The T2D Podcast - Prof. Derek O'Keeffe - Clinical Lead for the National Clinical Programme for Diabetes

This is the  fourth episode in the Patient-led T2D Podcast which aims to give you the answers to the questions that you want to know about type two diabetes.

This episode Prof. Derek O’Keeffe, the Clinical Lead for the National Clinical Programme for Diabetes will be talking to us about the way that type two diabetes is currently being managed in Ireland and the changes that are happening in the future. 

Thank you for all the responses to the initial questionnaire telling me what questions you had about type two diabetes and I hope that this podcast will go some way to answering them. Sinead Powell, Senior Dietitian with Diabetes Ireland answered some of your nutrition and diet ones in episode one and  in episode two, Prof. Diarmuid Smith Consultant Endocrinologist in Beaumont Hospital, Dublin, Ireland answered some of the more clinical ones.

If you could please take the time to answer the very short survey afterwards and let me know what you think of the information contained in the podcast, I would be very grateful. 

You can leave a comment here - https://www.surveymonkey.com/r/NQNSQ7X  all responses are completely anonymous.

 You can also get in touch with me via the following email address: olivia.crinion2@mail.dcu.ie.

 A transcript of the interview is available by emailing the address above.

You can see Derek's Bloom garden here - https://www.bordbiabloom.com/croi-the-cardiovascular-garden/

If you have any questions about the information contained in podcast or would like a transcript of any of the episodes, please get in touch with me via the following email address: olivia.crinion2@mail.dcu.ie.

Ethics approval has been granted by DCU for this study.

If participants have concerns about this study and wish to contact an independent person, please contact:

The Chair, DCU Humanities & Social Science Faculty Research Ethics Committee, c/o Dublin City University, Dublin 9. Tel 01-7008000, e-mail hss-frec@dcu.ie

Transcript

The T2D Podcast -  Prof. Derek O’Keeffe - Clinical Lead for the National Clinical Programme for Diabetes

Interview Fri, Aug 25, 2023 

SPEAKERS

Prof. Derek O'Keeffe, Olivia Crinion

Olivia C  00:00

Hello and welcome to Ireland's first patient-led type two diabetes podcast. And thank you to everyone who has completed questionnaires, volunteered for interviews and is listening now. Hopefully this will be a source of information for you. And of course, one which can be updated as the science evolves and your questions change. My name is Olivia Crinion and this podcast is part of a dissertation to complete a Master's degree in Science and Health Communication in Dublin City University. But it's more than that, I'd like to produce something that will make a difference in the lives of people with type two diabetes, to try to ensure that you have the most up to date information you need, to take charge of your own health and well-being. So this is the third interview with a diabetes medical practitioner. Today, Professor Derek O'Keefe, who is the clinical lead for the National Clinical Programme for Diabetes is going to talk to us and I will ask him some more of your questions in relation to type two diabetes and how it is treated in Ireland. Please remember to consult with your own health care practitioner before acting on any information that you may hear in this podcast,  as general information does not apply to specific individual cases.  So you're very good. Thank you so much for taking the time to talk to us today. Do you mind if first of all, I ask you what your role is as the Clinical Director of the National Clinical programme for diabetes is?

Prof. Derek O'Keeffe  01:40

No problem. So first of all, thank you for inviting me to speak about this topic. My name is Professor Derek O'Keefe, and I'm a consultant physician at the University Hospital Galway with a specialty interest in endocrinology, which is the clinical specialty of hormones in the body. I'm also the Professor of Medical Device Technology at the University of Galway, and I'm the clinical lead for diabetes in Ireland since January 2003. So the last few months. And I guess the role of the clinical lead in diabetes is for a consultant to provide clinical leadership in the area of governance and guidelines around how we deliver diabetes care in Ireland. And, you know, a big part of diabetes, your listeners might be aware is you know, the ratios of who have diabetes. So diabetes is a broad term diabetes mellitus. And 90% of diabetes mellitus is type two diabetes, and about 9% Is type one diabetes. And then 1% of diabetes mellitus is diabetes in pregnancy or the genetic diabetes that as we call it, so the majority of diabetes care and the word diabetes that when people hear about it in the media, it's usually referring to type two diabetes, because it's just so common and so prevalent. 

So my role in the National Lead job is to make sure that, you know, whether you turn up in a hospital in Galway or Cork that the way you're treated as a patient with diabetes should be consistent. And that's on a backdrop obviously, of a multi-faceted complex healthcare system, whereby different clinics or hospitals have different physical infrastructure, different staffing, and so on. But we don't have a budget for that kind of resources. We look after the guidelines and governance. So, for example, the five things that I set myself to do in my two year reign as a clinical lead, the first thing was to update the guidelines for type one diabetes. So you know how those patients should be managed clinically, from diagnosis all the way through management. And again, I'm not doing that as an individual. We set up a multi stakeholder multi professional working group, consisting of clinicians, such as dietitians, podiatrists, psychologists, medics, nurses, patients themselves, or representatives, it's really important to have the patient voice. So we have a type one diabetes working group that will update those guidelines. They haven't been updated since 2018. In Ireland, mainly because the pandemic obviously took everyone's attention. And then we're also updating the type two guidelines, again, that bigger cohort of patients with diabetes. So there's been a lot of changes in type two, which we'll talk about in a second. But again, updating those guidelines with a different working group of stakeholders. 

The third thing I would like to do in my tenure, is to get access to technology for patients with diabetes. And we can talk about that a second as well. That's really important, I think, by doing that I'm working again with lots of different stakeholders, including different state agencies, and the government essentially, you know, through the Oireachtas committees, and  then partnering with really great advocacy groups such as Diabetes Ireland. And then the other things we said we would do during our tenure that we would do a registry for type, for diabetes in Ireland, we'll talk about why that's important. We don't have a registry in Ireland, it's a complex thing to set it up, even if you do set it up, who actually owns it and runs it then? So again, I can talk to a bit about that. So they're the main things that we said we would do during the two years tenure ship off this. And they're all really important things. 

And the fifth thing and final thing I said I would do is a lot of medicine tends to be reactive, you know, there's a problem, we'll try and fix it as a problem and try and fix it almost like being in politics, it tends to be very reactive. So the fifth thing I said I would do, that wasn't there. But I'd like to have it there by the time I finish in January 25, is have a strategy. So to have a 10 year strategy of what diabetes care looks like, based on international standards. And I should say that that's really important. That last statement that everything I talked about with you, in the next 20 minutes or so, is based on EBM, which is evidence based medicine. So a lot of things you hear on planet Earth are based on anecdotal evidence people stories, people's opinion, they heard someone's brother sisters friend did this. And then this happened. And the problem with that is that that's not very scientific. And the only way we can actually make informed decisions is if we, you know, use the literature as it's called, the academic papers that are out there, the guidelines that have been developed by different professional bodies, to inform our decision making. So like 100 years ago, in medicine, a doctor who was training did exactly what his trainer told him or her, because that's all they knew. That was their scope of information, what the experts told the apprentice, the master apprentice model. And what happened in the 1980s., as we developed science internationally, we started to realise that we needed to have evidence-based medicine, that a lot of things we were doing traditionally didn't have a lot of scientific rigour, you know, 100 years ago, 50 years ago. And as medicine has evolved over the last 50, 100 years, we've seen that that is the cornerstone, so that if you come and see an endocrinologist here in Galway, and you have a problem with your thyroid, for example, they're going to treat you the exact same way as if you went to an endocrinologist at Harvard, or an endocrinologist in South Africa or an endocrinologist in Sydney. And that's because we all use the same international guidelines to treat Graves disease, for example, in thyroid or type two diabetes, if you come in with a complication of a diabetic foot or something like that. 

So having international guidelines is really important. And trying to get that into the country that you're working in is really important as well. We're lucky in Ireland that we've had a very solid scientific basis for decades now. And so what we're going to do with these guideline updates is improve them to 2023 standards, because, you know, new information comes out comes out all the time, new guidelines, new new papers, and the newer guidelines that have to reflect on what's happened since 2018, in type one diabetes and type two diabetes. So the strategy thing, that last the fifth point I was just talking about, that's really important, because, you know, when when a boat sets off from a harbour, it's going to get lost at sea unless it knows where it's going. So, you know, most ships when they set off, I'm a pilot. So when you take off in a plane, you need to know where you're going. So you need to have a plan, you need to have waypoints. So you know, you're following your plan that you will get to your destination. So we've set up a working group now that we have a working group that will spend a year from again, lots of different stakeholders to find out, what should diabetes care in Ireland look like over the next 10 years. And I think that'd be one of the, you know, really important legacies from my tenure as clinical lead.

Olivia C  08:43

You mentioned there. The fifth, in the fifth point, medicine being, had been reactive, and this is what you're trying to get away from, and be proactive, I suppose. And I know, one of the things that a lot of people are interested in is pre diabetes. And some of the literature has shown that actually pre diabetes isn't considered a proper diagnosis and some people while it is a very good place to start making changes that maybe people might not realise the importance of starting there has  diabetes been brought into the plan, sorry pre-diabetes.

Prof. Derek O'Keeffe  09:21

Yes, great question. Great question. So, so a couple of things there. So I think the first thing to say is that we live in an imperfect world. That's the first thing to say, right? And we all try and do our best, as we mentioned, based on the evidence to make us you know, as good as we can during our time here. And we're all here only for a very short time. I think everyone needs to remember that as well. The average human for example, in Ireland lives until at three or four. However, in 2023, if you were living in West Africa, where I practised for a while the average human lives until about 60. And equally I practice for a while down in Papua New Guinea, the average human lives until about 55. So that's the first thing to say, okay, so humans live at different time spans,  health spans as it were, depending on your geography. And it's not so much to do with the altitude of the sun, it's more about the healthcare system that you're in. So America, even though it's, you know, a much more advanced healthcare system, with technology, and so on, humans live less than America, they only live to about 77, which shocks lots of people when they hear that, and that's for lots of different reasons. 

But one of the reasons is access to health care. So that brings in another another complexity or whether you're in a public health system or a private health system, and a private health system, you pay for your care, obviously, unless it's an emergency, there's a federal mandate in America that an emergency everyone's treated, and they're billed later. But usually, it's the other way around, you have to pay for us and then get your care. And then in Europe, obviously, we have a social model of healthcare, whereby we all pay a certain amount of tax, we agree as a society to get taxed, so that money can go into health care. And it depends on your philosophy of life of which one you believe, I know, people in America who really love the model over there. So the model in America is essentially you eat what you kill. So if you're working hard and you're making money, and you have health care, because you have health insurance, however, if something happens in your life, our or maybe you don't have the advantages of other people, you don't do as well, because you don't have access to health care. In Europe, as I said, it's different. It's social, you come through the door of any hospital in, in most of Europe, but it could just say, Ireland, because we're talking about Ireland, you're all treated the same when you come through the front door. And I think that's a really good thing, in my view, but other people have different world views and society views. 

And it's related to the tax. Okay, so next question, then is you have a pool of money. So you have money for medicine in Ireland, because people have paid their tax into a pool. And that money then is finite, it's a limited amount of money, because you also need money for schools, you need money for roads. So you have a certain amount of money for health care. And so in health care, then you need money for cancer, you need money for cardiology, you need money for COPD, you need money for multiple sclerosis, you need money for diabetes. So there's a certain amount of money, okay, and that's in the public system. And it's pretty much the same in the private system as well. And then you also have other problems, even if you had all the money in the world. Do you have enough healthcare staff? Is there enough people coming through to be in the health care world be that a nurse podiatrist, a doctor, a physiotherapist, whoever it is? So there's all these different things you need to think about. Before you answer that question. 

The other thing that you need to think about is what's the goal of intervention? So if you give somebody a label of a condition, does it actually improve their outcomes by treating them, that's really important as well. So just because it gives somebody a label may not affect their lifespan, if you know what I mean. So what happened was, and this is true for a lot of diseases, not all of them, but a lot of them. Diabetes isn't a binary thing. You know, physiologically, except for type one diabetes, and I should say, so type one diabetes, what happens is, is that your pancreas, which is that organ, in the middle of your abdomen, that the pancreas, the upper abdomen, that that organ suddenly gets attacked by your own immune system, and you lose all the ability to make insulin. And in people that happens pretty quickly, in some cases, it can be a bit slower, but it's usually pretty quick. And the minute that happens, you don't have insulin in your body, and therefore you're not able to regulate your blood sugar. And it might just take us a side note here to explain that insulin is a hormone. And its job is very simple. When sugar goes into the blood, you eat your food, it gets digested, it goes into the blood, the sugar, the molecules get broken down from the carbohydrates, that sugar is in the blood, and it has to go into the cells, okay? And Insulin is the key that opens the doors on that blood vessel to let the sugar go into the cells. And if you don't have enough insulin, what happens is that the sugar stays in the blood. And so your sugar levels rise in the blood, okay. And that's why when you check their blood sugars, it's very high, because the sugar is still in the blood, it hasn't gotten into the cells, you might think that's the problem. But the problem actually is is the cells now have no energy, and therefore they have to start looking for other sources of energy in the cell, and they start burning fats, which then is called ketosis and causes all kinds of problems with acid acidosis. So you need insulin, okay? 

So if you don't have insulin with type one, immediately, that's a diagnosis because you can detect very high sugars and no insulin and the problems such as DKA, but for example, for type two diabetes, it's a more progressive condition. It's called a chronic progressive disease. So it's not acute almost like type one diabetes. So if it's a chronic progressive disease, and you mentioned there, pre diabetes and just for your listeners, what that means is we currently diagnosed diabetes with a lab test called the HbA1c, which is the glycosylated haemoglobin. And  what that basically means, is that you might have learned in biology in school, that haemoglobin is  the cell in the body that can carries oxygen around. Okay, so it goes into the lungs, it picks up an oxygen molecule and it goes around and delivers oxygen to all the  cells. And it lasts about three months before it's, you know, taken away again, by the spleen. And it's made in the bone marrow, so starts in the bone marrow, three months around the body carrying oxygen, like lifting bags of coal all around the body, it lifts oxygen, and then it gets destroyed in the spleen, and new ones are made. So that HbA1c sorry  haemoglobin, when it goes around the body for three months doing its oxygen work, if there's a lot of sugar in the blood, it tends to stick to it. Okay. And so if you look at the haemoglobin molecule, and you say, how much glucose is on it, how much glycation it has, you can get a rough idea of how much sugar is in that person's body for the last three months. Is it in the normal range? Which it should be? Or is it higher than normal, meaning the person has diabetes, there's too much sugar in the blood as the example I mentioned to you earlier. 

And so a good way of thinking about it is if a patient came into your clinic, for example, and you didn't have any windows, and you wanted to know, was it snowing outside, and you said to the patient, would you go outside and walk around for a while. And when they come in, you see snow on their jacket. And if there's a little bit of snow, that means it's snowing a little bit if there's a lot of snow, that means it's snowing a lot. It kind of you know, the jacket just picks up whatever is out there in the environment. So anyway, so they decided then, all the committees came together, you know, the International Diabetes committees in America, the ADEA, the American Diabetes Association, the Europeans, the Australians, and they said, what number of HbA1c causes problems. And they picked the number 48. So if your HbA1c, is greater than 48, that gives you a diagnosis of diabetes mellitus. Now, in type one diabetes, as I mentioned, you suddenly lose insulin very quickly, because your pancreas has been destroyed. And we can talk about that in a second if you want to how that happens. But pretty quickly, your A1c rockets up, you know from a normal A1c of 35 or 40, it suddenly goes to 55 or 100, you know, within three months because you haven't been treated correctly sorry, if you haven't had insulin and if you haven't been treated correctly, it goes high. 

Now, we normally pick up type one earlier because of all those other problems I mentioned with ketosis. But that's the principle with type two diabetes. It's a chronic progressive disease. So that means that over time, your HbA1c starts to creep up slowly. So it might start off at 38. I checked you now. And then I come back in three years time and you're maybe 50, then it's gone to 44 and then it goes to 58, then it goes to 56, then it goes to 60. That makes sense. Now, you actually may not have symptoms of type two diabetes, until your HbA1c hits 65 or 70, even though the diagnosis is at 48. And that's because they put the diagnosis of diabetes at 48. Because when you look again at the evidence at the trials, once your blood sugar is consistently within HbA1c higher than 48 for a prolonged period of time, you start to get the markers of disease. And what I mean by that is, is that you start to get a thing called micro albuminuria, which is basically small amounts of protein in your kidney. And that's a very early sign of kidney dysfunction. And we'll talk in a second, I think it's important, about the complications of diabetes, but that's why they picked the number 48. And when they picked the number 48, and I shouldn't say just for your listeners, again, you mentioned pre-diabetes, pre diabetes is 42 to 48 A1c. So if you're anywhere between 40 to 48, that's raising almost like a soccer like a yellow card of warning saying you're on the pathway to continue on and get diabetes at 48 and beyond unless, you get treatment. Okay. So by putting in a 48, there's loads of questions, and it comes up every year at conferences, should we change the number we diagnose diabetes at. 

And part of it is physiological, I mentioned to you there that microalbuminuria, small amounts of protein in the in the urine, which suggest the beginning of kidney damage starts at around 48, if you look at the graphs, so that's a good place to put the diagnosis. And part of it is a practical thing. And this is back to what I opened up with about the health system. If you diagnose too many people with the condition, there isn't the resources to treat it, especially. So if I say let's move the diagnosis of diabetes back to 42, now everyone at 42 has diabetes, but the problem is, is that they don't have any symptoms of diabetes, or you know, they don't have any complications of diabetes. And yet, you've just introduced probably hundreds of millions of more people into the clinical world, both for their own psychological burden of having a chronic disease, but then also into to the healthcare system. So we pick a number in this chronic disease that says okay, as of this number, you are now diagnosed with this condition, because we've looked at the evidence and we feel that once you go above this number of 48 there's a benefit in treatment. That makes sense. 

And just to take a side note, again with the complications of diabetes and I did engineering for many years before medicine. So I have this kind of, I suppose a logical way of looking at problems or maybe using analogies is what I do with my patients. I had a garden at Bloom last year, trying to explain this concept of cardiovascular disease because we hear about it a lot. And it's the most important complication of, of diabetes. So if you think of your blood vessels, okay, at Bloom I had a  cylinder, kind of a big circle, walking into the garden, if you listeners want to look it up, if they look up the Croi garden, in Bloom, you'll see the picture. Croi is a local cardiovascular charity here in Ireland here in Galway, sorry, they are a national charity in heart disease, and stroke, brilliant charity. So the idea is, is that when you were born, you have beautiful blood vessels, just like cylinders, or tubes. If you think of a Pringles tube or something like that, or a hose pipe, it's a perfect cylinder, okay, you're born on planet Earth, that's your cylinder that carries blood around your body, pumped from your heart down to your toes, carrying that oxygen, as we mentioned, and then all the breakdown of your digestion, your proteins and your sugars and so on, to help you live. Okay, so that oxygen goes to the cells gives them energy to switch on all the machines in the cells  as it were, and then you actually put in the raw materials, sugars and the amino acids to make things in the cells. So if it's your skin said it's making skin cells, if it's your eye cell, it's making the retina cells to allow you to see things. So that's how it works, basically. 

So if you lived the most perfect life, you know, eating the best food, exercising, meditating every day, maybe you're a monk in the Himalayas, okay. By the time you get to 30 years of age, and you're living in Katmandu in the Himalayas, and you look at your blood vessels, there'll be a little bit of thickening around the inside, that's just a natural part of living on planet Earth, you get thickening on the inside of your of your blood vessels. And then if you come back again, 30 years later, when they're 60, it's a little bit thicker. But this perfect human life, we'll call it, perfect diet, perfect exercise, perfect meditation, no stress, no illicit substances, like cigarettes, and so on. No bad habits, you know, whatever it is, you know, it's the perfect, so let's say, even that has thickening of the artery, okay of the blood vessels. Now, you imagine the average person who lives in the western world or even now, unfortunately, the developing world, and they don't have this idyllic perfect life, because they have lots of, you know, demands on their time and on their life. And maybe they have poor choices with their eating, or the type of food they eat isn't very nutritious, might be filling, but it's not nutritious. So that brings us into the world of what we call ultra processed foods. And this has been a major problem for our society for the last 30 or 40 years. And this leads to, you know, you've seen the graphs where, for example, the outbreak of the disease, obesity, you know, why people are much higher rates of obesity and everything they did, for example, in the 1970s. And that's, again, a multifaceted thing that we, we won't go into now. But the principle basically is, is that for example, if you're not exercising regularly, if you're overeating, if you're smoking, if you have a very sedentary lifestyle, by the time you look at that, you know perfect blood vessel that when you were born, if you look at that person at thirty, it's much thicker than the for example, the person who lived in Katmandu, because all those things that have they've been exposed to in the Western world, or in the developed world, as we call it, ironically, it's, it's increased the speed of the blockage. Okay. 

And again, if you continue to smoke, and you continue to do all those things like overeat and under exercise and have too much stress in your life, all those things, that blockage gets faster and faster and faster. And also, if you have conditions then like high blood pressure, high lipids, which is cholesterol, and high sugar, which has diabetes, guess what, that thickening accelerates at a multiple rate, okay, much, much quicker. So what happens is, eventually when that blood vessel think of it again like a tube is so blocked, that blood can flow through it anymore, you have what's called an occlusion in medicine. That means blood can't flow from the heart, down to the foot, for example. So all that fuel, that oxygen and food that the cells need in the distance at your foot can't get down there, because it's literally blocked somewhere along the leg, and therefore, all those cells power away, start to die, because they have no more fuel. They can't you know, they can't live, they don't have oxygen, they don't have fuel. And that's the basis then of cardiovascular disease in the body. And so what I mean, is it the ones that block first usually, are the smallest blood vessels. So if you think were the smallest blood vessels, because if you imagine it's a very small vessel, so it takes less to block them. The smallest blood vessels are the ones that run to the tips of your toes. So basically the ones that supply the nerves that go to your toes, because it's so far away. And if your listeners know that blood vessels get smaller and smaller and smaller as they kind of dissipate out in a tree structure and The vessels that go to your kidneys, they're tiny, the vessels that go to the back of your eyes, they're tiny. So the first diseases we often see in diabetes are retinopathy in the eyes, nephropathy in the kidneys and neuropathy in the nerves. So classically, somebody with diabetes might present with what's called a glove and stocking neuropathy, meaning that our fingers and toes start to lose sensation for that reason. They are the smallest blood vessel to go to the most distant parts, then what happens is the bigger blood vessels that take longer to block, but they will block if you don't look after your blood pressure, your cholesterol, your diabetes, your smoking, and all your things your eating and your exercise, they start to block and then you get what's called macro vascular disease, bigger vessels. And so they're the vessels then, in your heart, obviously, your coronary arteries start to block the vessels in your brain, your cerebral artery, so therefore, you can get a stroke and your heart, you get a heart attack, obviously, and then in your legs. So you start to get peripheral vascular disease, you start to get ulcers, and so on. So that's the mechanism behind it. 

And so when we pick the number of 48, to diagnose it, that's the kind of starting gun that people agreed, is when if we don't treat microalbuminuria, which is those small proteins in the urine, that will go on to develop into diabetic nephropathy, which is kidney disease, which then causes all kinds of problems, because you need your kidneys to filter the waste out of your body. So that's why that number was picked. And it's the same number that was picked for retinopathy. So you can start to detect early problems in the eye and intervene and make a difference. And then the same for all the other ones. So that's why we picked that number of 48. We see if we start to diagnose people here and tell them, Okay, you're HbA1c is 48, you have type two diabetes, now we need to talk about your treatment to prevent you having a HbA1c for a long time. So it's having it for a prolonged period, you know, months and years, not days, really, when it comes to long term complications, there's two types of complications as the long term complications I just spoke about. But then there's more of those symptoms or short term complications, whereby if your sugar's are too high, you feel very fatigued. And you, you have other complications, as I mentioned, like DKA, and so on. So that's why that number was picked at 48. And what it means essentially, is, if you are pre diabetic, you're getting a yellow card to say, you really need to change your lifestyle, to try and prevent to become diabetic diabetes, I should say, as well, I've had patients whose who've lost weight to try and improve, you know, their, their, their metabolic health, and they've still developed diabetes, or they've had diabetes, and they've lost weight, which has improved their diabetes, but their diabetes still continues because it's progressive disease. And I think that's important to say,

Olivia C  27:38

you've been absolutely great. And so much for all the information. Thank you so much for explaining everything to us. And we look forward to the new guidelines. For Type Two Diabetes, when they come out

Prof. Derek O'Keeffe  27:53

the next end of next year, end of '24, we should be launching the type one guidelines and the type two guidelines. With the registry group, just to touch on that, again, we've set up a multi stakeholder group, with epidemiologists, with academics with clinicians to say what does a registry look like? The best registry in Ireland at the moment, is basically the diabetic retinal screening programme. So this is where patients with diabetes who have been diagnosed gets sent for a review of their eyes, because that's a good early indication of again, like the microalbuminuria of how diabetic treatment is going. So they have a pretty good registry. The challenge is, is that in Ireland, we don't have a unique identifier. So God forbid, if they I think they have about 280,000 or 300,000 people on their database. But the problem is, is that we don't know if some of those patients have died, because it's not linked to the death records, for example. So they might call somebody back, someone doesn't turn up for an appointment, that doesn't mean that they're dead. So they can't make that inference. People just might have missed the appointment. 

So we need to have a registry that's active that's tied into lots of other registries. And that's unique to that patient. So they don't get a new number every time they maybe move house to a new city. And then you don't want the number of patients in a registry. Like there might be 300,000 people in Ireland with diabetes. Okay, that's, that's good news. Because then you can take that news and you can try and argue then for, you know, resources to look after those patients. And but equally you want to write straight, I can tell you for each of those 300,000 patients, what's their blood pressure, their cholesterol, and their blood sugar level and so on. So that if we do an intervention, like bringing a new medicine into Ireland or start a new programme, like we're doing now with the enhanced community care team, like a new dietitian programme, Does that have an impact on all those patients in the registry, so you can see impact? So actually designing the right registry, like if you want to think about like an Excel sheet, it allows you to, to have a good registry.

Olivia C  29:46

Thank you very much for talking to us. Thank you Professor, O'Keeffe for talking to us today and answering some more of the questions that people with type two diabetes have had. Thank you to everyone who has listened to the podcasts and And if you don't mind, please filling out a short questionnaire about any of the podcasts you've listened to. Even if you've only listened to a little bit of one of them. I'd love to hear your opinion. You don't have to have been diagnosed with pre diabetes or type two diabetes, but you do need to be over 18. Also, if you'd like to talk about the treatment of your type two diabetes, or the information that is contained in the podcast and might be interested in a recorded interview, you can get in touch with me, Olivia Crinion via email at the following address. Olivia dot Crinion at mail.dcu.ie That's Olivia dot c r i n io n number two@mail.dcu.ie. Thank you for listening