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The woman sitting across the table was distressed. She was 60 years old and had diabetes for 20 years. “Two months ago, I developed a bout of coughing, followed by a sharp back pain. The doctor asked for an X Ray and told me that I had fractured my spine! Nothing hit me, I did not fall. It was just a bad coughing spell. How did I break my vertebra?” The pain was severe for a few weeks but gradually settled and she was then allowed to move around with a brace. The woman had osteoporosis, a condition characterised by porous, fragile bones, which break with minimal or no trauma. Usually, weak bones do not result in pain unless they break, and a fracture is often the first clinical symptom.
What is osteoporosis?
Our skeleton provides a frame for our body and protection for the organs within, much like the metal beams and girders that support buildings. Like metal, bones also suffer wear and tear. Unlike metal, however, bones are living tissues and have a remarkable capacity to regenerate and heal. Sites of minor damage are constantly replaced by new, healthy bones. When the capacity of the body to form new bone is unable to keep up with bone loss, there is progressive weakening, resulting in osteoporosis.
During childhood and adolescence, our skeleton grows rapidly. Enabled by vitamin D, the skeleton builds its calcium stores, particularly during puberty. Boys have bigger bones than girls, and accumulate more minerals over a longer period of time. From the age of 30, we begin to lose bone gradually, a process that is accelerated at menopause in women. If left unchecked, this loss gradually weakens the bones, making them brittle and resulting in fractures. Typically, fractures due to osteoporosis occur at the hip, spine, shoulder or wrist and can have a life-changing impact.
Why are diabetics at greater risk of bone fractures?
People with diabetes have a greater risk of breaking their bones. In those with childhood onset, insulin-dependent type 1 diabetes, this risk is increased by two to four-fold. In those with type 2 diabetes, the risk of fracture is 30-50 per cent higher as compared to those without diabetes. We know that diabetes can result in several chronic complications, involving the heart, kidney, eyes and nerves. Fragility fractures can be regarded as a consequence of diabetes too.
Typically, it requires about 10 years (minimum five years) of diabetes to impact fracture risk. Poorly-controlled diabetes with complications confers a greater risk of fracture. Importantly, people with diabetes fracture at a higher bone density than those without diabetes. The T score is a number shown on the DXA bone density report. Typically, fracture risk is thought to increase if the bone density shows a T score of below -2.5, whereas in diabetes this figure is -2. This means that people with diabetes may require intervention earlier, maybe at a T score of -2 rather than -2.5. If they get a fracture, people with diabetes take longer to recover and have poorer outcomes, particularly after hip fracture.
Why are people with diabetes more prone to osteoporosis?
First, people with uncontrolled, long-standing diabetes have poor quality bones, which fracture easily. Second, they have lower muscle mass, which indirectly impacts their bone strength, and also makes them more prone to falling and breaking a bone. Third, older people with diabetes often have associated visual issues or nerve-related issues, which again put them at greater risk of falls and fractures.
How can people with diabetes reduce their risk of fractures?
1) Testing : People with diabetes should get their bone density checked at the age of 50 if they have had diabetes for more than 10 years. For those over 60, it makes sense to have your bone density checked anyway. A T score of below -2 requires attention. Your doctor will decide if you need medication or not. However, routinely checking BMD in younger people – below the age of 50 – is NOT recommended, even if they have diabetes.
2) Control your sugars: Good control of diabetes will protect your bones along with other organs.
3) Calcium: An adequate calcium intake is a must for our bones and dairy products are the main source of calcium. If you have milk allergy, lactose intolerance, vegan habits, or just don’t like milk, you may require supplements, to reach a daily intake of 800-1000 mg.
4) Vitamin D: This plays a crucial role in bone health, and urban Indians are commonly vitamin D-deficient. Increasing sunlight exposure can be a challenge because of the heat in summer and pollution in winter. Please make sure that you use vitamin D fortified milk products and take supplements as directed (1000-2000 IU/day).
5) Dietary protein: Proteins are important for our bones and critical for our muscle mass. Indian diets are often low in protein. Next time you visit the nutritionist/educator, don’t just discuss sweets. Find out ways to enhance your protein intake, to achieve at least 0.8gm/ kg of body weight daily.
5) Exercise: All kinds of exercise help in strengthening our muscles and bones, but weight-bearing exercises (exercising in erect posture) and resistance-training are the most effective.
6) Giving up smoking and controlling alcohol intake help keep our bones healthy.
7) Medication: If your doctor decides you need medication for your bones, even if you do not have any symptoms, please comply. It is similar to treating high BP, cholesterol or sugar, all of which produce no symptoms but can insidiously lead to long-term complications. Modern medication can reduce your fracture risk by half.
If you follow these principles, you can save your bones and reduce your fracture risk considerably.
Implementation and delivery of group consultations for young people with diabetes in socioeconomically deprived, ethnically diverse settings | BMC Medicine
Developing good value and life-stage oriented care
Introducing group consultations to the diabetes service in the two hospital implementation sites was not straightforward and required careful local experimentation. The appropriate balance between clinical and educational content became a matter of debate, as clinicians were concerned that the typical group consultations format (with standard one-to-one consultations in a group context) would alienate young people who already had low levels of engagement. Instead, they opted for a flexible approach primarily prioritising group interaction on clinically relevant topics, with individual needs addressed indirectly as part of group discussion, rather than replicating one-to-one consultations in the group setting. This also meant that group consultations were not implemented as a substitute to individual clinics but were used purposefully to augment and re-distribute care; when discussing with peers, young people opened up more than they would with clinicians, which resulted in better recognition of their needs and changed the focus of subsequent one-to-one consultations:
‘…they kind of open up. And they may for the first time accept that they’ve not been taking insulin as recommended, or as advised’ (Interview 25 Diabetes consultant)
Experienced diabetes specialist nurses and other members of the implementation team worked closely with a youth worker, whose contribution was instrumental to developing age- and life-stage appropriate, relationship-based group consultations. The youth worker participated actively in sessions, for example delivering ‘icebreakers’ as a group formation activity and contributing to discussions in a way that would level power dynamics, signifying that group consultations focused on young people’s priorities, rather than purely meeting service or cost-efficiency targets. Clinicians valued youth worker support which allowed them to focus on clinical management without juggling multiple roles for which (in many cases) they had never been trained for (such as facilitating groups of young people).
A typical clinic would start with introductions and an ice-breaker, followed by setting ground rules (see Table 2). Depending on the focus of the session, one or more specialists would join, such as diabetes consultants, dietitians, or psychologists. Topics included healthy eating, blood glucose sensors and measurements, exercise, psychology, sex and healthy relationships, hypos and blood tests, diabetic eye screening and annual review information sessions, sex and healthy relationships, and women’s health, among others.
Although clinicians originally intended for young people to be allocated to specific groups meeting repeatedly and developing long-term relationships throughout the programme, in practice, this proved difficult to sustain and group composition became more fluid. Regular attendees particularly welcomed new participants joining the clinics so they could keep learning from different experiences, but groups also benefited from a certain level of consistency to increase connections between members. The youth worker helped in building affinity quickly between young people who had never met each other so they would open up in discussions and feel supported. At the end of each clinic, participants provided feedback and suggestions for improvement in sessions facilitated by the researcher or the youth worker after clinicians had left the room; this was important for ongoing service co-production (alongside dedicated co-design sessions described elsewhere ) to continue meeting patient needs and providing young people with a sense of ownership over this new model of care.
Key challenges in the implementation and delivery of group consultations: staff experiences
Delivering group clinics involved working with uncertainty and managing multiple interdependencies across diabetes care pathways. It was not simply a matter of providing individual care to multiple people at the same time. Group consultations required a different degree, mode and depth of preparation, and engagement by clinicians and young people alike. The transition was gradual and required changes in established practices but also surfaced and challenged deeply embedded ways of thinking about patient-centred care provision.
Table 4 provides examples of how complexity underpinned the work required to deliver group consultations, including the challenges staff encountered. There was little scope for standardising the processes followed, especially at the beginning, when diabetes specialist nurses were learning through trial and error. Yet, the need to manage uncertainty continued throughout the programme; each session had to be treated as unique and required comprehensive preparation to meet changing patient needs and address all eventualities (unpredictable participation, parents attending, etc.).
Self-organisation underpinned efforts to informally co-ordinate between different clinicians providing one-to-one and group care to young people, in terms of selecting participants for group clinics, understanding their needs, inviting the right experts to contribute, and managing interdependencies with other care processes (e.g. diabetes education, individual appointments) (Q3). In-depth clinical and relational knowledge about young people mattered when deciding how to bring them together and facilitate the sessions so they would benefit most; this knowledge needed to be collectively accumulated and negotiated between different clinicians involved and drawn out of medical records. Informal, improvised, and spontaneous interactions between clinicians enabled ongoing co-ordination, largely driven by the efforts of the diabetes specialist nurses, but also other staff involved (e.g. diabetes consultants, research officer). Other practical and logistical challenges ensued, such as securing seminar rooms, adjusting booking processes, and maintaining continuity with the rest of the diabetes service (Q5).
Formal and informal opportunities were needed for reflection and sense-making, and to support learning within and across implementation sites (e.g. implementation and project meetings, co-design, training sessions). Development of adaptive capability became important for clinicians who were delivering a new model of care highly dependent on human relationships. Group clinics involved the dual challenge of delivering good clinical care and education, while facilitating a group of young people. In some cases, it was important for clinicians to engage in emotional work to support groups where conflict and competition emerged and to ensure outcomes remained positive (Q12). Health professionals drew on their skills consulting with young people, but also attended group facilitation training, held regular debriefs between implementation and clinical teams for ongoing adjustment of the model, and derived significant learning from on-the-job trial and error.
Attendance and young people’s motivations
Despite significant effort, mean attendance was relatively low at 32% for site A and 33% for site B—a challenge already familiar to those delivering young adult services. Local teams had to work creatively to make sessions worthwhile regardless of how many young people ended up attending. Despite suggestions that a ‘good’ session should include 6–8 patients, in practice, the ‘right’ number largely depended on the focus and facilitation mode of each session (e.g. more young people could meaningfully participate in a session about exercise compared to psychology). Larger groups did not always guarantee high levels of contribution; there were successful groups with as many as 4 young people who identified with each other and shared openly.
[…] it seemed to be around sort of three, four, five we were getting [to attend], even though you know, we invited more than twenty patients, within a good amount of time. So I think just trying to make sure a lot of people, or as many people as possible would attend, was the biggest challenge. (Interview 29, Diabetes Specialist Nurse)
An average of 4–5 young people attended each group consultation at both sites. Higher attendance rates were recorded when a small group of selected young people were invited for a specific care-focused intervention, such as flash glucose monitoring follow-up (range of 83–100% in three sessions). Variable attendance rates were observed at broader educational and self-management sessions (e.g. psychological health, healthy eating), especially when there was an open invite to all young people recruited at each site (range of 0–60% in 25 sessions). As group clinics continued, attendance was mostly from those who had attended previous sessions, suggesting group consultations appealed to and continued to attract a specific set of young people (5–6 young people attended 5–10 sessions in site A and 3–4 in site B), but the majority only attended a small number of sessions.
Some young people expressed feeling motivated to participate in group consultations, mainly to meet others with diabetes in their age group. However, others were unable to fit group consultations alongside standard, individual diabetes care and other responsibilities (such as family, education, employment, social life). They also expressed feeling ambivalent or in ‘two minds’ about this new service model as they did not know what to expect or did not feel ready to engage with their condition; some overcame initial fears although others chose not to participate at all.
But yeah, it’s like having a group clinic is so much nicer, in order to meet people. But then on the other hand, I think because you don’t really know them, you don’t have that personal connection with them, you don’t really want to voice out everything that you’re going through. Do you get that? I’m a quiet person, like I wouldn’t tell people what I’m going through if I don’t really know them. So I was in like two minds. (Interview 12, Patient 7—never attended)
If I’m being honest, at the beginning, I didn’t want to come. I did, but I didn’t. I just like – oh, when is it going to be, is it going to be really long, I might not like it. But I still came. And I liked it. I was like ‘okay, this isn’t what I was expecting’. I was not expecting it to be so laid back. I don’t know. It was really comfortable, the setting. (Interview 10, Patient 5—regular attendee).
Not all young people had disclosed their diabetes in their communities and they were unsure how to share deeply personal experiences. There was also an underlying resistance to supporting a new consultation mode if this would mean reducing individual appointments for cost efficiency.
Differences between attenders and non-attenders in implementation sites
In Tables 5 and 6, we present baseline characteristics of the 73 young people recruited in the two implementation settings, comparing those who attended one or more group clinics to those who did not attend any group clinics at each site (further comparisons with participants recruited in control sites are available in the detailed project report ).
At site A, comparing participants who did (N = 23) and did not (N = 27) attend any group clinics, there were no significant differences in sex, ethnicity, deprivation, speaking English as a first language, type of diabetes, or use of technology within the last year (Table 5). Those who attended were on average diagnosed at a younger age (11 vs. 16 years) and more likely to have attended group education sessions in the past (39% vs 7%), with borderline statistical significance (p = 0.033 and 0.053 respectively). There were no statistically significant differences in these variables when comparing attenders (n = 14) and non-attenders (n = 9) at site B.
Comparison of attenders and non-attenders at site A showed no statistically significant differences between these groups when comparing baseline clinical characteristics and questionnaire scores (Table 6). In contrast, attenders at site B had better glycaemic control (mean HbA1C 68 vs. 98 mmol/mol, p = 0.023) and had attended 80 vs. 50% of planned appointments within the previous year (p = 0.009).
Young people’s experiences in group clinics
Young people who attended group clinics (especially repeat attenders) discussed their experiences as predominantly positive: they felt better understood and supported, learnt new things from peers and clinicians, and were better able to normalise diabetes self-care. Only in a few instances did young patients express (initial) reluctance to share clinical details or found peer comparison challenging; in these cases, internal dynamics required careful management by clinicians.
Group clinics provided the opportunity to discuss emotions and frustrations with others going through similar challenges. Young people found peers could understand and identify with their experiences, which made them feel less isolated. They felt better able to engage in open discussion as they gained encouragement from each other when they started to realise how all were struggling to follow clinical recommendations:
F1: How, I just want to ask generally, how are you guys, like those on type 1, how are you guys finding carb counting? How do you get round it, how do you start all up? F2: I’m not going to lie I haven’t been really carb counting. F1: OK I’m glad to [have asked], I mean it’s a bad thing but it’s like I’ve been struggling so much I’m just like I’ve given up with it totally. Are you the same like? F2: (indicates agreement) (Site A, exchange between female patients in Clinic 2)
Being able to explore emotional challenges of living with diabetes was repeatedly mentioned as a key aspect of positive experiences in group clinics, compared to individual appointments, where young people expressed reluctance to voice their difficulties:
The one-to-one is more personalised, scientific. […] Where [the group clinic] is more lifestyle based. It’s more about how to live with your diabetes, rather than just manage it […] With the doctor, I kind of want to just get it over and done with really quickly, and then just go. So I wouldn’t, I don’t try to ask as many questions or I just forget. (Interview 27, Patient 16)
One of the young people with type 2 diabetes did express feeling alienated initially, in a clinic where everyone else had type 1 diabetes, but then explained: ‘it was [a] very welcome [environment] so, feelings of being left out didn’t last too long to be honest’ (Interview 24, Patient 15)
Another participant suggested that they felt less comfortable with individual appointments because they perceived them as ‘professional’—which at their life stage seemed alienating, as they were unsure how to navigate the rules of engagement and match them with their own priorities.
Social and situated learning emerged through a combination of patient input and clinical advice (e.g. on alternating injection sites, ketone testing or avoiding hypos), carefully facilitated by the diabetes specialist nurses who ensured young people gained insight without feeling judged or criticised. Learning emerged both for those newly diagnosed and for those diagnosed at a younger age, who had been looked after by their families and were only just beginning to learn how to care for themselves independently. Clinicians were surprised that young people had not already acquired this learning through individual appointments on similar topics.
Patient participants talked about how group discussions with peers helped them think about their diabetes differently and normalise their experiences through getting to know how others approached their self-care. This even resulted in some feeling more confident and comfortable with their condition to the extent they started disclosing to their workplace and friends:
[…] within the workplace I would never tell people that I’ve got diabetes, and stuff like that. Now, the other day I was speaking to my friend about where I should be injecting, where I shouldn’t be injecting. Feel like now I’m a bit more confident and comfortable with it. (Interview 13, Patient 8)
There was, however, some reluctance to share clinical details considered private (e.g. glucose levels) or have test results displayed on the computer screen for discussion. Others were not always prepared to discuss self-care aspects they were struggling with or to manage a group discussion that might have led to sharing beyond what they were comfortable with, so chose to control their contributions. For those newly diagnosed, comparison with peers was not always motivating, especially when they were comparing themselves with others doing worse:
And so what I was thinking is that would it get to a stage where it’s going to be hard for me to manage my diabetes. Yeah, it definitely did freak me out a bit, yeah. (Interview 14, Patient 9)
Costs of group consultations and health care
The average staff costs for setting-up and delivering group consultations were similar across the two implementation sites (£572 for site A and £545 for site B) (Additional file 1: Tables 1a and 1b). The average cost of clinic per participant was marginally higher in site A (£158) compared to site B (£127), due to poorer attendance in the former (average number of participants was 3.7 for site A versus 4.5 for site B) (Additional file 1: Table 2). The study participants attended on average 3.6 out of 5.9 scheduled appointments per year, including consultations with a diabetes doctor, diabetes specialist nurse, dietician, and psychologist. The average annual cost of scheduled care was £723 per patient per year. The study participants had on average 3.9 unscheduled contacts per year including A&E visits, hospital admissions, and contacts with general practitioners and diabetes specialist nurses. The average annual cost of unscheduled care was £2566 per patient (Additional file 1: Table 3).
BATON ROUGE, La. (BRPROUD) – According to one estimate, approximately 505,468 people in Louisiana, or 14.2% of the adult population, have been diagnosed with diabetes.
It’s common knowledge that most people with diabetes are cautious about how much sugar they consume. This is because the disease impacts the body’s ability to produce or respond to a hormone called insulin, which is key in regulating the metabolism of sugars and carbohydrates.
That said, experts say there are safe ways for people with diabetes to satiate sugar cravings.
Articles from sources such as Everyday Health suggest:
- Allow yourself an occasional treat, but plan for it– According to registered dietitian Karen Lau, “Make sure the meal is balanced with other foods. Cut out carbs from the main dish, and save it for dessert instead.” This can mean skipping bread, pasta, or potatoes so you can eat a small serving of dessert.
- Say ‘yes’ to fruit, in moderation– Instead of satisfying sugar cravings with processed foods, opt on fruit. That said, fruits do have carbohydrates, meaning you’ll still need to adapt your meal plan. But a small serving of fruit is typically feasible. One source suggests considering fruits with 15 grams of carbohydrates such as: one small apple, one small orange, one very small banana, 1/2 grapefruit, 3/4 cup of blueberries/blackberries/pineapple, one cup of raspberries or melon, 1 and 1/4 cup of whole strawberries.
- Take a few bites and make them last– Some healthcare experts recommend splitting a piece of cake with a friend or having half of a large cookie instead of the whole thing. This works best when a person eats with mindfulness, meaning they eat more slowly and take the time to savor the tastes they’re enjoying.
Living with diabetes does not necessarily require assigning all desserts to a death sentence. Instead, by planning meals with care, swapping out processed sweets for fruits, keeping dessert portions small, and slowing down to savor each bite of the treat, individuals with diabetes may still be able to enjoy some of their favorite sweets.