The impact of diabetes and the challenges it presents individual patients, their families and health services is a major issue of interest and concern. At present an estimated 3.5 million people in the UK have been diagnosed with diabetes but it is predicted that up to a further 549,00 people have diabetes that is yet to be diagnosed. Type 2 diabetes in particular has been growing at the particularly high rate and is now one of the world’s most common long term health conditions.
The impact on people who live with diabetes is considerable but its diagnosis and treatment costs also create a huge issue for the NHS. It is estimated that 10% of the NHS budget for England and Wales is spent on diabetes.
This Collection brings together NIHR research on several aspects of diabetes. We asked a number of health professionals and people with lived experience of diabetes to comment on selected Alerts that are relevant and important to them. Their commentary highlights what we can learn from the research summarised in the Alerts to better understand current approaches to the diagnosis and treatment of diabetes.
The Alerts included in this Collection are:
- The benefits and harms of aspirin for people with type 2 diabetes are finely balanced
- Self-monitoring of blood glucose provides no important benefit for most people with type 2 diabetes
- Diet and exercise can reduce the risk of developing diabetes during pregnancy
- Losing weight following type 2 diabetes diagnosis boosts chance of remission
- Damage to kidneys and eyes may start before people are diagnosed with diabetes
- New tool for assessing the severity of type 2 diabetes could help personalise treatment and improve outcomes
The benefits and harms of aspirin for people with type 2 diabetes are finely balanced
Johnny Lyon-Maris, General Practitioner
"The cry of “should I be taking a daily junior aspirin for this, doctor?” are heard regularly by all GPs. Of course the decision is ultimately the patient’s, but we are there to give the best information possible for health improvement. Although the evidence here is not clear cut, it reinforces the fact that I can continue (at the moment) to follow NICE guidance and not take aspirin for primary prevention in type 2 diabetes. The caveat of course is that it did help prevent vascular events in 1 in 100 patients, but also caused a major bleed in 1 in 100. As GPs we are masters of balancing risk and benefit and here is the perfect example of where they are equal."
Professor Kamlesh Khunti, Professor of primary care, diabetes, vascular medicine and a general practitioner, University of Leicester
"Diabetes is associated with cardiovascular disease and there is good quality evidence for the benefits of aspirin in people with established cardiovascular disease. However the use of aspirin for primary prevention of cardiovascular disease in people with diabetes has been controversial.
"This was a large randomised controlled trial with a long follow-up. The primary outcome was the first serious vascular event (myocardial infarction, stroke or transient ischemic attack or death from any vascular cause). The study shows that there was a significant 22% relative risk reduction in a primary outcome in favour of aspirin 100 mg. However, there was a significant 29% higher risk for major bleeding mainly gastrointestinal and extracranial bleeding.
"There is clear evidence for me in terms of clinical practice, and as suggested by NICE type 2 diabetes guidelines, that I would not be using aspirin for primary prevention of cardiovascular disease. However, there are a number of people with type 2 diabetes who have previously been commenced on aspirin for primary prevention. These are patients I would like to have a discussion at their consultation to see if they would like either to continue on low dose aspirin or stop the aspirin based on the findings from this study. While they have a small reduced risk of a cardiovascular event, this is offset by a high risk of a major bleed. I would leave it to the patient to decide whether they would like to stop the aspirin. Additionally low dose aspirin in this population normally needs to be prescribed with gastro-protective proton pump inhibitors. This adds to the number of the medications taken. Having to take numerous medications has been shown to be associated with poor adherence which could affect intake of the more beneficial drugs that the patient may be taking such as antihypertensive medications and statins."
Self-monitoring of blood glucose provides no important benefit for most people with type 2 diabetes
Angelina Whitmarsh, lives with type 2 diabetes
"Although this review shows there is no apparent long-term clinical benefit from self-monitoring of blood glucose, consideration should be given to the emotional effect. When I was first diagnosed with type 2 diabetes - and initially not on insulin - all I had was the six-monthly or yearly HBa1c results to give me any idea of my control and how well I was doing. So perhaps it should be highlighted that offering a short term period of blood test monitoring could have emotional/psychological benefits which impact on the whole person and their self-care, and could help to defer or prevent some long term complications as the person feels more engaged with their diabetic care from the start."
Johnny Lyon-Maris, General Practitioner
"Some of us love a gadget, and monitoring blood glucose can be helpful for patient activation but can also become obsessive in some. As a GP I have patients that are very keen to self-monitor their type 2 diabetes. This evidence is helpful to reinforce the fact that self-monitoring in most type 2 diabetes patients provides no difference in glucose control at 12 months, compared to not self-monitoring. It’s also worth bearing in mind that although the blood glucose monitoring meters are often provided free by the manufacturer, the cost to the NHS is significant in the prescribing of the monitoring strips."
Claire Senior, lives with type 2 diabetes
"I am very interested in the findings of this research which are obviously clinically correct but they don’t take into account the mental and emotional aspects of testing. I have had type 2 diabetes for 27 years now, controlled by diet, metformin and saxagliptin. It is the ability to self monitor which has helped me to keep my HBa1c stable and sufficiently low to keep me and my doctor happy. I only monitor a few times a week or if I am not well. If I am aware that my blood sugar is high according to my monitor I work hard to ensure that it comes down over the next few days by watching what I eat very carefully and upping my exercise level. It may not be statistically significant over the long term but the confidence it gives me in managing a condition long term is very important to my mental health. It is important to remember that we live with diabetes all the time, only having dealings with medical experts for less than an hour per year and the value of taking control for ourselves is very significant. For this reason, I think that for those who use it responsibly it is essential for them to be able to do it and its value should not be measured in clinical statistics only."
Diet and exercise can reduce the risk of developing diabetes during pregnancy
Dr Lucy Chambers, Head of Research Communications at Diabetes UK
"We know that around 16% of pregnancies in the UK involve gestational diabetes. We also know that gestational diabetes increases the likelihood of poor health for both mother and baby, and adds to their risk of developing metabolic conditions, such as type 2 diabetes, in the longer term. Interventions to prevent gestational diabetes from developing in the first place are therefore likely to significantly benefit the health of this and future generations.
"Guo and colleagues’ research is encouraging as it provides further evidence that interventions that support women to improve their diet and exercise habits during the first half of pregnancy can reduce the risk of gestational diabetes developing, and pinpoints factors that are important for the success of such interventions. It is research such as this which underpins decisions in Diabetes UK about how we can best achieve our ambition of a world where diabetes can do no harm."
Sarita Tailor, recently treated for gestational diabetes
"When I developed gestational diabetes last year, it came as a shock because I was unaware of diabetes in pregnancy. My risk factors were high: being of Indian origin, my age, being overweight and my family history of diabetes.
"The title of this Alert resonates with me because I believe it to be true, that yes, diet and exercise can help to reduce the risk of developing diabetes. However, it’s important to remember that one needs to be aware of firstly your risk factors of developing gestational diabetes and secondly, what can be done about it. Factors such as a family history of diabetes can be important, but are out of our control.
"If I were to have other children, I would do things very differently, as a result of having experienced gestational diabetes and not wanting to develop diabetes later on in life. Whilst I had gestational diabetes, I changed my eating habits to reduce my carb intake and increase my protein intake, and as a recommendation from the midwives, I moved about more, be it dancing about in my kitchen after a meal or a brisk walk.
"I believe that awareness amongst the high risk groups needs to be raised and ways of preventing the onset of gestational diabetes are also needed. For example, at the diabetic clinic where I saw the dietitian, another Indian lady was present but she did not understand how her blood sugars were high due to her diet. Some education around a diet high in carbohydrates would have been beneficial to her.
"It appears from the Alert that more research is needed in the UK. I would like to see more research into why Indian/Asian women are developing diabetes."
Angelina Whitmarsh, experience of gestational diabetes
"As someone who had gestational diabetes with both of my pregnancies this is particularly interesting to me. Mine were 31 & 28 years ago so exercise in particular was not encouraged and it was very much ‘take it easy’ and ‘eating for two’! Now we know that diet and exercise can be adapted to suit all ranges of fitness and any activity that encourages an increase in heart rate can be beneficial so in my opinion this is a very important Alert that needs to be flagged up with medical professionals to discuss with at-risk patients."
Mary O’Kane, Honorary consultant dietitian in adult obesity at Leeds Teaching Hospitals NHS Trust
"This research is important as it may decrease the number of women developing gestational diabetes.
"Supporting people to make dietary changes and become more physically active are key components of treatment for gestational diabetes. Many people attending our clinics will have a long history of dieting and weight regain. Although people are motivated to lose weight and improve their health, sustaining behavioural changes over a long period of time is difficult. Addressing barriers and encouraging people to continue with small achievable goals are important. Within our clinic population, we have women who wish to become pregnant and are keen to reduce the risk of any pregnancy-related complications.
"As a dietitian, my main focus of discussion is often on addressing barriers to dietary and lifestyle changes. This research has made me consider that I should start having discussions about the positive benefits of physical activity in pregnancy, especially with respect to prevention of gestational diabetes.
"The research suggests that women of Asian, African or Latin American origin had greater success of preventing gestational diabetes with dietary and physical activity interventions. Women should be given the opportunity to discuss dietary changes which take account of their culture. It is important that the dietary changes are easy to implement and accepted by the family too. For many people, changing from sedentary behaviours to achieving moderate intensity exercise for 50-60 minutes twice a week, may seem an unachievable and realistic target. It would need careful discussion. Community based programmes, which take account of cultural differences and are able to offer a range of options with physical activity interventions may be helpful to addressing barriers. Using apps such as Active 10 available from the One You NHS website may help women increase brisk walking in incremental steps.
"It is important that midwives are aware of this research so that there can be local discussions about how best to identify those who are at greater risk of developing gestational diabetes and who would benefit from support in the areas of weight management, dietary and physical activity interventions."
Losing weight following type 2 diabetes diagnosis boosts chance of remission
Suella Postles, in remission from type 2 diabetes
"“People who lost at least 10% of their body weight in the first year after diagnosis of diabetes were more likely to achieve remission at five years compared to those with stable or increased weight” I see myself as a good example of how this process can work and this Alert is an important wake up call for me to continue to watch my diet. Once diagnosed as pre-diabeteic last year, I immediately went through all my foodstuffs. All with any sugars went. I also got rid of almost all of my processed foods except those that were lower carbohydrate. My theory is if it isn’t in the house I won’t eat it... At my annual August check up I had somehow lost 16 lbs, a pleasant surprise. I was contacted by the Diabetes nurse who told me I was in remission and didn’t need to attend clinic until August 2021. I’m still tackling my enlarged waistline, eating our organic vegetable garden produce, attending my diabetes classes and groups and walking as far as my Chronic Fatigue Syndrome permits. I’m sure there is more to learn. I’ll work to get that stubborn visceral fat off simply to prolong my life."
Mary O’Kane, Honorary consultant dietitian in adult obesity at Leeds Teaching Hospitals NHS Trust
"The message that achieving at least a 10% loss of body weight in the first year after diagnosis of type 2 diabetes increases the incidence of remission at 5 years, is a powerful one to give.
"In the medical obesity and bariatric surgery services we have found that many people we support with severe and complex obesity tell us that a diagnosis of type 2 diabetes is a motivator for improving health. This Alert encouraged me to find the research paper and read more about the study.
"As a dietitian, I have always advised that weight loss is likely to improve the management of type 2 diabetes. The DiRECT study, which uses low calorie meal replacement drinks, has raised awareness amongst the general public that type 2 diabetes remission may be achieved; however, not everyone is able to adhere to the liquid meal replacements. Being able to state that achieving at least a 10% weight loss in the first year after diagnosis of type 2 diabetes is more likely to achieve remission at five years is a powerful message. The fact that it was achieved without intensive dietary and physical activity interventions may appeal to many.
"From the research, the people in this study were predominately white and seemed to have a BMI around 33-34 kg/m2 at the start of the programme. People who have recent onset type 2 diabetes are likely to benefit from this research. It is important that people have access to a range of treatment options that they are able to select from.
"Being able to diagnose type 2 diabetes early and have a sensitive, non-judgemental, non-stigmatising conversation with the individual in which objective information about treatment options are discussed, is very important. This research has been undertaken in primary care with GP and nurse input. Although the consultations were short, access to appropriate education material was available. Sharing of resources already developed would be helpful. Achieving at least 10% loss of body weight by less intense diary and physical activity interventions may be attractive and achievable to people who have recently been diagnosed with type 2 diabetes."
Angelina Whitmarsh, lives with type 2 diabetes
"This Alert shows what is possible for some people, though my own experience was different. Losing weight after diagnosis or even in the pre-diabetic stage can only have a positive effect long term. I lost three stone in weight but not until five years after diagnosis, so no reversal for me. I feel not enough is made of the long term impact that this diagnosis has on your life and the devastating effects of possible complications. People need to be shocked into taking hold of this diagnosis and then supported to make the changes needed. This will also overall reduce NHS costs of long term medications and the costs of treating complications."
Johnny Lyon-Maris, General Practitioner
"It is a striking fact that 1 in 10 adults over 40 have type 2 diabetes in the UK at a cost to the NHS of £6 billion a year. This study provides compelling evidence that for people not on diabetic medication or having had bariatric surgery, weight loss can put you into remission at five years after diagnosis. The best chance is to lose 10% of your body weight in the first year after diagnosis. This reinforces the importance of health professionals giving their newly- diagnosed diabetic patients support and encouragement. In my view it cements the necessity for the use of health coaches and psychological support for behavioural lifestyle change with patients. As a health professional I will continue to support and affirm the importance of weight loss, even with all the additional pressures on primary care, and not give up."
Dr Lucy Chambers, Head of Research Communications at Diabetes UK
"Research on remission of type 2 diabetes has turned the tables on what is possible for people with type 2 diabetes. For far too long, type 2 diabetes was accepted as a condition you lived with for life. But we no longer consider the condition to be life-long for everyone and now know that remission is a real possibility for some people.
"This research again underscores how important weight loss is for putting type 2 diabetes into remission and shows that even moderate weight loss can be beneficial. While this study and others, including the seminal DiRECT trial funded by Diabetes UK, focussed on diet and exercise for weight loss, we know that this doesn’t work for everyone and that some people may require different approaches or extra support go into remission. That’s why it’s important to continue to build our knowledge of remission and invest in new research that will uncover new ways to make remission a reality for more people with type 2 diabetes."
Damage to kidneys and eyes may start before people are diagnosed with diabetes
Suella Postles, in remission from type 2 diabetes
"This Alert is a good reminder to those of us living with the threat of type 2 diabetes of how much damage the disease can inflict on eyes and kidneys, even before diagnosis. It has made me think again about how important it is to watch my diet to keep diabetes at bay. When I was diagnosed I asked for a referral to our local eye specialist in Loughborough who said my eyes were fine. I am in remission now and intend to keep it that way."
Sharda Lavingia, lives with type 2 diabetes
"I found this Alert very interesting and useful as it makes clear the damage that diabetes can cause to the body. My husband had chronic kidney failure some years back and he received a kidney transplant so we are well aware of the impact that kidney damage has on people's lives. While he has done well with his transplant, kidney disease and the experience of the surgery is life-changing.
"In my husbands’ case he was diagnosed with diabetes after he received his kidney transplant - a shock for both of us, especially for him.
"I feel being aware of this kind of research is extremely useful as we get to know how diabetes impacts on someone’s life on a daily basis, and learn ways to cope with it."
New tool for assessing the severity of type 2 diabetes could help personalise treatment and improve outcomes
Angelina Whitmarsh, lives with type 2 diabetes
"As we are aware type 2 diabetes varies considerably between each person diagnosed with it, therefore a personalised analysis of the individual will not only make that patient feel more engaged as it is 'just about me' but will also give their condition the precise care that will achieve the best results and reduce their HBa1c, most definitely a win-win for patients, clinicians and NHS alike."
Learn more about our contributors
Dr Lucy ChambersLucy spent many years studying people’s eating behaviours as a PhD and postdoctoral researcher at the University of Sussex and University College London. She maintains links with the University of Sussex as Honorary Senior Research Fellow. Lucy subsequently moved to the charity sector in 2015 to work as Senior Scientist at the British Nutrition Foundation, before being appointed as Head of Research Communications at Diabetes UK in 2020. Lucy was diagnosed with type 1 diabetes in 2008.
Professor Kamlesh KhuntiProfessor Kamlesh Khunti is Professor of Primary Care Diabetes and Vascular Medicine at the University of Leicester, UK. He is Co-Director of the Leicester Diabetes Centre and leads a research group that is currently working on the early identification of, and interventions with, people who have cardiometabolic disease or are at increased risk of developing cardiometabolic diseases.
Sharda LavingiaSharda Lavingia came to the UK in 1970 from Uganda. She has had type 2 diabetes for the last 20 years as have many of her family members but has managed to keep it under control through regular practice of yoga, breathing exercises, meditation,diet and exercise. She lives in Birmingham where she works as a mindfulness trainer and holistic therapist, and is active in her local community.
Johnny Lyon-MarisJohnny Lyon-Maris is a GP and a member of the board of his local Clinical Commissioning Group. Johnny is an Associate Dean for GP Education in Wessex, Honorary Professor at the University of Winchester and an active medical education researcher. He also works as an International Development Advisor for MRCGP[INT] for Kosovo and facilitator for primary care physicians in Kuwait.
Claire Senior
Claire Senior has been living with type 2 diabetes for 27 years. Since her retirement from teaching 10 years ago Claire has been involved in a number of diabetes initiatives including being an enabler for a self help group in her village and teaching on a research project for Addenbrookes hospital.
Mary O’Kane
Mary O’Kane is an honorary consultant dietitian in adult obesity at Leeds Teaching Hospitals NHS Trust. Mary’s dietetic experience is in supporting people with severe and complex obesity in the medical obesity and bariatric surgery services. Many people she supports have type 2 diabetes.
Suella PostlesSuella Postles was diagnosed as pre-diabetic in October 2019, while she was doing a demanding one-year college course in horticulture and supporting family members with their illness. She found self-help groups and monthly NHS courses to enable her to learn to manage the condition by losing weight, keeping active and getting well-informed about diabetes.
Sarita TailorSarita Tailor works for a mental health charity. Having experienced gestational diabetes last year, she is now a mum to a beautiful baby girl. Sarita enjoys staying active and healthy for herself and her family.
Angelina WhitmarshAngelina was diagnosed with gestational diabetes in both her pregnancies. After a gap of 13 years, in 2005 she was diagnosed with type 2 diabetes, initially being put straight onto tablets and then in 2009 onto insulin. Angelina runs a support group through Diabetes UK for people living with all types of diabetes and has been part of many research panels and advisory groups. She is a patient representative with Clinical Commissioning Groups, providing feedback on services and pathways.
