective benefit to self-testing for PWD, that the overall effect of self-monitoring is small and that there is no published clinical evidence to support the benefits. However, this does not mean there is no evidence, but rather that it has not been gathered and interpreted. My personal experience, and that of every single T2D PWD I have spoken to, is that self-testing is an important part of coming to understand what is needed to better manage our condition, and understand the impact that different foods have on our blood BG control.

What can we do as individuals?

Whilst there are good and bad features in the guidelines, we need to remember that for most of us we will only have contact with a healthcare professional for a few hours a year at most. The rest of the time we need to take responsibility for managing the conditions ourselves. Here are a few tips that might help;

• Understand what health checks and services that every PWD should get; a good place to start is Diabetes UK’s 15 healthcare essentials. If you have a high tolerance for boredom, you might also wish to read through the document; it will help you understand what support should be available to you in the future
• Seek peer support; this comes in many forms but I would always suggest starting with the #GBDOC
• Reach out to those outside of our current peer support networks to offer support and advice to them
• Be more active! Head over to the good folks at Team Blood Glucose for advice on how to do this