NHS Diabetes Prevention Programme

There are currently 5 million people in England at high risk of developing type 2 diabetes – if trends continue then by 2034, one in ten will develop type 2 diabetes (NHS England, 2021). 

There is strong international evidence that behavioural interventions can significantly reduce the risk of developing the condition, through reducing weight, increasing physical activity and improving the diet of those at high risk (NEJM, 2001).

The NHS Diabetes Prevention Programme (NHS DPP) aims to target those identified at high risk and refers them to a behaviour change programme – those at risk are also able to self-refer. Eligibility criteria to join the programme are people aged over 18 with non-diabetic hyperglycaemia (NDH).

NDH is defined as having an HbA1c 42 – 47 mmol/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG) of 5.5 – 6.9 mmol/l. The blood result indicating NDH must be within the last 12 months to be eligible for referral and only the most recent blood reading can be used.

Referral routes into the programme vary according to local pathways. Primary mechanisms for referral are:

• Those who have already been identified as having NDH and have been included on a register of patients with high HbA1c or FPG.
• The NHS Health Check programme, which is currently available for individuals between 40 and 74. NHS Health Checks includes a diabetes filter, those identified to be at high risk through stage 1 of the filter are offered a blood test to confirm risk.
• Those who are identified with non-diabetic hyperglycaemia through opportunistic assessment as part of routine clinical care.

Individuals can also complete a risk calculation online and self-refer for further evaluation to commence the programme.

The programme runs for nine months and provides support to achieve a healthier weight, improve nutrition and increase physical activity. Delivery of the programme varies by geographical area.

Typically, the programme offers support to participants via:

• initial one-to-one assessment with a health and well-being coach
• attendance at a local group programme, which consists of nutritional guidance and support, strategies to enable long term progress and physical activity sessions and advice
• an end of programme one-to-one review with a health and well-being coach to celebrate success and consolidate learning.

Prevention programmes are available across the different countries, with Wales utilising the All Wales Diabetes Prevention Programme, Scotland utilising MyDiabetes MyWay - Diabetes Prevention, and Northern Ireland using their own Diabetes Prevention Programme.

Remission of type 2 diabetes

The DiRECT study (Diabetes Remission Clinical Trial) aimed to determine whether a structured weight management programme delivered in a realistic primary care setting was a viable treatment for producing remission of type 2 diabetes. Results showed that some people with type 2 diabetes can become non-diabetic again, at least for a period. A remission of diabetes will allow the patient to stop taking anti-diabetic drugs. This is important as the drugs are inconvenient and can cause side effects. The impact of remission on future health could be highly significant.

Following the DIRECT study, the Type 2 Diabetes Path to Remission Programme (T2DR) has been launched in England. This programme provides a low calorie, total diet replacement treatment for people who are living with type 2 diabetes and are obese or overweight. Eligible participants will be offered low calorie, total diet replacement products including soups and shakes consisting of 800 to 900 kilocalories a day for 12 weeks. During this time, participants will replace all normal meals with these products. See further information here: NHS England NHS Type 2 Diabetes Path to Remission Programme.

Whilst lifestyle advice remains the cornerstone of diabetes management, the addition of pharmacological treatments for diabetes helps people to control blood glucose levels, reduce cardiovascular risk factors and minimise the risk of developing long term complications.

Treatment for type 1 diabetes

Type 1 diabetes is characterised by an absolute lack of insulin production within the beta cells of the pancreas therefore insulin replacement therapy is an essential treatment to preserve life. Various insulin types, regimes and delivery devices (see insulin section) are available and are prescribed in conjunction with a treatment plan that centres on the individual needs and goals of a person. This should include a structured education program including dietary advice, carbohydrate counting, home blood glucose monitoring, activity, psychological health and the use of technology. This helps support the person with T1DM to adjust their insulin doses around their diet and other daily activities which affect their blood glucose. 

Insulin must never be stopped in people with type 1 diabetes. Metformin may be prescribed to support insulin therapy. Dapagliflozin 5 mg is no longer authorised for the treatment of patients with type 1 diabetes mellitus (GOV.UK).

Treatment for type 2 diabetes

Type 2 diabetes is a condition characterised predominately by insulin resistance. At diagnosis it may be possible for a person to reduce or maintain their blood glucose levels within an agreed target range and control the symptoms of type 2 diabetes by following a healthy diet and taking regular exercise. However, for some people, type 2 diabetes is a progressive condition and there may be a need to take prescribed diabetes medication alongside lifestyle measures to reduce high blood glucose levels. An important part of their treatment is structured group education to improve the knowledge and skills about managing their diabetes. 

Treatments for type 2 diabetes are available in both tablet and injectable preparations. Metformin is typically the first medication prescribed for people with type 2 diabetes. Other common groups of diabetes medications include:

• SGLT-2 
• DPP-4 inhibitors
• Sulphonylureas
• GLP-1
• GLP-1/GIP
• injectable GLP-1, GLP-1/GIP and / or insulin therapy.

Over time, many people with type 2 diabetes will also require insulin therapy, often in combination with some of the medications above. This is because insulin resistance can be followed by a gradual loss of ability to produce adequate insulin by the pancreas. It is important to remember this does not change the type of diagnosis and should be referred to as insulin treated type 2 diabetes. 

Treatment plans should always be agreed in collaboration with the person with diabetes and tailored to suit their lifestyle needs and goals. Type 2 diabetes is most effectively controlled when a person is involved in the management of their own programme of treatment. Strong self management skills play a key role in helping individuals reach and sustain healthy HbA1c, blood pressure and cholesterol levels. A typical management plan may include one or a combination of the following:

• diabetes structured education
• monotherapy - Oral medication such as metformin 
• combination therapy (See references below for “What next after metformin”)
• injectable GLP-1 and / or insulin therapy.

When deciding on medications it is important to consider the persons pre-existing conditions such as heart failure (consider SGLT-2 with proven benefit), cardiovascular disease (consider GLP-1, GLP-1/GIP or SGLT-2 with proven benefit) and chronic kidney disease (consider SGLT-2 if eGFR allows). The documented benefits and efficacy of newer diabetes medications can support treatment choices while also improving long-term outcomes for people with diabetes. Other clinical considerations include the need to reduce weight (consider SGLT-2 or GLP-1/GIP), minimise risk of hypoglycaemia (avoid sulphonylureas and insulin) and cost implications.

Maintaining blood glucose control and reducing cardiovascular risk is vital in minimising the risk of diabetes complications and therefore it is important that treatments are initiated and titrated proactively in response to deteriorating glycaemic control.

Further resources

• American Diabetes Association (2021) Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes 
• GP notebook shortcuts (2020) what next after metformin
• GP notebook shortcuts (2020) Medication in diabetes and kidney disease
• NICE guideline (updated 2022) Type 1 diabetes in adults: diagnosis and management

Nutritional management

Effective management of nutrition is recommended as an integral component of education and clinical care for those at risk of developing or living with any type of diabetes. Input from a registered dietitian should be offered to all people living with diabetes and those deemed to be at high risk of developing type 2 diabetes. The following recommendations are adapted from Diabetes UK. These recommendations can be used to develop individualised nutrition and activity plans.

Nutritional recommendations for the prevention of type 2 diabetes

• target weight loss of 5%
• restrict energy intake
• reduce total and saturated fat intake
• increase fibre
• increase physical activity
• include wholegrains, some fruit, green leafy vegetables
• reduction in red and processed meat, potatoes, sugar sweetened beverages and refined carbohydrates (CHO)
• multi component lifestyle interventions which are culturally sensitive to reduce risk in ethnic minority groups.

Recommendations for glycaemic control and type 2 diabetes

• aim for 5% weight loss in those who are overweight by reducing calories consumed and increasing energy expenditure
• aim for a Mediterranean style diet or equivalent
• offer individualised support to identify and quantify CHO intake, encourage low glycaemic index (GI) foods and consider reducing amount of total CHO. Low GI food take longer to breakdown raising blood glucose levels steadily and may be associated with improved HbA1c.

Recommendations for glycaemic control and type 1 diabetes

• education to support people with type 1 diabetes should be offered to identify and quantify dietary and CHO intake for glycaemic control specifically
• adjust insulin to CHO intake in people using multiple daily injections or insulin pumps (carbohydrate counting)
• aim for consistent quantities of CHO on a day-to-day basis in people on fixed insulin regimes.

Further resources

• BDA (Association of UK Dieticians). Food Fact Sheet - Glycaemic Index GI
• NHS UK. What is the glycaemic index (GI)?

Diabetic foods

People living with diabetes should avoid foods labelled as ‘diabetic’ / ‘suitable for diabetics’ as there is no role or benefit from the use of diabetic foods. ‘Diabetic’ foods have been a feature in many chocolate, sweets, biscuits, and bakery ranges available in a variety of high street outlets such as supermarkets, pharmacies and “health food shops” as well as being widely available on the internet. As ‘diabetic’ foods can be just as high in calories and fat, continued consumption of these foods can contribute to weight gain and increase an individual’s susceptibility to other health conditions, for example, heart disease and stroke (DUK / European Commission).

Carbohydrate counting

While people with type 2 diabetes are taught to be aware of the size of their carbohydrate intake, people with T1DM need a more exact measure called carbohydrate counting. Carbohydrate counting helps them to optimise their blood glucose control by adjusting their insulin doses. CHO can be counted in two ways, in grams or as CHO portions (CP). One CP is usually equal to 10g of carbohydrate.

Insulin-to-carbohydrate ratios (Insulin-CHO ratio) are different from person to person, depending on age, weight, activity levels and how sensitive the person is to insulin.

The diabetes health care team will help the person with T1DM diabetes to work out their insulin-CHO ratio and, eventually, a different ratio may be set for each meal. They will usually estimate the starting insulin-to-carb ratio and then fine-tune this based on blood glucose control.

Once the quantity of CHO of a meal and the insulin-carb ratio are known, then the insulin bolus dose for that meal can be calculated.

If the meal had 70g of carbohydrate and the Insulin -CHO ratio was 1 unit of bolus insulin for every 10g carbohydrate, then seven units would be given for that meal.

The amount taken will also depend on other factors such as current blood glucose level, illness or planned physical activity.

See: BERTIE Type 1 Diabetes Education Programme. BERTIE is a diabetes education course that teaches people with type 1 diabetes how to manage insulin doses, matching them to carbohydrate intake, and live life on a day-to-day basis.

Alcohol

Alcohol in moderate amounts can be enjoyed safely by most people with T1DM and general advice about safe alcohol intake (14 units or less per week) should be applied. However, alcohol intake is associated with an increased risk of hypoglycaemia for those taking insulin. Pragmatic advice for those who wish to continue to consume alcohol would be insulin dose adjustment, additional carbohydrate or a combination of both. Alcohol is contraindicated for those with hypertension, hypertriglyceridemia, some neuropathies, retinopathy and during pregnancy.

Smoking

There is a long established, clear link between smoking and the risk of developing type 2 diabetes due to increasing insulin resistance, caused by cellular damage. Increased insulin resistance caused by smoking, means those with already established type 2 diabetes may require intensification of diabetes medications (including insulin). Persistently elevated blood glucose levels caused by increased insulin resistance, leads to significant long-term complications affecting major organ systems within the body (Joshu and Tibbs, 1999).

People living with diabetes should be encouraged to stop smoking and educated as to the multiple health benefits. People living with diabetes can be referred to the local stop smoking services.

Older people with diabetes

Some older persons with diabetes may experience poor nutritional status with physical, social and psychological factors affecting intake. Education should continue to be offered to older persons, including dietary intervention – age should not restrict access. Dietetic input is key to assess nutritional status and formulate individualised care plans which take into account the changes in nutrients that are required as the body ages. Guidelines and care planning should be further adapted for those living with dementia with a focus on maintaining nutritional intake and preventing malnutrition.

Ramadan

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith. Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The European Association for the Study of Diabetes consensus recommendations emphasise the importance of patient factors and comorbidities when choosing diabetes medications including the presence of comorbidities, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, hypoglycaemia risk, weight issues and costs. Structured education and pre-Ramadan counselling are key components to successful management of patients with diabetes. These should cover important aspects like glycaemic targets, self-monitoring of blood glucose, diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast.

Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycaemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and foetal outcomes. Hypoglycaemia is a common concern during Ramadan fasting. To prevent hypoglycaemic and hyperglycaemic events, the adoption of diabetes self-management education and support principles are recommended. The use of the emerging technology and continuous glucose monitoring during Ramadan could help to recognize hypoglycaemic and hyperglycaemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier (Ibrahim et al, 2020).

Summary guidance for fasting during Ramadan

• Diabetes UK. Diabetes and Ramadan.
• The Muslim Council of Britain. Ramadan and Diabetes: A guide for patients.
• The Muslim Council of Britain & Diabetes UK. Managing Diabetes During Ramadan.
• TREND. Ramadan and diabetes.

Reversal of type 2 diabetes

Following the DIRECT study, the Type 2 Diabetes Path to Remission Programme (T2DR) has been launched in England. This programme provides a low calorie, total diet replacement treatment for people who are living with type 2 diabetes and obesity or overweight. Eligible participants will be offered low calorie, total diet replacement products including soups and shakes consisting of 800 to 900 kilocalories a day for 12 weeks. During this time, participants will replace all normal meals with these products. See further information here: NHS England NHS Type 2 Diabetes Path to Remission Programme.

Recommendations for weight management and remission for people living with type 2 diabetes:

• for overweight or obese people with Type 2 diabetes
• for remission, aim for weight loss of 15kg as soon as possible after diagnosis – this may be achieved by total diet replacement or meal replacement plans providing 800-1200 Kcal per day for 12 weeks
• to improve glycaemic control and CVD risk, aim for at least 5% weight loss achieved by reducing calorie intake and increasing energy expenditure.

Physical activity

Increased physical activity is associated with a 25-40% reduction in the relative risk of developing type 2 diabetes (Aune et al, 2015).

Weight management, physical activity and exercise have numerous benefits for people with type 2 diabetes – improving blood glucose control, cardiovascular risk factors and well-being. Target activity should be at least 150 minutes per week of moderate to vigorous physical activity over at least 3 days.

In type 1 diabetes, physical activity can improve cardiovascular fitness leading to a reduction in CVD and mortality. However, there is limited evidence of improved glycaemic outcomes, and whilst exercise will reduce blood glucose levels, it is also associated with increased hypo and hyper glycaemia. For planned exercise, reduction in insulin is the preferred method to prevent a hypo. For unplanned exercise, additional CHO may be required.

Diabetes UK has produced a number of information prescriptions which assist the health care professional to educated the person living with, or at risk of developing diabetes.  

Physical activity and lifestyle tips for managing type 2 diabetes

Leicester Diabetes Centre (LDC) has highlighted five important health behaviours people with diabetes should be aware of to help them better manage their condition. These are the five S’s: 

• sitting / breaking up prolonged sitting
• stepping
• sleep
• sweating
• strengthening.
  
  Leicester Diabetes Centre. Type 2 diabetes: physical behaviour tips

Managing type 2 diabetes isn't just about medication – daily habits around movement, exercise, and sleep make a real difference in health and blood glucose levels.

Key points to advise patients

Physical activity and good sleep improve blood glucose, reduce health risks, and support long-term wellbeing for people living with type 2 diabetes. Offer the following advice to patients:

• Take a break from sitting down: Move every 30 minutes to improve blood sugar control. Even simple movements help.
• Add more steps to your day: Adding just 500 extra steps a day can reduce health risks. A brisk 5–6-minute walk daily may add years to your life.
• Improve your sleep: Easier said than done, but aim for consistent, good-quality sleep. Too much or too little sleep, or poor sleep patterns, can make diabetes harder to control.
• Strengthen muscles: Activities like tai chi and yoga are said to improve insulin sensitivity and help manage blood sugars. (Kanaley, J A et al. (2022) Exercise/Physical Activity in Individuals with Type 2 Diabetes: A Consensus Statement from the American College of Sports Medicine, Med Sci Sports Exerc. Feb 1;54(2):353–368.)
• Exercise regularly: Aim for 150+ minutes of moderate or 75+ minutes of vigorous exercise weekly. Don’t let more than two days pass without moving. Combine cardio with strength, flexibility and balance activities.  

Self-management skills are an essential part of diabetes care and with the help and support of nursing staff the condition can be managed to help people stay healthy and prevent complications.

Diabetes UK provide resources for health care professionals to increase the provision and uptake of diabetes self-management education.

Education

There are many different types of education programmes available to those living with diabetes across the UK, all these are dependent on commissioning and what is available in the local area, these may include:

• DAFNE (Dose Adjustment for Normal Eating). A working collaborative of 75 diabetes services from NHS Trusts and Health Boards across the UK and Ireland. It is a structured education programme in intensive insulin therapy for adults with type 1 diabetes providing them with the necessary skills to estimate the carbohydrate content of their meal and to inject the correct dose of insulin.
• DESMOND. A group of self-management education modules, toolkits and care pathways for people with, or at risk of, type 2 diabetes. The programme offers training and quality assurance for health care professionals and lay educators to deliver any of the modules to people in their local communities. There is also a DESMOND BAME (DESMOND CULTURAL ADAPTATION — DESMOND) course available, which is a culturally specific programme for people with Type 2 diabetes from South Asian communities, both newly diagnosed and established.
• X-PERT Diabetes Programme. A programme for people with diabetes and aims to increase the knowledge, skills and understanding of the condition in order that they can make lifestyle choices to manage their blood glucose levels effectively.
• Type 2 Diabetes and Me. An online step-by step guide for people with type 2 diabetes that provides information about the condition and the options and support available to them.

Additionally, there are online resources available now to support patients further:

• BERTIE Online. A type 1 diabetes course – no referral needed. The online BERTIE course is for people living with type 1 diabetes. It helps people understand and manage their diabetes in a way that’s right for them. Anyone can simply register on the website and start the course.
• MyType1Diabetes - Know More. This is a free platform to help patients learn more about living with type 1. It allows them to take charge with a range of digital support tools and resources, empowering self-management effectively.
• Healthy living for people with type 2 diabetes. If people are living type 2 diabetes and  in England, there's a new online education NHS programme that supports people to live well with type 2 diabetes.

Treatment for diabetes aims to help people with the condition to control their blood glucose levels and minimise the risk of developing complications over time.

Treatment for type 1 diabetes

Lack of insulin production by the pancreas makes type 1 diabetes particularly difficult to control. A management plan defined by the diabetes team that centres around the needs and goals of a person typically includes dietary advice and maintaining a constant health weight, home blood glucose monitoring and exercising regularly. Unfortunately, the treatment cannot eliminate the need for insulin or reverse the disease.

Insulin

All patients with type 1 diabetes will need to have daily insulin injections as their body is unable to produce any insulin. The injections come in the form of a syringe, insulin pen or insulin pump.

Images of insulin syringes, pens and pump.

The reason that insulin is injected is because if it were taken as a tablet, it would be broken down in the stomach and would not enter the blood stream. When a person is first diagnosed, the diabetes team will teach them the correct procedure for their injections. This involves showing them when, where and how to inject themselves and how to adjust insulin doses. They will explain how to store the insulin and safely dispose of the needles.

The team will also discuss the management of diabetic emergencies, such as hypoglycaemia and information relating to sick day rules, and driving a vehicle or operating machinery. The person will be educated about insulin dosing and safety. Each person who is taking insulin may carry an 'Insulin Passport' or 'Insulin Safety Card'.

Treatment for type 2 diabetes

It is possible for a person to initially control the symptoms of type 2 diabetes by following a healthy diet, taking regular exercise and keeping their blood glucose levels within an agreed target range. Type 2 diabetes can  be a progressive condition for some people, so they may eventually need to take diabetes medication which will usually be in tablet form. A treatment programme will be tailored to suit the person's needs by the diabetes team and will typically include one or a combination of the following:

• changing to a healthier diet
• medication such as metformin
• injectable therapies that may include insulin and GLP-1/GLP-1/GIP.

Keeping blood glucose levels under control is vital in reducing the risk of diabetes complications. If a person is overweight, weight loss can often help to reduce the extent of diabetes symptoms. Type 2 diabetes is effectively controlled when a person is involved in the management of their own programme of treatment. Effective 'self-management' is essential to successfully achieving their healthy targets for HbA1c, blood pressure and cholesterol levels. A person with type 2 diabetes may need (or eventually need) medication that reduces high levels of blood glucose. In the first instance this will usually be glucose-lowering tablets (sometimes a combination of more than one type of tablet) and it may also include injectable insulin. Some oral medications for lowering blood glucose levels can cause hypoglycaemia for example, Gliclazide, Glipizide and Glimpiride.

As research in diabetes continues, new and more effective medication are becoming available that assist with weight reduction and improve blood glucose level control in some people with type 2 diabetes without causing hypoglycaemia. Oral medication include: Sitagliptin, Linagliptin and Saxagliptin (Alogliptin and Vildagliptin). Injectable therapies (GLP-1) include: Exenatide, Liraglutide Semaglutide, Dulaglutide exenatide (bydureon), a once weekly preparation.

Further resources

• Diabetes UK shop (2020) Meds & kit.
• Diabetes Specialist Nurse Forum presentation. Insulin Types & Available Medicinal Forms in the UK
• NICE. Type 2 diabetes in adults: choosing medicines (PDF)
• Your Diabetes. Adult Insulin Passport

Self-management

Diabetes is one of the few serious medical conditions for which the outcome relies almost entirely on the person’s ability to self-manage. This is why structured group education and individualised care plans are so important to improve peoples ability and confidence to manage their own diabetes.

People living with diabetes need on-going advice and support about maintaining a healthy diet, keeping active and monitoring their health. People living with diabetes spend around three hours per year with a health care professional; for the remaining 8,757 hours they must manage their diabetes themselves’. Diabetes can be a burden, but most people can live relatively normal active and healthy lives and even small adjustments to their lifestyle can make significant improvements. Most diabetes management relies on a person 'self-managing' the condition, so their motivation is a major consideration regarding effective treatment. The health care professional can support the person to identify and set realistic goals and planning smaller steps to achieve and maintain these goals. The health care professional also has an important role in assessing self-care abilities and referring the person for further support where a gap is identified.

All patients should have their blood glucose levels checked by a health care professional every two to six months. The diabetes health care team should discuss the patient’s blood glucose levels with them and agree a target range with them. Many people with diabetes monitor their blood glucose levels at home using a simple finger prick blood test. They may need to do this several times a day, depending on the type of treatment that they are receiving.

Patients who use insulin – that is all with type 1 diabetes and some with type 2 – should usually test their blood glucose three to ten times per day depending on how difficult their blood glucose levels are to control. This allows them to judge the effectiveness of their previous dose of insulin and helps them to determine the amount of insulin needed for their next dose. Patients with type 2 diabetes should test their blood glucose levels at least once a day, although not all type 2 patients, like those treating their condition through diet or using metformin, need to monitor and it will be down to their own self-management programme which is has been agreed with their diabetes team.

Careful monitoring of blood glucose levels will reveal individual patterns of blood glucose changes. This can help the person with diabetes to see if the treatment programme is working, help plan their meals and activities and to make the necessary amendments if required. Regular testing allows for a quick response to high blood glucose (hyperglycaemia) or low blood glucose (hypoglycaemia). This response could include insulin and adjustments to diet and exercise regimes. It is vital that the patient understands the importance of regular testing. Many patients claim to know when their blood glucose levels are too high but unfortunately this is often not the case. The way that they feel is generally not an accurate guide to what is happening unless their blood glucose levels are very high.

Emotional well-being and mental health

The impact of diabetes on the person, and the level of self-management required can significantly affect emotional well-being and mental health. As mentioned above people with diabetes spend on average, three hours a year with a health care professional and the remaining 8,757 hours managing diabetes themselves. People with diabetes are twice as likely to suffer from depression and are more likely to be depressed for longer and more frequently. Around 40% of people with diabetes struggle with their psychological well-being often because of the demands of the disease. It is important to recognise how cultural and socio-economic factors can increase the burden of diabetes. The NHS spends an extra 50% treating the physical health of someone who has type 2 diabetes and poor mental health compared to someone with type 2 and no mental health problems. For people without diabetes, having depression increases someone’s risk of type 2 diabetes by 60%.

Diabetes specific psychological disorders

• diabetes distress occurs in 42% in people with T1D, 36% in T2D. Assessment of emotional distress should not be addressed as a separate co-morbid ‘condition’ that is diagnosed and treated only when detected
• needle phobias, injecting fear
• eating disorders – affect >30% of women in their early 20’s with T1D
• 64% of people with diabetes feel down and 1/3rd are interested in counselling from a trained professional.

Factors which impact on emotional wellbeing across type 1 and 2 diabetes

Diabetes distress

Diabetes distress is a natural and rational emotional response to living with a demanding, long-term condition. People feel frustrated, defeated and/or overwhelmed by diabetes. All feelings are focused on diabetes so outwardly an individual may not seem unhappy. It’s not the same as depression - where people feel negative about themselves, others and the future - and it’s not a ‘disorder’. Multi-national studies estimate that at highest levels, diabetes burnout affects 44% of people diagnosed with type 1 or type 2 diabetes. And it’s been consistently linked with higher HbA1c levels. Diabetes ‘burnout’ is a state of physical and emotional exhaustion caused by the continuous stress and efforts to self-manage diabetes. Distress may be a natural reaction to having managed their diabetes over a long period of time - without a single day off.

Distress / burnout may coincide with a particularly demanding time for example relationship difficulties, family stress or bereavement. When these events happen, diabetes may naturally be seen as a low priority. Developing diabetes-related complications can be the motivation some people need, but others find themselves asking ‘What’s the point?’ and wondering why it’s even worth trying.

Diabetes distress / burnout can be indicated by the following symptoms:

• feeling overwhelmed and defeated by diabetes
• feeling angry about diabetes and frustrated about the demands of managing it
• feeling as though diabetes is controlling the person’s life
• worrying about not taking enough care of diabetes but unmotivated or unwilling to change
• avoiding parts of the diabetes routine e.g. attending appointments, testing
• not caring about blood sugar levels
• reverting to unhealthy behaviours e.g. poor diet
• feeling alone and isolated with diabetes.

As clinical psychologist, Dr William Polonsky, describes, ‘they are at war with their diabetes – and they are losing it’.

Management of diabetes distress may include:

• explaining what diabetes distress is and that many people with diabetes experience it
• explaining the signs and consequences of diabetes distress (e.g. the impact on their daily self-management and well-being)
• acknowledgement of the significant daily efforts required to manage diabetes – this by itself may reduce the distress
• 'normalise’ negative emotions about diabetes
• use a validated tool in line with local policies and procedures
• explore the most appropriate support for the individual, for example, diabetes education or revising their management plan, advice on lifestyle changes, emotional or social support, or a combination of these
• if a decision is made to refer, consider a diabetes specialist health professional for difficulties with diabetes management and support or a mental health professional, a psychologist or psychiatrist (preferably with an understanding of diabetes) for stress management or if other emotional problems such as depression or anxiety or more complex psychopathology are underlying the diabetes distress.

Psychological Disorders and Diabetes

People with underlying mental health issues or psychological disorders are at higher risk of diabetes. Medications such as antipsychotics can increase the risk of type 2 diabetes by as much as 60% and many of the atypical antipsychotics have impaired glucose tolerance as a side effect, this is often due to weight gain caused by medications.

As patients get older the risk of diabetes also increases, meaning patients with dementia or Alzheimer's are also often at risk. These conditions can be challenging as patients may lack insight into understanding their diagnosis of diabetes, meaning it is harder to get them to consent to any treatment or to accept treatment on a regular basis leading to increased risk of complications.

Eating disorders and Intentional Insulin Restriction (‘Diabulimia’)

Among people with diabetes, the full syndrome eating disorders are rare. The most common disordered eating behaviours are binge eating and insulin restriction/omission but prevalence is not well established. Eating problems in people with diabetes are associated with sub-optimal diabetes self-management and outcomes, overweight and obesity, and impaired psychological well-being.

Intentional insulin restriction (IIR) or omission for the purposes of weight loss is sometimes referred to a ‘Diabulimia’ – IIR is the preferred clinical term. Estimates of insulin omission have been reported in up to 40% of people with type 1 diabetes. People may also omit or restrict insulin for other reasons than weight loss (e.g. fear of hypoglycaemia). Eating disorders are associated with early onset of diabetes complications and higher morbidity and mortality.

Evidence for the management of eating disorders in combination with diabetes is very limited. Thus, in practise, generally eating disorder treatments are applied to address the needs of people who are living with both conditions.

Healthcare professionals in both primary and secondary care should:

• consider emotional and psychological support as part of the remit of the whole multidisciplinary team
• ensure they have adequate training and supervision to identify psychological problems in people with diabetes and deliver an appropriate level of proactive support as part of ongoing diabetes care, including through the care planning process
• be familiar with the emotional and psychological support services available to their patients both locally and through national organisations such as Diabetes UK.
• deliver a diagnosis of diabetes without blame or stigma, and give sources of support and information at diagnosis. Time should be allowed to agree a care plan.
  (Diabetes UK, 2019)

Having a quality conversation about emotional health and diabetes 

It’s important to ask people about their emotional health at every appointment. Just because everything may seem okay the first time you ask, this can change over time. Don’t think of this as an added extra. If someone is struggling emotionally, they’re going to find looking after their diabetes much more difficult (Diabetes UK, 2019)

Top tips

Step 1 – Opening up the conversation

Ask “How are you feeling?”

Step 2 – Making the most of the conversation

Gain insight before the appt, open questions, active listening, reflection, info prescriptions, positive language, use of time, validated scales / tools

Step 3 – Safely closing the conversation

Agreeing actions at the patients pace, ask them to summarise, ‘what questions do you have?’, End on a positive, emphasis on importance of well-being, refer as necessary.

Language matters

The language used by healthcare professionals can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it day-to-day. At its best, good use of language; verbal, written and non-verbal (body language) which is more inclusive, and values based, can lower anxiety, build confidence, educate and help to improve self-care. Conversely, poor communication can be stigmatising, hurtful and undermining of self-care and have a detrimental effect on clinical outcomes. The language used in the care of those with diabetes has the power to reinforce negative stereotypes, but it also has the power to promote positive stereotypes (NHS England,2018).

Top tips

1. Recognise that some words, phrases and descriptions are potentially problematic, whatever the intention of the user.
2. Use language (including tone and non-verbal gestures) that is:
   -  free from judgment or negative connotations, particularly trying to avoid the threat of long-term consequences or scolding (‘telling off’); is inclusive and values based language.
   -  person-centred, (also known as ‘person first’) to avoid labelling a person as their condition.
   -  collaborative and engaging, rather than authoritarian or controlling.
3. Review the use of common expressions and what underlying attitude they may convey,
   regardless of intention.
4. Avoid language which attributes responsibility (or blame) to a person for the development of their diabetes or its consequences.
5. Avoid language that infers generalisations, stereotypes or prejudice, or links one individual with previous experience of others of a similar background or in a similar
   situation.
6. Use or develop an empathic language style which seeks to ascertain a person’s point of
   view of their condition, rather than assume.
7. Listen out for a person’s own words or phrases about their diabetes and explore or acknowledge the meanings behind them.
8. Become alert to the use of language, and non-verbal communication i.e. body language and recognise if it may be creating a negative effect.
9. Consider how to limit any negative effects from language used, both for yourself and
   with others around you.

There are over currently over 30 different insulin preparations available which fall in to the following main types: 

Insulin is used to manage blood glucose levels in various regimes which can include single insulin types or insulins used in combinations. Typical insulin regimes fall into the following:

Basal

• Basal insulins are often given once a day, often at night to control pre breakfast blood glucose levels.
• Insulin Glargine (Lantus) (Abasaglar), Insulin Detemir (Levemir), Insulin Degludec (Tresiba), and U300 Toujeo 300 Units/mL have the advantage of greater predictability, potentially less weight gain, and lower risk of hypoglycaemia, particularly at night compared to intermediate acting insulin.
• They can be given as a basal insulin or in a Basal Bolus regimen.
• Basal insulin alone is suitable for type 2 diabetes. 

Basal plus

• These regime’s often progress from basal insulin regimes’ and introduce 1 or 2 injections of rapid acting insulin with meals to prevent blood glucose levels rising after food. 

Basal bolus or multiple daily injections (MDI) 

• MDI is a combination of basal insulin once daily and rapid acting insulin with each meal. 
• This regime is suitable for people with type 1 and type 2 diabetes. 

Mixed

• Mixed insulins contain a proportion of rapid or short acting and a proportion of intermediate acting insulin. 
• The number following the name of the insulin identified the proportion or rapid or short acting insulin (E.g. NovoMix 30 indicates that the proportion of rapid acting insulin with in the mixture is 30%) 
• This regime is suitable for people with Type 1 and Type 2 diabetes but is more restrictive than MDI. 

Appropriate insulin regimes should be decided in partnership with the person with diabetes, focusing on their lifestyle, considering when they eat, activity levels, occupation and if they are able to self manage or will require support with administration. 

Appropriate training should be provided and should include but is not exclusive to: 

• insulin type and how it works in relation to meals
• administration 
• device
• storage
• sharps disposal 
• driving 
• management of hypoglycaemia 
• blood glucose monitoring 
• self-titration (if appropriate).

High strength insulins

All insulin is available in a concentration / strength of 100 units/ml. This should be the most commonly prescribed insulin strength and always used for new insulin starts.

Some manufacturers have developed insulin with a higher strength formulation e.g. 200 units/ ml & 300 units/ml. These offer the same insulin action but in less volume and can be very useful for patients on doses greater than 40 units to help with insulin absorption and lower the risk of lipohypertrophy (lumpy injection sites).

These insulins only are available in pre-filled pens to ensure that the correct dose: volume concentration is given. The patient still dials to the same dose but a different volume is given.

Biosimilar insulins

Biosimilar insulins are a biological copy that is not identical but demonstrates similarities to the original product in terms of quality, efficacy, cost and safety.

Some of the currently available biosimilar insulins are Abasaglar and Semglee. These are not interchangeable and therefore it is important that insulin is prescribed by brand name.

More biosimilar insulin products are soon to be available in the UK.

• For information about insulin types and insulin delivery including insulin pump therapy, see: Diabetes UK (2020) Meds & Kit.

Insulin should be initiated and managed by people with suitable knowledge and qualifications. If required you may need to refer people who require insulin to your local Diabetes Specialist Team. 

Further resources

• Diabetes on the Net. The six steps to insulin safety. An essential module for all those prescribing, managing or administering insulin, with the overall aim of reducing insulin errors in clinical practice. Its focus is on insulin use within the primary-care setting.
• Diabetes Specialist Nurse Forum presentation. Insulin Types & Available Medicinal Forms in the UK