176 - Diabetes

The number of people in the UK with Diabetes has passed three million1. “The numbers have gone up 60% in the last decade”. Diagnosis counts were at 2,086,041 in 2005 (when such figures were first published) and stand at 3,333,069 at the end of 2014. This ignores the estimated 590,000 undiagnosed cases2. Please note that those figures do not agree with the quoted headline.


90% of diabetes sufferers have Type II diabetes, which is, to a large extent and, as I hope you will appreciate, an often avoidable disease. Diabetic under 19s (therefore) are mostly (96%) Type 1 diabetics, 52% boys. Across the whole population, 56% of diabetics are male. Distribution by nation and age is shown below, from here. According to the National Paediatric Diabetes Audit, children of Asian origin were 8.7 times more likely to have Type 2 diabetes than their White counterparts and children of Black origin were 6.2 times more likely.

Age        E&W          Scotland

0 – 9       0.22%           0.26%
10–19     0.99%           1.23%
20–29     1.69%           2.09%
30–39     3.83%           3.55%
40–49     10.69%         9.69%
50–59     18.95%        18.97%
60–69     26.05%        26.46%
70–79     24.14%        24.67%

80+         13.42%       13.07%

From Diabetes: Facts and Stats we have figures from the end of 2013;

Country               Prevalence    Number of people

England                 6.0%               2,703,044

Northern Ireland   5.3%                    79,072

Scotland                5.2%                   252,599

Wales                    6.7%                    173,299

UK total                     6.0%                3,208,014



Diabetes should have, according to National Institute for Health Care and Excellence (NICE), eight care processes. These are the checks identified as essential in high quality care for people with diabetes and include getting blood pressure and blood glucose levels measured, as well as the kidney function monitored, otherwise poorly-managed diabetes can lead to health complications such as kidney disease, stroke and amputation. At present only six in ten people with diabetes in England and Wales receive all eight care processes. Diabetes UK says “Diabetes already costs the NHS nearly £10 billion a year, and 80 per cent of this is spent on managing avoidable complications. So there is huge potential to save money and reduce pressure on NHS hospitals and services through providing better care to prevent people with diabetes from developing devasta ting and costly complications.

The eight processes often referred to are titled, in a diagram I found (p6): blood pressure, serum creatine, HbA1c (blood glucose control), chloresterol, BMI, smoking, foot surveillance, urine albumin. A ninth might well be eye screening. Over 80% of patients receive each but for the last, and around 60% receive all of the above [which I think disagrees with headline statements again].



“The NHS must prioritise providing better care, along with improved and more flexible education options, for people with diabetes now, and give them the best possible chance of living long and healthy lives. Until then, avoidable human suffering will continue and the costs of treating diabetes will continue to spiral out of control and threaten to bankrupt the NHS. Now is the time for action.” 

I suspect good deal of type II diabetes is avoidable, and I hope to show that this is so. The 2010 APHO model commentary says, in its Key Messages:

It is estimated that 3,099,853 people aged 16 years and older in England have diabetes in 2010

•   Comparisons with the 2008/09 Quality and Outcomes Framework data suggest that only 72.9% of adults with diabetes are currently diagnosed.

•   Prevalence of diabetes among adults to rise to 8.5% in 2020 and 9.5% by 2030

•   Approximately half of the increase in estimated diabetes prevalence is due to the changing age and ethnic group structure of the population and half due to increasing obesity


A massive 10% of the NHS budget can be called diabetes spending, from the direct care costs, to the cost of direct consequences and to the social care costs, currently estimated (7p4) as £23.7 billion. While press coverage suggests things are dire, the provision of care has hardly changed (7p5) in terms of percentages of possible cases receiving treatment.

Continuing to quote from Diabetes UK ‘State of the Nation’ paper7: While there is nothing that can be done to prevent Type 1 diabetes, Type 2 diabetes can often be prevented or its onset delayed. This can be done by identifying those at high risk of developing Type 2 diabetes, and implementing effective risk reduction interventions – a diabetes prevention programme. However, the main risk identification programme – NHS Health Check – is still not being implemented fully across England. Referral to risk reduction programmes for those identified as high risk is inconsistent. Obesity – the most significant risk factor for Type 2 diabetes – is increasing. This situation can be addressed by a range of individual and whole population interventions designed to help people maintain a healthy weight.

I found a range of suggestions how this should be done, often including what we might describe as alternative funding, such as changing the national attitude to health. One such message might be ; you are responsible for your health, and the state resents having to stump up when you are being incompetent. This fits well with my steadily firmer opinion that self-induced injury deserves little or no sympathy. Another message is that you really must look after your weight and body shape and to do this you should eat better and exercise more. From a government point of view this means, among other things, that funding for development of sport (which often means sporting facilities) can come from other budget areas—that is, expenditure outside the NHS ought to reduce the NHS costs.

As a society what we need to do is reduce the number of people becoming diabetics. You won’t be cured: the type II form is a managed condition, not a curable one, so the issue is that we (the people) must avoid adding to the burden. The 2015 report7 says  up to 80 per cent of cases of Type 2 diabetes can be delayed or prevented (quoting a WHO report from 2005). It also says (p10):

While identifying people who are at high risk of getting Type 2 diabetes is critical, this is just the first step in a prevention pathway. Those individuals with modifiable risk factors then need to be supported to reduce their weight.

NICE guidance specifies that people identified as being at high risk of Type 2 diabetes should be offered intensive lifestyle interventions. However, it is unclear whether this is happening in all cases – or, indeed, who is responsible for referrals and follow up – and the provision of intervention programmes is patchy. This means the Health Check programme will not deliver the health and economic benefits that it should.

Being overweight or obese is the most significant risk factor for Type 2 diabetes, and accounts for 80 to 85 per cent of the risk of developing this condition. Maintaining a healthy weight, eating a balanced diet, and being active, are therefore the most effective ways of preventing Type 2 diabetes.

However, there has been a marked increase in obesity over the past 20 years. In England, 61 per cent of adults and 30 per cent of children are now overweight or obese. Almost 9 out of every 10 people diagnosed with Type 2 diabetes are overweight.

If we are going to reverse these trends, and stop the sharp rise in Type 2 diabetes, more must be done to support all parts of the population to make healthier choices. Individuals are often working hard to achieve a healthy weight. Government, the NHS, local authorities, employers, and the food and drinks industry need to match that determination.


What is not clear is what fraction of people if any can be cured of their diabetes, though it makes a great deal of sense to try to slow any slide to more extreme forms of the disease.  It is clear that we can reduce the extent but no-one is attempting a prediction of how much. It remains clear that we can cause the numbers to cease rising, but not whether we can in any sense reduce them. The implication is that there is no known cure.


I encourage you to read some of the linked pdfs so as to be aware what treatments occur and how much care is provided. It is in the nature of the spread of support required that this is additionally expensive to society. The many different visits made by a patient has a social cost and similarly the liaison between different care departments and providers adds significantly to case load and costs.


I am left asking repeatedly how did we get into such a mess, while recognising that to some extent this is a consequence of having (had) a nanny state—when the state interferes so thoroughly in one’s life, the message received is that one should surrender all responsibility. This is muddled but understandable thinking, when what should have been perceived is that when things go badly wrong, the state (our society) will provide support. As the pendulum swings in the opposite direction and particularly while state spending is under the microscope, so it is understandable that the state must find ways of undoing this situation. This means, among other things, that we individually and collectively must take (back) responsibility for our health and to accept for ourselves the consequences of earlier actions. I do not expect the swing to move vary far, but move it must.


As an active sportsman still, I remind readers that sport can damage your health. This occurs when doing more than the body can stand at that moment. It is not true that all sport damages health nor even that doing any sport will damage your health (more the opposite of that), but a surfeit of sport, just like a surfeit of food, may well do damage.

The quote below will need to be modernised; suggestions please.

“All the things I really like to do are either illegal, immoral, or fattening.” Alexander Woollcott, 1933 3

Obviously, Wollcott was not a runner.



DJS 20150817



Are you at risk? The simplest test I found is to measure your waistline. At 37” for men and 31.5” for women, these do not strike me as large figures. The defining ‘at risk’ line varies a little for ethnicity and height.

Note also that the relatively low numbers of type 1 (insulin-dependent) diabetes, the as yet unavoidable form, are also rising8.  The reason for the surge is unclear, but experts suggest the changes are too fast to be explained by genetic factors alone. Changing childbirth trends, such as women having bigger babies and a greater number of caesarean-section births, may be partly responsible. Experts witnessed higher increases in eastern Europe, where lifestyle habits were changing more rapidly than in the richer European countries.

Britain is nowhere near being the worst nation with this problem, but that is neither excuse nor palliative. In the US a recent study shows that the risk of having type II diabetes has doubled from 1989 to 2011 (a 3.2% annual average sounds far less)9. The figures are affected by living longer, which oddly means that more folk will develop the disease and more still will have the ensuing complications. This pattern is repeated around the world (but they’ll shout about it more) and, having more obese folk than most, will lead any comparative tables.

I continue to be concerned that a small annual growth has huge consequences. The increase of 1.2 million more diabetics in  2005-2014 to the 3.3 million mark could be represented by a 4.6% annual increase. The population growth in sub-Saharan Africa, at 2%, is much higher than we can feed. Tolerable increases are figures under 1%, and really we’d like bad things to decrease. Also, I am concerned about representations that send a misunderstood message.  Six out of 10 people in England and Wales receive the eight care processes recommended is not wrong, since 60% is the correct figure, but such a statement wholly ignores any relative importance of the care treatments, their relative costs and all overlap in results. Since some of the tests are infrequent anyway, there could all too easily be data collection failure. Among the scarier headlines is that diabetics having amputations is on the rise— well it would be, since the numbers themselves are rising. The small sample of figures I found (116/week to 135 across four years suggests to me a year-on-year rise of 3.9%, lower than the 5.3% annual rise in the disease. This suggests advice is being followed. My very crude measures don’t take into account which sub-population of diabetics are those likely to need amputation, and the figures I found don’t distinguish between losing a toe or a leg. Which is to say I failed to find a meaningful figure, but that readers should recognise the magnitude of the ‘complications’ I refer to above. Far better to avoid having the disease where possible.




Webpages used or visited:

Top pic from www.healthwatchtowerhamlets.co.uk, being the first high-quality pic I found on Google.

https://www.diabetes.org.uk

http://www.theguardian.com/society/2008/oct/20/health-nhs argues for more sporting facilities

http://www.theguardian.com/society/2012/may/03/diabetes-link-smoking

https://www.diabetes.org.uk/Documents/About%20Us/Statistics/Diabetes-key-stats-guidelines-April2014.pdf

5  http://www.yhpho.org.uk/resource/view.aspx?RID=81090 links to the 2010 APHO diabetes prevalence models.

6 https://www.diabetes.org.uk/About_us/What-we-say/Statistics/

7 https://www.diabetes.org.uk/Documents/About%20Us/What%20we%20say/State%20of%20the%20nation%202014.pdf

8 http://www.theguardian.com/lifeandstyle/2009/may/28/diabetes-under-fives-to-double

9 http://www.theguardian.com/society/2011/oct/27/diabetes-health


Footnotes:

1 Diabetes UK extracted figures from NHS data. The pdf I quote from4 seems to use well-documented evidence (refs, P17) and is clear where numbers are predicted. It is also clear where numbers have been gleaned from and therefore that the comparisons might well be suspect.

It is perfectly possible that the figures are make to look worse by the level of ‘undiagnosed’. I noted that several reports chose to add in the unknown element when convenient to make a figure look larger. If the undiagnosed volume is indeed 590,000 on top of the 3.33 million recognised diabetics then we have an on-built assumption that the proportion of the ‘extras’ is consistent with the ‘recognised’ figures - around 17% of the whole and increasing in a similar way. This would be easily changed if diagnosis became (or has become) more effective, adding people to the official list earlier than before and thus adding to the apparent increase.

3 Alexander Woollcott, "The Knock at the Stage Door" in Reader's Digest (December 1933); also in A Dictionary of Catch Phrases : British and American, from the Sixteenth Century to the Present Day (1986) by Eric Partridge and Paul Beale, ISBN 041505916X, ISBN 9780415059169  Funny man. Read the wiki entry

© David Scoins 2017