Sunday, 3 April 2016

New(ish) Type 2 guidelines

Long grass, thistles and fir trees
Harlow Carr, July 2015
On one of my recent days off I visited an old friend, which was so tremendously rejuvenating that I definitely didn't mind spending four hours in the car getting there and back. I can't explain how satisfying it feels to have in depth interesting conversations about anything and everything with someone who has known me for more than thirty years and is entirely on the same wavelength.

I use this blog partly for therapy, to sort out my thoughts and opinions by writing them down. I don't know why it's better than a private diary, but somehow it is. However, there are many issues that are unsuitable for public scrutiny, and simply cannot be included no matter how much I would like to wrestle them onto the screen. On that day I talked privately about many of these issues, and feel all the better for it. My friend is wise, and sensible, and I feel lucky to be able to tap into that wisdom and sense.

At the end of that day I attended another Diabetes Education Club evening - I can report that this time the buffet was loads better than the standard sandwiches and cold sausages. In terms of the meeting content, it was all about the finished NICE guideline about the treatment of Type 2 Diabetes. This took about a year to finalise because there was uproar when the first draft was published. I've had a look back through the blog and it doesn't look like I wrote about it at the time.

In primary care, most GPs are not diabetes specialists, so the guidelines published by NICE are intended to help these non-specialists choose the right way forward for the patient in front of them. These same guidelines are also supposed to inform patients of how their treatment should be managed, help organisations assess whether the care they provide to patients is of good quality, and also allow Clinical Commissioning Groups (CCGs) to ensure they are getting value for money in the services they are responsible for. A tall order.

The problem was a difficult one. People with Type 2 Diabetes come in all shapes and sizes, the treatment options are very varied and the range is growing all the time. The guidelines are drawn up with strict parameters - they must be based on evidence, so if nobody has bothered to do a formal trial then no evidence exists. [There is a fairly famous paper highlighting this issue which describes the design of a formal trial to compare mortality when jumping from a plane with and without a parachute.] The guidelines must also take cost into account, so an expensive treatment would have to show significant benefit beyond that of a cheaper treatment.

The uproar at the draft was because a strong recommendation was made for a medication that had pretty much been sidelined by most medical practitioners. I can't comment on why this obsolete treatment was brought out of obscurity, but I imagine it was because sufficient evidence existed of its benefit, and it must be very cheap. To their credit NICE took account of the feedback, amended the draft, repeated the consultation process, and eventually published an amended version which seems to have better reflected consensus within the diabetes community.

The most amusing moment of the evening for me was when it was pointed out that the previous guideline had recommended low dose aspirin for lowering of cardiovascular risk in people with Type 2 Diabetes, but this recommendation had been reversed in the latest version. "What are we supposed to do," asked one doctor plaintively, "when patients ask why we told them to do one thing then and something different now?" "You should try being a Dietitian," I pointed out. "We have to do that all the time."

This led into a conversation about the latest dietary options. I have many of these conversations with Dietitians, so it was interesting to hear what  these GPs thought. One was very much in favour of Very Low Carbohydrate diets, while another favoured the Very Low Calorie option. Both of these are perfectly valid choices, but the Dietitian's skills lie in helping the individual to decide what is right for them. The relevant guidelines follow this kind of pathway:
1. The most effective lifestyle therapy in Type 2 Diabetes is weight loss
2. There is no evidence about the best way to lose weight and keep it off
3. So the best diet for a particular individual is the diet a) that works and b) is sustainable, whatever it consists of.

I was going to put in provisos about 'nutritionally complete' but for most people if the diet consists of nothing but cabbage soup or 100% marshmallows it will probably fail the 'sustainable' criterion. So yes, I will stand by 'whatever it is'.

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