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With an estimated 700 people diagnosed with diabetes each day in the UK, pharmacy is well-placed to support the day-to-day realities of this chronic condition – from the initial screening through to the provision of essential health checks and services and signposting to additional sources of support.
In addition to the 3.5 million people with diabetes in the UK – 90 per cent of whom have type 2 – it is estimated that more than half a million individuals are living with the condition unaware and undiagnosed.1 Pharmacy has a key role to play in diabetes screening, both in detecting undiagnosed disease and pinpointing patients at high risk of future development. Recently published estimates, based on data from the Health Survey for England, indicate that over 10 per cent of the English population are currently at increased risk of type 2 diabetes, with HbA1c levels hovering in the pre-diabetic danger zone of 42-46mmol/mol.1
“We want as many people as possible to be assessed for the risk of type 2 diabetes so that those who are at high risk can get the support they need to prevent it and those who have type 2 diabetes but do not know it can be diagnosed,” says Diabetes UK chief executive Chris Askew. “Having risk assessments available for free in the heart of people’s communities will make it easier for people to access them and so increase the number of people who are aware of whether they are at risk”.2
Current NICE guidelines recommend that pharmacists use validated self-assessment questionnaires or validated web-based tools for screening.3 The Diabetes Risk Score (riskscore.diabetes.org.uk), developed by the University of Leicester in conjunction with Diabetes UK, uses seven key questions and a points-based system to identify if an individual is at low, moderate or high risk of type 2 diabetes. This tool is available free of charge to healthcare professionals working in hospital pharmacies, independent pharmacies or group pharmacies of 20 branches or fewer.4
Regardless of which screening tool is used, pharmacy teams also need to be equipped to provide customers with the information and advice required to complete and interpret the questionnaires accurately and appropriately. The results of any diabetes risk assessment carried out in-pharmacy should be passed to the individual’s GP and any customers with intermediate or high risk scores should be encouraged to follow-up with their doctor as soon as possible as a confirmatory diagnostic blood test and/or ongoing risk management may be required.
Clearly it is unrealistic to screen each and every customer in the community pharmacy setting, so how can staff best pinpoint those patients at high risk of type 2 diabetes? NICE advises that individuals from the following specific groups be encouraged to participate in pharmacy-led screening initiatives3:
• All eligible adults aged 40 years and above except pregnant women
• People aged 25-39 of South Asian, Chinese, African-Caribbean, black African and other high-risk black and minority ethnic groups
• Adults with conditions that increase the risk of type 2 diabetes, including cardiovascular disease, hypertension, obesity, stroke, polycystic ovarian syndrome (PCOS), a history of gestational diabetes and mental health problems.
NICE says it is particularly important to explain to people why, even though they feel healthy, they can still be at risk of developing type 2 diabetes but can reduce their risk by making lifestyle changes.3
In addition to opportunistic screening, NICE stresses the importance of publicising the opportunity for diabetes risk assessment in pharmacies.
As well as deficiencies in disease detection, not everyone in the UK with a definitive diabetes diagnosis is currently receiving all the essential health checks and care processes their condition demands.
According to the most recent National Diabetes Audit, 38 per cent of type 2 diabetics in England and Wales failed to receive all eight annual health checks required to manage their condition effectively.1 This is a particularly worrying statistic given the well-known and serious long-term consequences of sub-optimally managed and/or monitored diabetes, which range from cardiovascular disease to renal damage, retinopathy, amputation and neuropathy.
Shortfalls in service provision and uptake are further evidenced by the fact that only just over a third (37.4 per cent) of all patients with type 2 diabetes are currently achieving the treatment targets recommended to reduce their risk of developing diabetes-related complications.1
Breaking this figure down shows that the worst short-comings lie in achieving blood glucose (HbA1c <6.5 per cent) and cholesterol (<4 mmol/l) goals – just 26.4 and 40.5 per cent of patients respectively meet recommended treatment targets.1 Performance was slightly better in the area of blood pressure control, where 68.7 per cent of patients reached the target level of <140/80mmHg, but this still equates to one-third of sufferers with potentially dangerous, poorly controlled hypertension.1 Perhaps even more concerning, from a public health perspective, is the fact that these figures have not changed significantly for the past three years.1
There are opportunities for community pharmacists to expand their role into the practical management of type 2 diabetes and its complications. Of the 15 essential healthcare checks and processes advocated by Diabetes UK, many can be easily and effectively carried out in the community pharmacy setting. Examples include measuring blood pressure and blood fats, giving dietary and smoking cessation advice, and offering a flu vaccination service.5
Diabetes also increases the risk of sexual dysfunction in men and women and can be caused by lifestyle factors and medication side-effects, both of which pharmacists are equipped to provide helpful advice on. Evidence from a pilot study carried out in two UK pharmacies shows the value that pharmacy-led interventions can add to overall diabetes care. Customers with type 2 diabetes who received a pharmaceutical care package benefitted from a range of improvements, including better medication adherence, reduced co-morbidities and increased patient satisfaction.6
Pharmacy can further help type 2 diabetes patients achieve key treatment goals by supporting them in the optimal use of prescribed medications to control not only their blood glucose levels, but also hypertension and dyslipidaemia. Insulin and some of the newer injectable type 2 diabetes therapies can present particular problems with administration and compliance, which pharmacists are well-equipped to address
with regular medicines use reviews.
Side-effect management and avoidance of drug-drug interactions are also important areas of focus in diabetes, where patients are often on multiple medications to manage their condition.
Simple lifestyle changes remain a key weapon in the war against type 2 diabetes and their impact should not be underestimated – particularly given that the main modifiable risk factor for type 2 diabetes is an increased waist circumference or being overweight/ obese.
According to NICE, essential elements of lifestyle change programmes should comprise ongoing tailored advice, support and encouragement to help individuals carry out a minimum of 150 minutes of moderate intensity physical activity each week; gradually lose weight to reach and maintain a body mass index within the healthy range; increase consumption of wholegrains, vegetables and other foods high in dietary fibre; reduce the total amount of fat in the diet and eat less saturated fat.3
Pilot studies have shown that customers have high regard for pharmacist-led patient support and are more likely to be compliant to type 2 diabetes-driven lifestyle interventions and healthy living education when it is provided in a community pharmacy setting.6
Healthcare technology is a rapidly growing trend with total unit sales of wearable devices, smart watches and fitness bands expected to top 38m in 2016.7 A wide array of wearable technology, from wristbands, watches and earphones is now available that can track users’ physical activity, record steps and count calories – in addition to more diverse functions such as monitoring sleep patterns and tracking mood. The basic health monitoring features typically offered by most wearable technology prove particularly popular with customers looking to lose weight and get fit.
Other new and more advanced fitness-focused wearables are also entering the market. For example, products are now available that are able to track speed and form during body weight exercises by detecting the range of motion and strength used. These provide real-time feedback to the user to improve the effectiveness of their exercise programmes. Smart clothing with biometric sensors woven into the fabric is also under development.
Similar to the traditional wrist band or watch-based devices, these sensors can measure heart rate, respiration rate and volume, steps taken, calories burned and sleep. The health data collected is then sent to a mobile app. Insoles and shoe liners have also been developed that can measure steps taken and calories burned.
Moving from the fitness focus to more basic health monitoring, customers with type 2 diabetes already have access to a wide range of home blood pressure, glucose and cholesterol monitoring kits. Low-cost digital blood pressure monitors used at home may give a more realistic reflection of an individual’s true BP (by removing the so-called ‘white coat’ effect) and allow patients the security of self-monitoring their condition over the long-term.
Self-monitoring of blood glucose is an important element of care for some patients with diabetes and provides an accurate picture of blood glucose level at the time of the test.
Home blood glucose testing involves pricking the side of the finger and placing a drop of blood on a testing strip, which is then read by the device. This allows patients to immediately gauge their current blood glucose level, and also helps with long-term monitoring and achievement of blood glucose targets. Similar tests are available for cholesterol, where the finger is pricked with a small lancet and blood placed on a test strip impregnated with reagent chemicals.
In the near future, BP tracking looks set to go mobile with the advent of new wrist-worn devices that act as clinically accurate blood pressure monitors providing real-time BP readings. The aim is to allow patients with chronic illness to better record and manage their health data.
Other new ground-breaking devices include smart hearing aids that allow users to control their hearing via an app and smart electrocardiograms that can measure cardiac activity over a three-day period using a flat recording device clipped to a patch worn under the user’s clothes,
In addition to such devices, a host of web-based tools and apps are available to help customers achieve their health goals – be it losing weight, getting more active or stopping smoking. Many of these are free, easy to use and can be accessed via a smartphone or computer. As Laura St Quinton, lead for NHS web and mobile app development, explains: “Research tells us it takes at least 21 days to form a new habit. Having an app in your pocket that provides regular nudges along the way is a huge help.”
Apps and tools which may be particularly useful for type 2 diabetes customers include8:
• The NHS weight loss plan ‘Losing weight – Getting started’: This 12-week plan blends calorie counting with exercise to help people shed weight safely and sustainably
• My FitnessPal: This platform incorporates a database of over two million food products making calorie counting easy and is available free of charge from several sites
• One You Easy Meals: This recipe app helps with shopping and food sourcing to ensure people make smarter and healthier food choices
• ‘Couch to 5k’ running podcasts: ‘Couch to 5k’ is a hugely successful initiative launched by the NHS that is designed to get anyone, regardless of their baseline fitness levels, active and able to run 5 kilometres in just nine weeks. The plan is delivered though a series of podcasts that can be downloaded to any mobile device and is further supported by an active online community
• Fitocracy: This is a fitness app with overtones of the video gaming world in which users track their workouts to earn points that unlock interactive features such as ‘beat quests’ and slaying the ‘laziness dragon’. Fitocracy is also bolstered by a social network of supportive members who provide further motivation, inspiration and advice.
Many of these online health and fitness trackers are able to synch with today’s smart wearable technology – giving pharmacy customers the best of both worlds when it comes to mobile health monitoring.
1. Diabetes UK. Facts and Stats. November 2015
2. Diabetes UK. Boots to offer in-store type 2 diabetes risk assessments. Press release: January 2013. Available at: diabetes.org.uk/About_us/News_Landing_Page/Boots-to-offer-in-store-diabetes-risk-assessments
3. NICE Guidelines PH38. Type 2 diabetes: prevention in people at high risk. July 2012. Available at: nice.org.uk/guidance/ph38/chapter/1-Recommendations#recommendation-1-risk-assessment
4. Diabetes UK. Diabetes Risk Assessment Tool. Available at: diabetes.org.uk/Professionals/Diabetes-Risk-Score-assessment-tool
5. Diabetes UK. 15 Healthcare essentials. Available at: diabetes.org.uk/Guide-to-diabetes/Monitoring/15-healthcare-essentials
6. Medicine Digest. Community pharmacists in the front line. Diabetes Update; Winter 2012: 34-36
7. 10 Healthcare wearables, devices dominating CES. InformationWeek Healthcare. January 2016. Available at: informationweek.com/healthcare/mobile-and-wireless/10-healthcare-wearables-devices-dominating-ces/d/d-id/1323787? image_ number=1
8. NHS Choices. Health and fitness trackers. Available at: nhs.uk/conditions/nhs-health-check/pages/tools-and-technology-that-can-help.aspx