Returning diabetes and obesity services to the ‘new normal'

Hospital and community diabetes and obesity services are gradually resuming and scaling up delivery of care

As health services continue to grapple with providing care in the ‘new normal’ caused by the Covid-19 pandemic, there is rising concern about missed opportunities and early warning signs being ignored in people with chronic diseases such as diabetes. Hospital and community diabetes services are gradually resuming and scaling up delivery of care and are now reaching out to patients in need of check-ups and intervention.

In August the HSE and Diabetes Ireland launched an awareness campaign urging people with concerns about their diabetes to seek medical advice from their pharmacist, GP or hospital diabetes team and reassured them that diabetes services are resuming.

Throughout the pandemic, the diabetes community and diabetes healthcare providers have worked and adapted to support and empower people in self-managing their diabetes at home. Maintaining this self-management will continue to improve quality-of-life and reduce the impact on health and the likelihood of complications. However, if someone has concerns, or is experiencing symptoms or an issue that they are unsure of; they are being reminded to contact their GP or diabetes team in the hospital.

Dr Diarmuid Quinlan, GP and National ICGP Clinical Lead for Diabetes, commented: “The majority of GPs will review any individual with a medical issue, initially by phone or virtual consult and will see face-to-face if physical examination is required. People with diabetes should not be reluctant to make contact and can be reassured that the medical profession will take all precautions necessary to protect both themselves and their patients from exposure to Covid-19.”

Prof Sean Dinneen, Consultant Endocrinologist and Clinical Lead, HSE National Clinical Programme for Diabetes, highlighted the importance of seeking help despite the current challenges: “We are in a very fluid environment and diabetes services are experiencing significant capacity issues at present as the health service deals with this pandemic. However, it must be stressed that delays in seeking medical attention often results in additional care being needed.”

If people with diabetes experience any of the following symptoms, they should contact their diabetes team or healthcare provider:

• Ongoing high blood glucose or ketone levels.
• Constantly feeling thirsty or needing to go to toilet more often than usual.
• Any breaks in skin that are not healing.
• Those with diabetes who are pregnant.
• Having an unexplained high temperature.
• Have nausea, vomiting or diarrhoea for longer than 24-hours.
• Have concerns about any aspect of their health.
• Symptoms of any illness that is not getting better.

Dr Anna Clarke, Diabetes Ireland, said: “We know people are delaying contacting GPs and hospital diabetes teams in the belief that they are helping those professionals cope with the current Covid-19 burden, but in doing so may be risking their own health as their problem escalates. It is vital to seek medical attention early and be treated and reassured.”

Prof Dinneen added: “The Covid-19 pandemic presented our health service with a set of unprecedented circumstances resulting in disruption to the delivery of non-Covid care including routine diabetes care. The remarkable work carried out by healthcare teams across the country and the support, co-operation and understanding of patients, service users and families during the recent first phase of the Covid-19 response is very much appreciated by all in the health service. We have now reached a point where a renewed focus upon the needs of people with diabetes is both timely and clinically necessary.”

Obesity

The Irish Society for Clinical Nutrition and Metabolism (IrSPEN) has cautioned that patients with obesity are at higher risk of complications from Covid-19 – and need equal access to treatments as the health system begins to address backlogs and schedule new appointments.

To help manage this challenge, obesity consultants from around the world have together published guidance on prioritising access to surgery and treatments for those with obesity and associated diabetes.

Tallaght University Hospital, Consultant Endocrinologist, Dr Conor Woods stated: “Similar to most elective surgery, metabolic procedures have been postponed during the pandemic. However, due to the progressive nature of diabetes, delaying surgery can increase future health complications and even earlier death.

“The traditional ‘weight-centric’ criteria for patient prioritisation needs to change. For the period ahead, a new triaging approach for obesity and diabetes surgeries and treatments has been agreed internationally.
IrSPEN Spokesperson and Metabolic Physician (one of the authors of the new guidance that appeared recently in The Lancet Diabetes and Endocrinology) Prof Carel le Roux said overcoming ‘obesity stigma’ was an essential first step for effectively delivering the plan.

“Obesity is at epidemic scale in Ireland, as over a million people live with or are at risk of the complications of the disease. Ireland’s public health system has the lowest funding per capita for obesity treatment in Europe. Type 2 diabetes is a major complication of obesity and affects 200,000 people. This single obesity complication accounts for more than 10 per cent of the overall healthcare budget.”

Guidelines

If patients are well enough to be safe surgical candidates, preference should be afforded to those with the greatest risk of morbidity and mortality from their disease, if it is probable that this risk can be reduced by surgery, the new guidelines note. This logic would apply, for instance, to many surgical candidates with poorly controlled type 2 diabetes or substantial metabolic, respiratory, or cardiovascular disease.

Traditional BMI-centric criteria for patient selection, however, tend to skew access to bariatric and metabolic surgery in the opposite direction. Despite strong evidence that surgery achieves its greatest health benefits among patients with type 2 diabetes, a minority of those who have such operations have preoperative type 2 diabetes or cardiometabolic disease, the guidelines state.

Furthermore, the document notes that in many publicly funded healthcare systems, candidates for bariatric and metabolic surgery are currently placed on a single elective surgery waiting list, regardless of their indication. Priority is established largely on a first-come first-served basis, rather than on clinical need. “This approach is comparable to putting all colorectal surgery candidates on the same waiting list with similar priority, regardless of whether their diagnosis is cancer or benign neoplasia. A strong need therefore exists for clinically sound criteria to help prioritise access to surgery in times of pandemics with limited resources. These criteria can also inform future waiting list management and decision making about the structure of surgical services,” the guidelines say.

The guidelines recommend that patients be prioritised into three categories:

• Surgery within 30 days for those who have complications of previous metabolic surgery.
• Surgery within 90 days for patients with substantial risk of complications of diabetes or who have poor control of their diabetes, despite complex medical regimens or using insulin.
• Standard access to surgery for patients who are unlikely to deteriorate within six months, but these patients need to be optimised using intensive medical treatment.

Given the risks of severe complications from Covid-19 in patients with diabetes and obesity, the recommendations include that Covid-19 screening be mandatory prior to any obesity treatment, that keyhole surgery remains the best approach and that personal protective equipment (PPE) should be used.

IrSPEN member and Metabolic Surgeon Prof Helen Heneghan added: “Although we will be particularly focussed on how we should restart activity in the immediate post-Covid-19 period, the new guidelines also provide a framework for clinical prioritisation long into the future.”

Stigma

Research on attitudes carried out by IrSPEN in 2019, found that people with obesity are looked down on as lazy, over-indulgent, and deserving of what they get – and this prevents effective treatments from being publicly funded.

A recent concern is an increase in stigmatisation following speculation that people with obesity may be asymptomatic carriers and increase the spread of Covid-19.

James Cushnan a patient from Letterkenny with diabetes who had his metabolic surgery postponed due to Covid-19 added: “Doctors, policymakers, and hospital managers must recognise the seriousness of diseases that require metabolic surgery and ensure these operations are not further delayed due to the widespread misconception that obesity and diabetes are lifestyle conditions of laziness and that surgery is a ‘last resort’.”

Self-management programme for adults with long-term health conditions available free in south-east

The HSE/South-East Community Healthcare is offering a free, online group self-management programme for adults with long-term health conditions.
Called ‘Living Well’, it is to cater for adults 18 years and over and is suitable for people living with one or more long-term health conditions, including diabetes, and/or caring for someone with a long-term health condition.

There is one workshop each week, for six weeks, that lasts for 2.5 hours. Over the six-week period, participants on the Living Well programme will develop skills such as goal setting, action planning and problem solving. Workshops also cover topics such as managing medication, coping with difficult emotions, low mood and feelings of depression as well as communicating with family, friends, and the healthcare team.

Outlining detail of the initiative, Kate O’Connor, Self-management Support Coordinator for Long-Term Health Conditions, SECH, said: “Our programme is usually delivered in a classroom setting. However, during Covid-19 restrictions, it is available online. I am anxious that online delivery is not a barrier to participation. Therefore the southeast Living Well team will provide practical one-to-one sessions with anyone who would like to take part, but feel they do not have the skills or the confidence.”

“Living Well participants have reported that their confidence has increased and that they feel better able to make positive changes to their lifestyle, such as exercising more.

They also report feeling more connected to their community and have less feelings of depression and anxiety.”

For more information or to book a place on Living Well, contact Ciara on (056) 7784272 or 087 408 8325, email SelfManagementSupportsSECH@hse.ie.

More information is also available at www.hseie/LivingWell.