In the latest EASD e-Learning module, leading experts in diabetes care and research guide learners through the latest ADA/EASD consensus report on managing type 2 diabetes.

The first of two new modules on the management of hyperglycaemia in type 2 diabetes launches today. The module, titled ‘ADA/EASD 2022 consensus report – background, rationale and components of care’, outlines key components of the much-lauded report, sharing insights into how they were produced and the rationale behind them. A second module, due to launch in 2024, will take a closer look at the central concept of personalised care and how to implement the report.

The list of authors and presenters of the new module reads like a roll call of leading diabetes experts from around the world. They include Professors Melanie Davies and John Buse (co-chairs of the report writing group), plus Professors Peter Rossing, Tsvetalina Tankova, Geltrude Mingrone, Vanita Aroda and Dr Billy Collins – all of whom were also members of the writing group. Professor Buse paid tribute to the positive impact that the diversity of the group had on the final report. 

“We tried to get representation from the primary care community, people that are more accustomed to dealing with complications, methodologists in meta-analysis and subgroup analyses… We also tried to get a heterogeneous group with regards to geographical representation, gender, etc. I think the representation that we’ve had from the primary care community, from epidemiologists, really has rounded out the recommendations in a very positive way.” 

Professor Davies agrees: “I think it’s much more holistic, so we’ve really taken that step from emphasising the person-centred approach, the really holistic approach to management. I think this time there’s a bigger focus on implementation… We’ve got all this great evidence, we know in some ways what we should be doing but getting that into practice, that’s probably been a bit more of a focus this time round.”

Another area of difference between the new consensus report and its previous iterations is the greater emphasis on social determinants of health. Says Professor Buse: “The way I like to talk about it is, as a provider, getting into the head, the heart and the home of the person with diabetes, to really try to understand what it takes to make things work. That’s another big section that’s been added this year: practical pointers for providers with regard to making things work.”

These two modules replace the existing modules in EASD e-Learning’s ‘Management of hyperglycaemia in type 2 diabetes’ course, which focused respectively on the 2018 consensus report and its 2019 update. EASD Programme Director Dr Eleanor D Kennedy commented: “Our modules on the 2018 and 2019 consensus reports have been two of the most popular and highly rated modules on the platform and were among the first EASD e-Learning modules to be accredited for continuing professional education by the UK’s Royal College of General Practitioners. We hope these two new modules will be similarly well received.” 

Enrol today on the new module at Management of hyperglycaemia in type 2 diabetes module 1 ‘ADA/EASD 2022 consensus report – background, rationale and components of care’.

Certificates of completion

The modules on the 2018 consensus report and its 2019 have now been retired and are no longer available on the platform. However, anyone who has successfully completed the older modules and passed the end-of-module assessment will still be able to access their certificates of completion on their ‘My account’ page.

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

In EASD e-Learning’s latest module, which launches today, Professor Eelco de Koning examines the different patient journeys for islet transplantation that are available to people with diabetes, according to which transplantation technique best suits their condition.

Karim, a 58-year-old man with long-standing type 1 diabetes, rising blood pressure and signs of rapidly declining kidney function, attends your clinic. Despite his use of technology and the education and support he receives from his local diabetes team, he has recently been experiencing distressing hypoglycaemic events. While attending a local diabetes peer-support programme, he has heard about various therapeutic options, including developments in the field of transplantation, and would like to discuss these with you. As your discussions progress, he asks specifically whether an islet or pancreas transplant would be best for him and what would be the advantages and disadvantages of both options. How would you advise him?

Such scenarios are at the heart of the new module from Professor Eelco de Koning, ‘Patient journeys in islet transplantation’. Karim’s will be a familiar presentation for many healthcare professionals working in the field of type 1 diabetes. Yet those responsible for referring people with diabetes for transplantation often lack knowledge of islet and pancreas transplantation. According to Professor de Koning, only 25% of endocrinologists and nephrologists in the Netherlands have been exposed to the ins and outs of donor pancreas and/or islet transplantation.

Professor de Koning’s new module addresses that shortfall head on with a detailed examination of the contraindications and prerequisites for certain procedures, including simultaneous pancreas/kidney transplantation, kidney transplantation alone followed by pancreas/islet transplantation, solitary pancreas or islet transplantation, or more advanced technical support and no transplantation. 

The module combines an introduction to the practicalities of these options with a general call for better integration of pancreas and islet transplantation centres with expert diabetes centres to enable optimal decision making and streamlining of referrals. 

Learning outcomes

On completing this module you should be able to:

  • Explain the range of transplantation techniques available to treat a subgroup of people with diabetes and severe beta cell failure and the goals and outcomes of each technique
  • Examine the advantages and disadvantages of each available transplantation option and the factors diabetologists and nephrologists should consider when referring patients to specialist transplantation centres
  • Plan the review and referral of typical patients with diabetes and severe beta cell failure to specialist transplantation centres, highlighting the importance of shared decision making to support patients to balance the risks and benefits of transplantation when making treatment decisions

For Professor de Koning’s module ‘Patient journeys in islet transplantation’, enrol on our course Islet transplantation.

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

In a welcome return for ‘The briefing room’, a group of diabetes research luminaries examine the rise to prominence of medications that work by stimulating receptors for GIP and GLP-1 – and where things may be headed next.

“The GIP story is a real rollercoaster,” says Professor Cliff Bailey. “Although GIP originally stood for gastric inhibitory polypeptide, it subsequently became shown to stimulate insulin secretion. So it became a glucose-dependent insulinotropic peptide… Also, originally, GIP was identified as a 43-amino acid peptide and then later it was realised that it was only 42. So we never really knew whether the initial experiments that we did were entirely justified.”

The story is representative of a field of research that seems to have been singularly marked by false starts (a similar misreading of the amino acid sequence of the bioactive form of GLP-1 complicated its early investigation). Fast forward to today, though, and we can look back on a trail of medications based on these compounds, each one more effective than the last – and in ways that may have surprised the original investigators. 

It’s a trail that is compellingly described by the participants in this second edition of ‘The briefing room’. These include – as well as Cliff Bailey – Professors Stefano Del Prato, Baptist Gallwitz, Francesco Giorgino, chaired admirably by Michael Nauck. Between them, they describe how numerous obstacles were overcome (the role of the venomous saliva of the Gila monster reptile is a particularly vivid plot twist) and the true potential of these medications was gradually revealed.

The twists and turns are compelling. But it’s the range of properties at the story’s heart that really stand out. As Michael summarises: “Insulin secretion was stimulated, glucagon was suppressed without a risk of hypoglycaemia, appetite was reduced, caloric intake was reduced, body weight was reduced in the long run. We had effects on glucagon, we have effects on the cardiovascular system that translate into real benefits preventing myocardial infarction, stroke and the mortality associated with such events. And there always was an improvement from agent to agent, showing a very large potential.”

So what does the future hold? “I certainly am not in a position to say how far this will go,” says Michael. “I hope that there is still some potential left for future development. The most recent development is co-agonists stimulating both GIP and GLP-1 receptors. It’s called ‘twincretins’ because it combines the action of the two original incretin hormones and it has smashing results in terms of glycaemic control, leading patients into the normal range of HbA1c and allowing reduction in body weight by 20% or more, which probably contributes to a major benefit in terms of metabolic health and cardiovascular consequences. We also have to admit that there remain some open questions, which, of course, is always good for scientists like us. Because they offer a chance that we will find out details of the mechanisms, which then will lead to better future developments of drugs that incorporate this new knowledge that we still have to work on.”

Get the full story in the second episode of ‘The briefing room’, ‘Incretin-based medications’.

Professors Michael Nauck, Stefano Del Prato, Francesco Giorgino and Baptist Gallwitz will be participating in a live EASD e-Learning Q&A session on this topic, chaired by Professor Chantal Mathieu, at the EASD conference on Wednesday 21st September at 12.00 in the Virchow Hall.

Many people with diabetes have to cope with the significant health challenges presented by living with more than one chronic condition. To launch EASD e-Learning’s new course on conditions commonly associated with type 1 and type 2 diabetes, Professor Bruce Wolffenbuttel’s module focuses on comorbidities in type 1 diabetes.

Comorbidities in type 1 diabetes – not only other autoimmune-related conditions but obesity too – have significant implications for treatment and quality of life. “We all think of diabetes as a glucose disease where we to try to attain as good control as possible,” says Professor Bruce Wolffenbuttel, Emeritus Professor of Endocrinology and Metabolism at the University of Groningen, The Netherlands. “We try to treat hypertension and try to treat dyslipidaemia. But other diseases that coincide with type 1 diabetes also need attention from the diabetes team – they should be an integral part of diabetes care.”

Obesity, although more commonly discussed in the context of type 2 diabetes and not strictly speaking a comorbidity, is the first topic Bruce addresses in his module. It’s an important issue for people with type 1 diabetes, with long-term follow-up in the DCCT EDIC study showing sizeable increases in body weight over time. As Bruce points out, intensive insulin treatment may itself play a part in this – not least by encouraging excessive carbohydrate intake to combat hypoglycaemia. Whatever the cause, this weight gain translates into significant consequences for both the treatment of diabetes and the development of complications (cardiovascular, in particular) – raising blood pressure and increasing both intima-media thickness and coronary calcifications.

The module’s main focus, though, as might be expected, is on autoimmune comorbidities. As a condition that originates in autoimmunity, it makes sense that type 1 diabetes should overlap with other autoimmune disorders, and Bruce shows data from the UK Biobank that explains, at least in part, why some of these so often go hand in hand. Type 1 diabetes, hypothyroidism and coeliac disease, for example, all share a similar risk in the HLA system, located on chromosome 6. 

Of the autoimmune comorbidities associated with type 1 diabetes, the most prevalent are the thyroid disorders, coeliac disease and vitamin B12 deficiency –  all of which have a significant impact on quality of life. These are all explored in detail. Bruce’s central point – that identifying and treating these comorbidities should be an integral part of the care provided by the diabetes team – is well served by this module, which provides vital information practitioners will require to plan the diagnosis, monitoring and treatment of people with type 1 diabetes and comorbidities.

For Professor Wolffenbuttel’s module, ‘Type 1 diabetes and comorbidity’, enroll on the new EASD e-Learning course ‘Multimorbidity and diabetes’, launching today.Professor Wolffenbuttel will be participating in a live EASD e-Learning Q&A session with Professor Cees Tack titled ‘Comorbidities in type 1 and type 2 diabetes’ at the EASD conference on Tuesday 20th September at 13.00 in the Virchow Hall.

In a new series of films on Horizons, leading researchers and clinicians from around the world talk about the journal articles that have left a deep impression on their understanding and practice in the field of diabetes.

Scientific discovery is a slow, painstaking business. Eureka moments are few and far between. Even so, it’s the breakthroughs that stick in the mind. Those turning points – usually accompanied by a much pored-over journal article and hinging on the sharing and accumulation of knowledge over many years – when, for the scientific community, the penny finally drops and our collective understanding advances.

The history of diabetes research is unusually blessed with such moments. The Diabetes Control and Complications Trial, which conclusively demonstrated the importance of tight glycaemic (and blood pressure) control in preventing the complications of type 1 diabetes. The United Kingdom Prospective Diabetes Study, which did much the same for type 2 diabetes. And of course, just over a century ago, the discovery of insulin itself.

We wanted to know which trial results and articles had been breakthrough moments for our authors and collaborators. Starting earlier this year, whenever we were filming a module or panel discussion, we began asking presenters or participants to choose the diabetes-related journal article that had had the biggest impact on them, and to explain how it had affected their understanding of diabetes and their practice as a researcher or clinician. The result is a new film series -‘Gamechangers’ – which starts on Horizons this week.

To kick the series off, EASD President Professor Stefano Del Prato chooses two articles, separated by 20 years but closely connected by subject (the effects of phlorizin on glycaemia and insulin secretion) and ultimately by their potential to transform the treatment of diabetes:

Rossetti L, Shulman GI, Zawalich W, De Fronzo RA. Effect of Chronic Hyperglycemia on In Vivo Insulin Secretion in Partially Panceatectomized Rats. J Clin Invest. 1989 (Oct):80; 1037-1044.

Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, Mattheus M, Devins T, Johansen OE, Woerle HJ, Broedl UC, Inzucchi SE. EMPA-REG OUTCOME Investigators. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. NEJM. 2015 (Nov): 2117-2128.

Watch the first film in the ‘Gamechangers’ series, ‘New vision, new treatment’ presented by Professor Stefano Del Prato, launching this week on Horizons.

For more on this topic, enrol on the following EASD e-Learning course:

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

In his new module for EASD e-Learning, Professor Eelco de Koning considers the various options available for restoring normal glucose regulation by replacing insulin-producing cells – whether through islets or whole pancreas transplantation.

Eelco de Koning, Professor of Diabetology at Leiden University Medical Center, The Netherlands, is in no doubt about the challenges posed by diabetes self-management. “We should all realise that the insulin-producing cell is the perfect closed-loop system,” he says. “It measures glucose continuously. It provides the right signals to the secretory part of the insulin-producing cell, providing exactly the amount of insulin that is needed. The insulin will have its effect on glucose uptake, especially in muscle and fat tissue. And the lowering of glucose by increased glucose uptake will be detected by the glucose sensor. In our treatment of patients with severe beta cell failure, we try to mimic this sensory function and the secretory function of the cell as well as possible. But it is impossible to achieve a perfect mimicry of this. And therefore, chronic hyperglycaemia will always exist, even with the advanced hybrid closed-loop systems that are currently available. So the only real solution for completely normal glucose regulation without risk of hypoglycaemia is replacement of the insulin-producing cells. But how do we do that?”

This last point is the central question addressed by Eelco’s module. Several transplantation options are now available, including islet transplants, simultaneous pancreas-kidney transplants and pancreas transplantation alone. All carry risks – not least the necessity for immunosuppressive treatment for as long as the transplant endures. Whole pancreas options carry additional surgical risk, including bleeds, leaks and fistulas. Islet grafts will likely require more than one infusion of islets due to the high rate of beta cell mass-loss involved. All are constrained by availability of donor tissues.

Weighed against these are the benefits in terms of glycaemic control, risk of diabetes complications, long-term survival and quality of life. Of huge significance for many transplant recipients is the associated relief from hypoglycaemia – a benefit Eelco is keen to highlight, and spoke passionately to in his podcast on ‘The patient who changed the way I think about diabetes’. He describes the case of a middle-aged woman whose life had been seriously disrupted by repeated episodes of severe hypoglycaemia and loss of hypo awareness. “When we performed an islet transplantation it really transformed her life. She still needed a little bit of long-acting insulin, but still her life changed in a way that she was able to go out again, to go shopping, to interact with her friends, to have a social life. This example showed me what the impact of type 1 diabetes can be on patients that have to live with type 1 diabetes every minute of their life. And it also showed me the power of islet replacement therapy, the enormous impact that can have in a positive way on the lives of patients with type 1 diabetes.”

Eelco’s module ‘Pancreas and islet transplantation’ launches this week on the EASD e-Learning platform.

Don’t miss ‘Hypo impact’, Eelco’s contribution to our series The patient who changed the way I think about diabetes’, available on Horizons.

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

The centrality of disrupted beta cell function to type 1 diabetes is widely understood. Less commonly appreciated is the vital part it plays in type 2 – a role that takes centre stage in Professor Hindrik Mulder’s new module.

In his module ‘Stimulus-secretion coupling in pancreatic beta cells’, the first in EASD e-Learning’s new course ‘Beta cell biology’, Professor Hindrik Mulder starts by addressing head on the significance of dysfunctional beta cells in the pathogenesis of type 2 diabetes.

“To develop type 2, it’s not sufficient to be insulin resistant. You can be as insulin resistant as you may and you will not develop diabetes – as long as your beta cells are strong and healthy enough to deliver the right amount of insulin, at the right time.”

What follows is a fascinating exploration of what we currently know about beta cell biology – focusing in particular on the complex intracellular triggering pathway by which healthy beta cells regulate blood glucose. Along the way, Hindrik examines the impact of recent innovations – including genome editing and stem cell research – which promise to revolutionise what is possible in beta cell biology research.

It’s a topic close to Hindrik’s heart. He has been actively researching in this field at Lund University, Sweden, for several years, developing metabolomics and imaging techniques to explore metabolic events in beta cells and islets. More recently he has elucidated how genetic variants associated with type 2 diabetes contribute to disease mechanisms.

Given the rarity of monogenic forms of type 2 diabetes and the multi-gene and multifactorial nature of the condition’s most frequent form, why should we pay attention to these genes? “I think it’s really important to understand how the disease develops,” Hindrik explains. “The more we learn, the better we understand it. But also, we can actually base treatment on understanding how these genes are implicated in the development of type 2 diabetes. It could be a pathway that we could perhaps affect by some drug. So it’s very helpful to the pharmaceutical industry that we have all this information about these genes that are involved in the development of the disease. These genes will help us to identify drug targets. And since diabetes is such a severe disease affecting so many people, it’s really important to find as many useful therapies as we possibly can.”

For more on this topic, including from Hindrik’s research colleagues at the Lund University Diabetes Centre, watch out for other modules in the Beta cell biology course, coming soon.

For more on the causes of type 2 diabetes, enrol on the following EASD e-Learning modules:

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

For the latest in our series ‘The long and the short of it’, renowned psychologists with a specialism in diabetes, Professors Bill Polonsky (University of California, USA) and Frank Snoek (Amsterdam University Medical Center, Netherlands) discuss the psychosocial aspects of diabetes technology.

Recent decades have revolutionised what’s possible in diabetes self management with the arrival on the market of new technologies to support blood glucose monitoring and insulin delivery – or even to combine the two. But how far have these innovations actually benefited people with diabetes, not just in terms of their health outcomes but also their quality of life?

Between them, Professors Bill Polonsky and Frank Snoek have many years of active engagement with this topic – both as clinicians and as researchers. One thing they both agree on is the potentially transformative power of new technologies, in particular pumps, continuous glucose monitoring (CGM) and closed-loop systems. Says Bill: “From clinical experience I know that for many people with diabetes [these technologies] can bring an ‘Aha!’ moment. Certainly with sensor technology, it’s like someone turning a light on in a dark room. And that enthuses them about wanting to become more engaged with their diabetes care.”

Frank agrees, though he is careful to distinguish between his experiences as a clinician and as a researcher. Bill shares this observation. “As a clinician I’ve seen numerous examples of how it benefits people in their daily lives. As a researcher – not so much. So far, the research doesn’t show as much as we might hope.”

Quite why that may be, neither is sure, though they agree that it’s likely something to do with the way research is carried out, or how certain outcomes are measured. “A topic for a future discussion,” Frank suggests. What’s obvious, though, is the divergence in access to technology – which the two can testify is manifest both in the USA (where access is dictated by the patient having an insurer willing to pay) and in Europe, where national health systems have different approaches to reimbursement for such technology. For Frank this raises the troubling issue of inequality: “It’s worrying that technology actually increases the divide rather than closing that gap.”

The criteria according to which healthcare professionals deem people with diabetes to be suitable (or unsuitable) to have access to new diabetes technologies are also of concern to both. Frank explains that in the Netherlands, access to real-time CGM has been limited to those doing ‘poorly’ – with the result that people with better diabetes control are effectively punished by being denied access to technology that could improve their quality of life. In the USA, Bill points out, the bias has worked both ways. Access to CGM was initially limited to people with good control – therefore not available to people who needed it the most.

“There is implicit bias in these decisions about who gets access,” Frank says. “Its often based simply on healthcare professionals’ (HCPs) gut feelings about who might benefit. Ultimately, both hope the time will come soon when HCPS can ditch the inclusion criteria – stop thinking about people qualifying for technology and watch out instead for those people who are going to struggle with these technologies.

So what problems might be associated with diabetes technologies? Frank highlights the problem of perfectionism some people with diabetes may have. “Technology enables them to take that impulse even further – increasing the burden of living with diabetes.”

Bill agrees. “We sometimes see an obsessive-compulsive quality, and people in competition to achieve ‘great numbers’, seeking 100% time in range. Some people drive themselves nuts doing this. And put themselves at risk from hypoglycaemic problems as well.”

There are also problems relating to a lack of guidance and support in how to use the technology, and both argue that people need ‘problem-solving’ support for how to use these tools in order for them to really make a difference.”

Finally, HCPs need to be careful not to let the data generated by these technologies become another stick to beat their patients with. Says Frank: “they should be prepared to talk with their patients in a non-judgmental way about what these technologies reveal in terms of their behaviours.”

“There is so much blaming and shaming in diabetes,” says Bill. “It makes it very difficult for patients to stick with it.”

For more on this topic, see the following EASD e-Learning content:

For more from Professor Frank Snoek, enrol on his module Fear of hypoglycaemia, module 3 of our Hypoglycaemia course.

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

Patient education and support are crucial for effective diabetes management, right? So far, so uncontroversial – but what should that education encompass? Who should provide it, where and when? These are just some of the questions addressed in our latest module.

In his new module, An introduction to patient education in diabetes, which launches this week, Dr Joao Filipe Raposo traces the development of patient education in diabetes back to the earliest days of insulin treatment – in fact, almost to the moment insulin was first discovered by Banting and Best.

“Education and patient involvement were fundamental to achieving the benefits of insulin,” he points out. “For the first time in the history of medicine, patients had to be involved in their treatment and surveillance, since it was not possible to keep patients with a lifetime condition in hospitals, and with multiple daily injections of insulin. Since that time, in Canada, in the USA, in Portugal, patient education has been a requisite for healthcare providers.“

As well as being a professor at the NOVA Medical School in Lisbon, Dr Raposo is Clinical Director of Portugal’s Diabetes Association (the APDP) and President of the Portuguese Diabetes Society. He credits diabetes patient organisations such as these with much of the early advances in this field, citing the example of Ernesto Roma – the APDP’s founder. As an intern at the Massachusetts General Hospital, Dr Roma visited Joslin’s celebrated diabetes clinic in Boston, where Banting and Best sent the first vials of insulin in 1922. On his return to Lisbon in 1925, Roma set about introducing not just insulin therapy but education in the skills patients required to use it effectively – creating an educational department at the association that provided group lessons and individual tuition in nutrition, insulin administration and glucose monitoring.

It’s a story that was to be repeated many times over in the years after insulin therapy was first introduced (RD Lawrence and the British Diabetic Association is another example – see

Times – and treatments – have changed considerably since then and Dr Raposo’s module is a valuable guide to the evolution of the tools and terminology employed in diabetes patient education over the years – including key concepts in disease models, behaviour change and self-care behaviours. The module also includes practical case studies highlighting the benefits of particular approaches to diabetes patient education, barriers to effective education and the role of technology in diabetes self-care and structured education.

For Dr Raposo’s new module, enrol on the EASD e-Learning course Patient education and support.

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

In the latest episode of The long and the short of it, professors Larry Fisher and Frank Snoek get to grips with some of the emotional aspects of living with diabetes – focusing on diabetes distress and depression.

One of the first points Professors Frank Snoek (Amsterdam University Medical Centre, Netherlands) and Larry Fisher (University of California, USA) make in their fascinating and wide-ranging discussion is just how important it is to understand the difference between diabetes-related distress and depression.

Diabetes distress, often linked to an overwhelming sense of powerlessness to control blood glucose and a fear of hyper- and (in particular) hypoglycaemia, is to be expected. As Larry says: “One would expect people living with this condition to have these experiences at some stage.”

His point is borne out in the statistics: around 35-45% of people with diabetes have elevated distress levels – a fact bemoaned by both professors given how easily distress can be addressed and reduced.

Depression on the other hand – “major depressive disorder or clinical depression, not just depressive symptoms; it’s a psychopathological diagnosis” – is much broader, affecting all aspects of life; tends to be episodic (whereas distress tends to be more chronic), and significantly has a lower prevalence relative to diabetes distress (estimated rates for depression in diabetes range between 4%-17%).

Clinical implications

Frank agrees that the distinction is crucial – and not only from a scientific point of view. “It also has important clinical implications for people with diabetes. It’s important to be able to tell people if the symptoms of distress that they are experiencing are ‘to be expected’. One of the things we do as clinicians and as psychologiests is to normalise these feelings. That can be a huge therapeutic intervention in itself.”

The distinction also has significant implications for how we approach diabetes-related psychological problems. “Only one in 20 people with diabetes distress also has clinically depressive symptoms,” Frank observes. “That’s an intriguing finding because it clearly demands us to think about the difference between these entities – anxiety, distress, depression, etc.

Larry reiterates the point: “They are not two sides of the same coin. They are very, very different. And that means very different clinical approaches – not only in terms of what to do about it, but who should be doing it and where those different interventions can occur.”

For instance, it’s important to get to grips with diabetes distress not just for the well-being and happiness of the patient – it may have an effect on other disease outcomes. Frank highlights that there is a stronger association between diabetes distress (much the more prevalent of the two conditions) and difficulty self managing than between depression and self management

What can be done?

The good news is that diabetes distress is extremely malleable and there are lots of things that can be done to help people overcome it.

‘Normalisation’ itself – reassuring people that the distress they are experiencing is normal – is one approach both Frank and Larry highlight. “Normalisation is an incredibly powerful and simple technique,” says Larry. ‘You don’t need to refer somebody to do that. That can be done in regular, traditional comprehensive diabetes care settings. Which suggests that maybe comprehensive care needs to include dealing with the emotional part of diabetes as well as glucose levels.”

What about other interventions? Can therapy reduce the problems people with diabetes distress experience with self-management? Based on his own clinical trial experience, Larry says yes, it can. “People who are distressed don’t have the bandwidth to adopt and process some of the interventions, such as diabetes education. It constrains energy, motivation and engagement. Once you begin to address the emotional portion of that, they become much more open. One of the striking things in our last trial  – which did not deal with management at all – was that there was a 20% increase in continuous glucose monitoring (CGM) adoption within the month following the intervention.”

But what about people with diabetes-related depression? “I find it reassuring,” says Frank, “to see that most of the approaches that have been shown to be relatively effective in depression in the general population are effective in people with diabetes. But we also know from our research that if you incorporate diabetes distress in your depression treatment, it becomes even more effective. And more acceptable to people.”

Incorporating diabetes into depression treatment will, however, require the involvement of psychologists or psychiatrists with diabetes knowledge – a combination, Larry cautions, that can be hard to find. As the two professors conclude, there’s still a lot of work to be done in this area.

Catch Larry and Frank’s full discussion in The long and the short of it, Diabetes distress and depression.

Pressed for time? Watch the short version of their presentation.

For more on the topics raised in this film, enrol on the following EASD e-Learning module:

(Module 3 in our Hypoglycaemia course.)

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