This article has been written by Dr Khan in his capacity as ‘Make Type 2 Diabetes Different’ campaign ambassador, and has been developed and funded by Novo Nordisk. Opinions expressed in this article are Dr Khan’s own, based on his clinical expertise. The Make Type 2 Diabetes Different campaign and the Make Type 2 Diabetes Different expert steering committee were initiated, organised and funded by Novo Nordisk. As a steering committee member, Dr Khan was paid honoraria by Novo Nordisk for his involvement in the campaign.
I have often heard type 2 diabetes being referred to as a 'lifestyle' disease – that it is the result of choices people have made during their lifetime that have affected their health in such a way in that they become insulin resistant.
In my experience, much of the management is about trying to get people with type 2 diabetes to change the way they behave in order to better their health. They are sent on courses that are aimed at educating them about food types and portion sizes. They are given appointments with specialist nurses, dieticians and doctors who give them further advice on how they can overhaul the way they eat and increase the amount of activity they do.
All of this is invaluable and certainly has a role to play. But coronavirus has opened our eyes to an uncomfortable truth, that often for many people their 'lifestyle' is not a choice, and that it may be a result of factors out of their control: poverty, education, genetics and lack of social movement.
The Make Type 2 Diabetes Different campaign, developed and funded by Novo Nordisk, aims to empower people with type 2 diabetes to make small changes to their lives to help them regain control of their condition. The campaign started by listening to insights shared by people living with type 2 diabetes about their challenges and unmet needs when it comes to managing their condition. A multidisciplinary expert steering committee was then convened and insights were used to inform the focus of the campaign.
Find out more about the Make Type 2 Diabetes Different campaign here: https://www.novonordisk.co.uk/MakeT2DdifferentHCPs
The article was initiated, funded and reviewed by Novo Nordisk.
We know that people from poorer socio-economic backgrounds are disproportionately affected by COVID-19 as a result of many of these factors, we also know that many of these things play a wider role on a person’s health, including the risk of them getting type 2 diabetes.1 And, in my opinion, we have also seen just how hard it can be to make policy changes on a national level that have an immediate effect on these populations.
Social determinants of health
According to Public Health England type 2 diabetes in England is 40% more common among those who are in social class V (people who are most socioeconomically deprived) compared with those in social class I.2 In addition, people in social class V are three and a half times more likely than those in social class I to be ill as a result of diabetic complications.2
Combine these statistics with the fact that if people with poorly controlled type 2 diabetes contract COVID-19 they are more likely to require hospitalisation3 and are at increased risk of death,4 it really has shown us that poverty and social class are not necessarily lifestyle choices but cycles that people simply feel powerless to break free from.
We need a fresh approach to how we treat these patients. GP surgeries often have a 'specialist' GP who manages the practice’s patients with diabetes, and they are often part of a team including a diabetes practice or specialist nurse and other professionals. In my experience, all of this can sometimes leave those without a 'specialist' interest in diabetes feeling deskilled.
Complications present in many ways
At my surgery, I am that GP with a specialist interest in diabetes. I get many 'tasks' and queries from my colleagues about everyday diabetic problems (and I must confess, I do the same to them when it comes their areas of interest). But this only works when patients come in to see their clinician with that enigma that is 'one problem'.
We all know that never happens – patients are complex and those with long-term conditions, more so. Complications of type 2 diabetes present in a myriad of ways and it is often hard enough for clinicians to decode them, let alone for patients to know that the symptoms they are presenting with may be related to their diabetes.
Whenever I talk to my GP trainees about type 2 diabetes they inevitably give me that look of fear: they feel it is too vast a topic for them to get their heads around and that there is someone else in the surgery who is better equipped to deal with it.
I tell them it is important to the patient journey that when they come in to see their clinician about a problem that may be diabetes related, rather than referring them to see a colleague, it is better that the clinician is able to advise the patient within that appointment. With type 2 diabetes rates predicted to increase in the UK,5 the waiting time to see even specialist GPs and nurses can be so long, patients could deteriorate while waiting.
Different approaches to type 2 diabetes
This is where different approaches to type 2 diabetes care are needed. Rather than bombarding people with information about what they 'should' be doing, we need them to know we understand what has got them to this point. In my experience, showing them a picture of a plate made up of carbohydrates, fruit, vegetables and meat that may not be culturally appropriate to them is simply a waste of time.
I want people with type 2 diabetes to take ownership of their long-term illness, I want them to be able to understand it fully and for them to come to us so we can give them the tools to manage their condition in a way that is appropriate to them.
That is why we have developed a Motivational Conversation Guide for healthcare professionals as part of the Novo Nordisk 'Make Type 2 Diabetes Different' campaign. This is a quick reference guide on how to apply motivational interviewing techniques during consultations with people with type 2 diabetes.
I have found motivational interviewing to be an invaluable technique to help people with diabetes talk themselves towards change, based on their own values and interests (rather than my own!). ‘Listening to understand’ is another key component of motivational interviewing, to help people with type 2 diabetes feel heard while also strengthening our relationship.
Download the Motivational Conversation Guide here: https://www.novonordisk.co.uk/MakeT2DdifferentHCPs
- Dr Khan is GP with a special interest in type 2 diabetes in Bradford.
- Sanders R. Evidence Search and Summary Service Outline: Covid-19, low incomes and poverty. Iriss 2019. Available at: https://www.iriss.org.uk/resources/esss-outlines/covid-19-low-incomes-and-poverty. Last accessed: April 2021.
- NICE. Public health need and practice. Type 2 diabetes prevention: population and community-level interventions. PH35, May 2011. Available at: https://www.nice.org.uk/guidance/ph35/chapter/2-Public-health-need-and-practice. Last accessed: April 2021.
- McGurnaghan SJ, Weir A, Bishop J et al. Risks of and risk factors for COVID-19 disease in people with diabetes: a cohort study of the total population of Scotland. The Lancet: Diabetes and Endocrinology 2021; 9: 82–93.
- Holman N et al. Type 1 and Type 2 diabetes and COVID-19 related mortality in England: a cohort study in people with diabetes. NHS England, 2020.
- Diabetes UK. Us, diabetes and a lot of facts and stats. Available from: https://www.diabetes.org.uk/resources-s3/2019-02/1362B_Facts%20and%20stats%20Update%20Jan%202019_LOW%20RES_EXTERNAL.pd. Last accessed: April 2021.
Document number: UK21DI00025
Date of preparation: April 2021