The latest module from EASD e-Learning unpicks the complex pathway of events involved in exocytosis within the beta cell – and explores some of the points along that pathway that have been implicated in the development of type 2 diabetes.

Exocytosis – the process by which insulin granules fuse with the beta cell’s plasma membrane and release their precious cargo – is critical to sustained insulin secretion in response to glucose.

It’s a finely balanced, highly localised process, depending on myriad individual chemical processes along the way, as Professor Lena Eliasson of the Lund Diabetes Centre in Sweden, presenter of the first part of this module explains. “You have ATP that regulates the membrane potential of the cell. That leads to the increase of calcium and calcium triggers the exocytosis, the fusion of the insulin granules with the plasma membrane. ATP also regulates the priming process of the granules to make them ready for this fusion with the plasma membrane.

“Then there’s cyclic AMP (cAMP), which we get from the binding of GLP-1, for instance. That is increased. And cAMP is important for the priming process as well. Finally, there is a third factor that is also important for the priming of granules and that is temperature. The priming and exocytosis of granules cannot go on if we have too low a temperature. It should be a temperature that we see in our bodies to get this process to work.” 

With such a complex process, there are a great many points at which things can go awry – contributing by turns to reduced exocytosis, reduced insulin secretion and, ultimately, increased likelihood of developing type 2 diabetes. “Many of the exocytotic genes have a reduced expression in islets from human donors with type 2 diabetes,” says Professor Eliasson. “For instance, there is reduced expression of syntaxin-1A. There is reduced expression of Munc-18. There is reduced expression of several important synaptotagmins.”

But although there is reduced expression of such exocytotic genes as, for instance, syntaxin and the synaptotagmins and SNAP25, there are actually no polymorphisms or variations of the genes coding for these proteins in the islets connected to the development of type 2 diabetes. “This makes us think that there must be other factors that can regulate the expression of these genes,” Professor Eliasson adds, “factors that are important in the development of type 2 diabetes.”

Several factors have been linked to the regulation of exocytotic genes. There is a specific splice factor that can regulate their expression. There are epigenetic factors, such as increased methylation. And there are non-coding RNAs, called micro RNAs (miRNAs), which can regulate the expression not only of exocytotic genes but also of other genes important for beta cell function. “The miRNAs can be very essential in the rapid adjustments that need to occur in the beta cell upon the development of type 2 diabetes,” Professor Eliasson explains. “When the beta cells need to respond to the increased demand from the target tissues of more insulin, miRNAs can set in to regulate certain gene expression to increase the insulin secretion rapidly. Failure to do so will lead to type 2 diabetes.”

All of which is suggestive of potential targets for treating type 2 diabetes. The potential clinical application of research in this area is taken up in two additional sub-modules attached to this module. Professors Malin Fex and Erik Renstrom (both of them also Lund Diabetes Centre luminaries) explore in more detail the roles played, respectively, by mitochondria and calcium in the exocytotic process.

Professor Fex, in her fascinating examination of the importance of mitochondrial metabolism for beta cell function, highlights melatonin and serotonin receptors as potential targets – demonstrating, for instance, how people with a genetic variant linked to the melatonin receptor MTNR1B express more receptor, thereby reducing insulin secretion and raising type 2 diabetes risk.

Professor Renstrom, in his survey of calcium’s role, singles out the transcription factor MafA and its role in controlling gamma-4 expression (which, in turn, affects calcium channels, exocytosis and insulin secretion) as a future target for restoring beta cell function in diabetes.

For Lena, Malin and Erik’s module ‘Exocytosis in pancreatic beta cells and its role in type 2 diabetes’, enrol on the EASD e-Learning course ‘Beta cell biology’.

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.

Learner feedback helps to ensure that the EASD e-Learning programme is up to date, evidence based and meets the needs of learners. It is also important that learners know their feedback is taken seriously. Dr Gillian Manning, EASD e-Learning’s Clinical Education Lead, reports on the feedback we’ve received over recent months – and what’s been done to address it.

The e-Learning team aims to review learner feedback it receives from learners who complete the module feedback form or email us via [email protected] every two to three working days. We try to respond as quickly as possible to resolve reports of technical or content issues and to keep the person providing feedback informed of our actions.

To help create a better, more engaging user experience and in response to your feedback, over the last three months we have:

  • Included at least two self-assessed case studies in each of the new modules launched in February, March and April
  • Added opportunities for active learning and self-assessed knowledge tests within new modules
  • Set many of the end-of-module multiple choice questions in a clinical context to support the clinical application of learning
  • Continued to upgrade all of our 79 modules to meet the same standards

How could our modules be improved?

Here are some of the key points of feedback we have received over the last quarter of 2022 – together with actions we have taken to address them.

‘Could you provide more information on very low calorie diets (VLCD)?’
Information on VLCDs was included in the module launched in April, ‘Understanding the causes of type 2 diabetes and how to achieve remission’

‘Could you include more pictures and real cases, case studies or case discussions?’
We are working to strengthen this aspect of our work. All our new modules now include at least two case studies and those launched between March and June 2022 included three or four. Other projects focused on case studies are currently in development

‘Please provide more specific information on how to use drugs in pregnancy and on dose adjustment of insulin during pregnancy’
These topics will be included in the updating of our two pregnancy-related courses -Gestational Diabetes Mellitus and Pregestational diabetes in pregnancy. These have already been refilmed and are due to be relaunched later this year

‘Can you provide downloadable PowerPoint slide sets of the module content?’
We do supply downloadable PDFs of certain key graphics – particularly those with small text or complex layouts where users may need to enlarge content for better legibility. However, the content is not held on our system in a PowerPoint format

Clinical application of learning

One type of feedback we are always particularly interested in receiving is how learners plan to apply what they have learnt from a module to their own practice. Here are some of the examples we’ve received in recent months.

I will…

  • Search for other microvascular complications in patients with diabetic kidney disease
  • Consider referral to a nephrologist when needed
  • Apply the frequency of monitoring guidelines
  • Teach sick-day rules to prevent diabetic ketoacidosis (DKA)
  • Choose the right patients for continuous subcutaneous insulin infusion (CSII)
  • Improve communication with patients at diagnosis and diabetic review appointments
  • Evaluate patients planning to perform Hajj
  • Encourage others to undertake this course
  • Explain the benefits of exercise for prevention and management of type 2 diabetes
  • Continue to work with patients trying to prevent diabetes by giving lifestyle advice and signposting, referrals for weight-loss programmes, etc.
  • Apply this latest knowledge and skills in my daily practice for better management of diabetic foot
  • Apply suggested treatment, prevention and approach with my patients with non-alcoholic fatty liver disease (NAFLD)

New launches

So far in 2022, we have launched the following courses and modules:

CPD accreditation update

One question learners have repeatedly asked us over the years is whether CPD points are available for completing our modules. So it was with great pleasure that we were able to report having gained educational accreditation from the UK’s Royal College of General Practitioners (RCGP) for 10 of our modules back in 2021. Since we last reported back to you on this issue, a further three modules have been accredited – enabling you to earn CPD points while you learn from 13 of our modules.

The newly accredited modules include:

We are currently preparing to submit a further 10 modules for accreditation by the UK’s Royal College of Physicians (RCP). Applications to other organisations are also planned.

Keeping modules up to date and relevant

We often receive feedback from learners asking for updates to some of our modules. Our periodic review cycle is designed to keep courses and modules up to date – and learner feedback forms part of that review process. We make minor updates within our modules in response to feedback from learners, as well as from authors, assessment setters and expert reviewers.

For some courses, we add additional modules to cover important new evidence, as illustrated by the new modules in the Diabetes and Ramadan and the SGLT-2 inhibitor courses. In 2022 we have already re-filmed and updated six modules in our Gestational diabetes mellitus and Pregestational diabetes in pregnancy courses, which will be relaunched later this year. We will also be restructuring and updating the SGLT-2 inhibitor course, with re-filming planned within the next four months.

Please do continue to send us your feedback, either by filling in the learner feedback form when you complete a module or directly via: [email protected]

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.

Learner feedback is a two-way process and central to the ongoing development of the EASD e-Learning platform. Dr Gillian Manning, EASD e-Learning’s Clinical Education Lead, reports on activities in this area over recent months.

This update highlights some of the feedback we have received from you in the last few months. We also wanted to let you know what action we’ve taken in response to your feedback. If there is anything else you would like to know or if you have feedback you would like to share with us, do get in touch. We would be particularly interested to hear how you are applying learning from our modules to your own practice.

Continuing professional development (CPD) accreditation

Many learners ask whether CPD points are available for completing one of our modules. We are pleased to report that since we first gained educational accreditation from the UK’s Royal College of General Practitioners (RCGP) for seven of our modules back in October last year, a further three modules have been accredited. These are:

We are currently preparing to submit a further 10 modules for accreditation by the UK’s Royal College of Physicians (RCP). Applications to other organisations are also planned.

Recent learner feedback

Your feedback highlighting which parts of a module were most useful and which could be improved continues to be monitored on a monthly basis. This feedback is included in our periodic review process. Any errors in content that you identify are reviewed by the e-Learning team and action is taken to correct errors as soon as possible. We are continuing to develop our systems to speed up our response to any errors in content or technical issues learners identify.

Case studies

In response to feedback, back in November 2021 we began adding more case studies to our modules, with the aim of ensuring that each of our 75 modules includes at least two case studies. We are also gradually strengthening the end-of-module assessments, which will include more case-based, multiple-choice questions.

Accessing end-of-module assessments

We occasionally receive feedback that a learner is unable to access the end-of-module assessment. The reason is usually because not all of the screens of learning have been completed. The assessment will not appear until all screens have been marked ‘complete’. .

Your 2021 feedback in summary

Number crunchers
  • 274 learners completed a learner feedback form in 2021
  • 120 of the learners completed the new, shorter form introduced mid-way through the year
  • When asked “Overall, how would you rate your satisfaction with module”:
    • 84% reported being very satisfied
    • 15% reported being satisfied
    • 1% reported being unsatisfied
    • 0% reported being very unsatisfied
  • 97% of learners reported that the module was at the right level for their current knowledge and experience
Applying your learning

Learners highlighted many examples of how they were intending to apply the knowledge gained from an e-learning module in their practice including:

Guidelines and communication with patients:

“I will add some of the information about it (DKA) to our hospital guidelines”  (Diabetic ketoacidosis)

“I will be able to provide better feedback to pump patients” (Technology and type 1 diabetes)


“I will consider how to incorporate newer and more effective ways of screening for peripheral neuropathy into our checks of people with T2DM” (Diabetic peripheral neuropathy)

“I will screen children earlier” (Diagnosis of type 1 diabetes)

Investigations and diagnosis

“I will try and diagnose diabetic peripheral neuropathy (DPN) earlier and use of point of care devices in our hospital” (Diabetic peripheral neuropathy)

“I will be careful to take the urine samples from the patients in the right circumstances or repeat the test for confirmation” (Diabetes and the Kidney)

Non-pharmacological approaches to management:

“I will explain the importance of weight loss to patients with NAFLD and ensure they are all seen by a dietician” (Non-alcoholic fatty liver disease)

“I will advise more about physical activity” (Insulin Resistance)

“I will assess the risk for the fear of hypoglycemia and measure it” (Hypoglycaemia)

Pharmacological approached to management:

“I will be aware of the importance of intensifying therapy early (Therapeutic inertia)

“I will consider all of the benefits of GLP1 RA and not only glycemic control” (GLP-1 receptor agonists)

“I will consider precautions for the use of SGLT2 inhibitors and consider this class in people with high CVD risk or established CVD” (SGLT-2 inhibitors)

Research and teaching:

“I will apply more of this metric in my research” (Time in range)

I will use the explanation of stages and DKA when teaching others and the people I see” (Technology and type 1 diabetes)

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.

Seven EASD e-Learning modules have now been accredited as educational resources for continuing professional development by the UK’s Royal College of General Practitioners (RCGP) and will carry the college’s quality mark. We take a closer look at what accreditation means for learners.

Starting today, RCGP accreditation marks will appear on the module and course introduction pages for seven accredited modules, with more expected to follow in the coming weeks and months. Welcoming the news, EASD e-Learning Programme Director Dr Eleanor D Kennedy commented: “The RCGP accreditation mark’s presence on our modules will mean that GPs and other members of the healthcare professional diabetes team can be confident the education they select has been independently assessed to ensure a consistent and high-quality educational resource.”

“The RCGP accreditation mark is an identifiable symbol of quality assurance that associates educational activities with professionalism, expertise and commitment to the highest possible standards of general practice,” she added. “This helps to demonstrate the important contribution EASD e-Learning modules can make to the delivery of safe, high-quality care for people at risk of or living with diabetes.”

What does RCGP accreditation involve?

RCGP accreditation follows an independent validation of these modules’ quality, judged against standards set by the RCGP. Educational resources accredited by the RCGP are considered to be of high quality and relevant for general practitioners’ CPD and revalidation needs.

What does accreditation mean in terms of CPD points?

The RCGP recommends that one CPD point should be awarded for each hour of learning on an RCGP-accredited educational resource. You can find an estimated duration for each of our modules at the bottom of that module’s introduction page.

Which modules have been accredited?

The following modules now carry the RCGP accreditation mark:

  • Non-alcoholic fatty liver disease, Module 1
    • NAFLD – epidemiology, pathophysiology and diagnosis
  • Diabetes and the kidney, Module 1
    • Overview of diabetes and the kidney
  • Management of hyperglycaemia in type 2 diabetes, Modules 1 and 2
    • ADA/EASD 2018 consensus report
    • ADA/EASD 2019 update
  • Hypoglycaemia, Module 1
    • Reducing hypoglycaemia
  • Insulin resistance, Module 1
    • Insulin resistance, the metabolic syndrome and type 2 diabetes
  • Phenotypic variability, Module 1
    • Phenotypic variability in type 2 diabetes

How do I find an accredited module on the EASD e-Learning site?

From now on, course cards for any courses that include accredited modules will be marked with an orange ‘CPD’ button. The same button will also appear on the course content ladder. The RCGP accreditation mark itself will appear on the module and course introduction pages for all RCGP-accredited modules. And as of this week, accredited EASD e-Learning modules will be listed in the RCGP’s own register of accredited CPD courses, at

How can I prove that I have completed an accredited module?

When you successfully complete any of our modules, you are given the option to download a personalised certificate of completion (these certificates are generated automatically and can be accessed via your dashboard). From now on, certificates for modules that have been accredited will include the RCGP’s accreditation mark together with information on the module’s duration and the number of points earned for each hour of learning.

What happens if I completed a module before it was accredited by the RCGP?

As part of the process of preparing modules for accreditation, we made improvements to the way modules are assessed and expanded their practical clinical content. Consequently, if you completed a module before it was accredited but want to obtain a certificate of completion that includes the RCGP accreditation mark, you will need to retake the end-of-module assessment. If you do not wish to retake the assessment but nevertheless would like to have a certificate for your own records, you can still access a personalised certificate of completion for the module. However, this will not include the RCGP accreditation mark.

Will more modules be submitted for accreditation?

Further modules have already been submitted to the RCGP and in time we will be submitting more, so watch this space. The entire website will also be submitted for accreditation by the UK’s Royal College of Physicians (RCP) in 2022. Plans are in place to submit our online courses to national accrediting bodies around the world.

To find out more about RCGP accreditation, click on the RCGP accreditation mark below.

Changes are afoot on the e-Learning platform – all aimed at making it easier for you to let us know what you think about our courses and alert us to any technical problems.

Starting this week, regular visitors will notice a new presence on our pages. To the right of the screen, wherever you are on the site, there is now a toolbar, which includes a number of options to help you communicate with us.

If something isn’t working the way you expect it to, you can click on ‘Report a technical problem’ and a short form will be presented. This feedback is monitored on a daily basis during the week and you can expect a response within two working days.

Alternatively, if you notice something that needs changing in the content itself, or there are topics you would like to learn more about, then you can use the ‘Feedback on course content’ button.

For other general enquiries, there’s a simple ‘Contact us’ button.

To support the dialogue between us and our users further still, the toolbar contains a ‘Your messages’ button, where you can access correspondence about issues you’ve raised with the e-Learning team, all in one place.

“Listening to our learners is at the forefront of ensuring the EASD e-Learning programme is up to date, evidence based and meets the needs of our learners,” said Dr Eleanor D Kennedy, Programme Manager for the e-Learning platform. “We hope these changes to our page design will make that dialogue easier and more satisfactory for our learners – as well as helping us to make continual improvements.”

Further developments to the toolbar are planned for the future – including the addition of course-specific glossaries and a series of ‘How to’ films to make it easier to navigate the site. So watch this space…

Listening to our learners is at the forefront of ensuring the EASD e-Learning programme is up to date, evidence based and meets the needs of our learners. It is also important that you know your feedback is taken seriously.

As we launch some new features on the platform – several of these have been designed in response to your comments; others have been designed to make it easier for you to share your thoughts on how we do things – we thought this would be a good opportunity to let you know about some of the areas where your feedback has made a difference to the e-Learning platform and content over the past year.

Certificates of Completion

Many of you asked for a Certificate of Completion. In response to this feedback, as of last September, all learners who have successfully completed a module can download a Certificate of Completion from our website.

Continuing Professional Development (CPD) Accreditation

We are often asked whether learners can gain CPD points from doing our courses. We are currently in the process of preparing to submit an application for CPD accreditation later this year. A successful application will provide external validation of the quality of the courses and enable us to publish information about the number of accredited learning hours (or points) per programme and link this to the Certification of Completion.


We have always provided transcripts of the audio recordings within courses but we received feedback asking for transcripts of the video recordings as well. We have now added these to each course to support your learning.

Reflective learning templates

Reflection drives learning and is an integral part of CPD, appraisal and revalidation. With that in mind we have added a reflective learning template to the site to encourage you to reflect on your learning from each course or module and set out your action plans and revisit them as you achieve each action. These can then be included in your CPD portfolio.

New courses and modules

Many of you have put forward suggestions for new courses or new modules within existing courses. Some of these have already led to new course content, including on type 1 diabetes and exercise and on psychology and diabetes, modules on which will be launched later this year. Other ideas are currently being reviewed by the course development team.

Launching soon

New tools for feedback
One of the innovations to our platform that we are launching shortly is a toolbar that will appear to the right of the screen wherever you are on our site. This includes a number of feedback options.

Report a bug
If something isn’t working the way you expect it to, use this button to report any technical problems. This feedback is monitored on a daily basis during the working week and you can expect a response within two working days.

Provide feedback
If you notice something that needs changing in the content itself, or there are topics you would like to learn more about, use this button to let us know. (Alternatively, you can use the ‘Provide course feedback’ link that appears at the lower left-hand side of every screen of learning.) We review this feedback on a monthly basis.

We are also developing a number of other items on this toolbar to make your experience of our courses easier and more fulfilling – including special ‘how to’ films to help you navigate the site and a series of glossaries explaining some of the more obscure specialist terms used in our courses.