The growing problem of diabetes

Fiona Godlee, The BMJ

Type 2 diabetes affects nearly 10% of the world’s adults, and rates are rising rapidly, especially in low and middle income countries.1 In the UK it affects about four million adults (6% of the population), and if nothing changes this will grow to about five million by 2025.2 And new figures released this week by Diabetes UK show that in England and Wales nearly 7000 people under age 25 now have type 2 diabetes (doi:10.1136/bmj.k4929).

With such numbers, diabetes in one form or another now makes up a substantial part of any doctor’s day (doi:10.1136/bmj.k4723). So what can you do for your diabetic patients? Firstly, don’t call them that, says Judith Hendley (doi:10.1136/bmj.k3119). She wants to be identified as a person first and not as a diabetic patient, a label that reduces her “to someone with diabetes and nothing else.”

Secondly, consider your use of language generally. Hendley suggests avoiding questions such as “Are you well controlled?” She says, “This feels like a question about my behaviour and how ‘good’ I have been.” Better to ask open questions that don’t judge or make assumptions, for example: are you having any difficulties with your blood sugar at the moment, and what is most important to you right now? Such reframing may sound trivial, but, says Hendley, it “could make a big difference to how the people in front of you see themselves and their condition—and how they see you.”

As for the factors behind the global diabetes epidemic, there’s always more to learn. Analysis of data from two large cohorts of nurses confirms the key role of unhealthy lifestyles (doi:10.1136/bmj.k4641). A systematic review looks specifically at the effect of fructose on glycaemic control and concludes that this depends on the source of fructose and how much extra energy it provides (doi:10.1136/bmj.k4644). Sweetened drinks and some other foods that add excess “nutrient poor” energy were most likely to adversely affect glycaemic control.

Weight loss is essential for management of diabetes and can lead to remission, but once achieved it can be hard to maintain. In what may be a ground breaking randomised trial, Cara Ebbeling and colleagues found that energy expenditure was higher when people ate a low carbohydrate diet during weight loss maintenance (doi:10.1136/bmj.k4583). People randomised to a high carbohydrate diet had higher concentrations of the hormone ghrelin, which is thought to reduce energy expenditure.

Ultimately the burden of diabetes is unsustainable. While patients and health professionals manage as best they can, the real and urgent solutions rest with our governments.

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

Dorothea Lange - Migrant Mother

Dorothea Nutzhorn naît en 1895 à Hoboken, New Jersey, dans une famille d’immigrants allemands de la deuxième génération. À l’âge de dix-huit ans, elle se lance dans la photographie et apprend son métier dans un premier temps à New York, auprès de photographes portraitistes de studio bien connus. Par la suite, en 1918, elle ouvre son propre studio à San Francisco et adopte le nom de jeune fille de sa mère, Lange. Son studio devient vite un centre de la vie artistique de la ville et lui offre une indépendance vis-à-vis de sa famille, en tant que jeune mère de deux garçons et épouse d’un peintre célèbre, Maynard Dixon.
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Farm Security Administration/Office of War Information Black-and-White Negatives

What we must learn from mesh

Fiona Godlee, The BMJ

What can we learn from the shameful story of vaginal mesh? That thousands of women have been irreversibly harmed; that implants were approved on the flimsiest of evidence; that surgeons weren’t adequately trained and patients weren’t properly informed; that the dash for mesh, fuelled by its manufacturers, stopped the development of alternatives; that surgeons failed to set up mesh registries that would have identified complications sooner; and that the National Institute for Health and Clinical Excellence and the UK regulators let them off the hook (doi:10.1136/bmj.k4137, doi:10.1136/bmj.k4164). As our editorial says (doi:10.1136/bmj.k4231), unless mandatory national registries are now established another mesh tragedy is inevitable.

The mesh story tells us something else: the extent to which surgeons, researchers, and professional bodies are entangled with the device manufacturers. This is nothing new. Indeed discussion of it will be as tediously familiar to most readers of The BMJ as it is to us editors. But we make no apology for raising it again. Why? Because of the evidence that researchers’ conclusions and clinicians’ decisions are influenced in favour of their sponsors’ products. If this were not the case, why would manufacturers spend the money? GlaxoSmithKline has just confirmed the usefulness of paid opinion leaders by reinstating payments to clinicians who speak and write about its products (doi:10.1136/bmj.k4157).

So I have two questions. First, should clinicians and researchers take money from industry? My answer is no. We don’t allow judges or journalists to take money from the people they are judging or reporting on. Doctors should be equally independent in their advice to patients. This is why, uniquely among the major medical journals, The BMJ ensures that the authors of clinical education articles and editorials are free from relevant financial interests (doi:10.1136/bmj.g7197). As for industry sponsored research, we welcome the call by Paula Rochon and colleagues for journals to ensure that academic authors retain full control of the process (doi:10.1136/bmj.k4224).

Second, given that doctors and researchers do take money from the industry, should the details be readily available to patients and the public? My answer is yes. Jonathan Gornall found this wasn’t the case with mesh (doi:10.1136/bmj.k4164), despite NHS guidance on declaration of financial interests. NHS trusts are catching up with their responsibilities, but slowly. The Association of the British Pharmaceutical Industry’s database is voluntary and therefore ultimately ineffectual. The device industry’s equivalent body, the Association of British HealthTech Industries, has refused to take even this baby step. The GMC has been asked to establish a register of doctors’ interests (doi:10.1136/bmj.h396) but shows no signs of doing so.

In the US the Sunshine Act hasn’t solved the problem (doi:10.1136/bmj.k4151) but it has put doctors on notice (http://bit.ly/2C94j6G). Other countries should follow this lead.

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

End the culture of fear in healthcare

Navjoyt Ladher, The BMJ

A key finding of the independent report into deaths at Gosport War Memorial Hospital, where around 600 people received fatal and medically unjustified doses of opioids, was a hospital culture of uncritical deference to doctors and a fear of raising concerns. In an essay this week Philip Darbyshire and David Thompson issue an urgent call for the report to serve as a tipping point in ending professional hierarchies in clinical practice (doi:10.1136/bmj.k4270). Subservience and deference, endemic in health systems, are harming patients, they say, with professionals fearing retribution, disapproval, career limiting consequences, and worse if they dare to question or challenge colleagues.

How do we begin to dismantle the deeply embedded hierarchies of status and profession? Darbyshire and Thompson find answers in the existing evidence base for strong leadership to create safe, open, questioning healthcare organisations, where patients and families are included in decisions, and bad behaviour is not tolerated, no matter the rank. “We do not need more research,” they argue, “we need more leaders with the courage and creativity to implement what we already know.”

Courageous and creative leadership is essential to tackle issues discussed elsewhere in The BMJ, be that taking action on climate change (doi:10.1136/bmj.k4410), providing healthcare to forced migrants (doi:10.1136/bmj.k4200), having honest conversations about what intensive care can achieve (doi:10.1136/bmj.k4135), or dealing with the drivers of chronic diseases, such as diabetes. On this last point, a feature this week looks at the emerging specialty of lifestyle medicine (doi:10.1136/bmj.k4442). Practitioners use behavioural approaches to encourage change in diet, physical activity, sleep, stress management, and substance use. It offers a promising and sustainable approach to treating and preventing disease and is increasingly becoming part of the medical student’s curriculum. Critics say, however, that it needs to prove it can truly make a difference to patients’ lives, particularly in the context of wider social determinants of health.

The importance of preventive approaches in health is reflected in the inclusion of “prevention and lifestyle” as one of six new categories in The BMJ Awards next year (doi:10.1136/bmj.k4434). The awards, now in their 11th year, celebrate excellence in UK healthcare. Do enter, or nominate a colleague, if you have a project worthy of recognition (thebmjawards.bmj.com).

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

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5. Gewässerperlen - Die schönsten Flusslandschaften der Schweiz von Martin Arnold und Urs Fritze, AT Verlag
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