How can the NHS prevent the tidal wave of diabetes?

How can the NHS prevent the tidal wave of diabetes?

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In the UK, more than 3.2 million live with diabetes, up from 2.1 million in 2005. The majority (90%) have type-2 diabetes, which is linked to poor diet and obesity.

Diabetes arises when the body loses its ability to use or make insulin, a hormone that helps regulate the amount of sugar in the blood, causing uncontrolled blood sugar levels. Patients with diabetes are at risk for macrovascular complications such as myocardial infarction and stroke, and microvascular complications such as nephropathy, retinopathy, and neuropathy. It can lead to devastating complications such as blindness, and was the cause of 22,000 early deaths last year.

Many diabetics experience peripheral neuropathy (nerve damage), which can result in a loss of sensation or persistent, nagging pain. The loss of sensation can lead to sores or infection in the feet, which, if left undetected necessitate lower limb amputation (135 per week across the UK); diabetic peripheral neuropathy can also cause gnawing, tingling, shock-like, or shooting pain in the extremities, which causes great distress and has no cure.

The spiralling numbers of diabetes patients, following the trend of obesity, shows that the public may still be unaware of the severity of these conditions.

Human cost aside, what about the NHS?

The dramatic growth in the numbers of people with diabetes underlines the urgent need for prevention, before the disease burden overwhelms the NHS.

  • The NHS spends 10% of its entire budget managing diabetes
  • Diabetes already costs the NHS nearly £10bn a year, and 80% of this is spent on managing avoidable complications
  • In 2014-15, there were 47.2 million items prescribed in England for diabetes
  • Diabetes prescription accounted for 4.5% of the total number of items prescribed and 10% of the total cost of all prescribing
  • Since 2005-6, prescribing of antidiabetic drugs has risen by 107%, with the net ingredient cost increasing by 138.6%

Despite this exorbitant spending, the charity Diabetes UK has warned that only 60% of patients receive all the care processes they require for effective monitoring and treatment. There is huge potential to save money and reduce pressure on NHS hospitals and services, but without successful diabetes prevention, this figure will unquestionably rise to unsustainable levels.

If nothing changes then what will happen?

The shocking recent headline that ‘Diabetes cases soar by 60% in past decade’ (1) is likely to have worried many, because – as with obesity – it is not an easily reversible trend. Many believe that obesity causes prediabetes (non-diabetic hyperglycaemia), a metabolic condition that almost always develops into type-2 diabetes

According to data from Public Health England, five million adults in England are pre-diabetic; using much broader criteria, Diabetes UK actually estimates a UK-wide figure of around 18 million people as being risk of developing diabetes; and the British Medical Journal suggests a staggering third of all adults in England are already pre-diabetic (2). However, some doctors have questioned the value of the pre-diabetic diagnosis (3), arguing that only a small number – perhaps one in 10 – will go on to develop diabetes.

Despite these widely variable outcome predictors for diabetes, the fact that diabetes prevalence has soared, and obesity – the greatest risk factor for developing DM – continues to “spread”, it is highly likely that diabetes prevalence will continue to grow.

Cause of diabetes: unhealthy lifestyle, genes or gut microbiota?

Diagnoses are not always clear-cut: obesity and diabetes result from complex interactions between environmental and genetic factors. However, with 80% of people with type-2 diabetes being overweight or obese at the time of diagnosis (according to the International Diabetes Federation), the explanation for the recent exponential increases in numbers of type 2 is being placed on the expanding waistlines of the nation. Excess abdominal fat is an especially high-risk form of obesity: abdominal fat causes pro-inflammatory mediators to be released from fat cells, which effectively reduce insulin responsivity, a major trigger for type-2 diabetes.

Recently gut microbiota has shown to be involved too. Using mice genetically predisposed to obesity and metabolic disorders Ussar and co-workers showed that this phenotype is the result of interactions between gut microbiota, host genetics, and diet (4). This is somewhat encouraging: individuals may be amenable “reprogramming” of microbiota for ameliorating the development of metabolic disorders and may offer hope for faecal transplants in the future.

So what’s new? Is it as simple as healthy eating and more exercise?

Although diabetes medication is routine treatment, it basically helps to control the condition and is not preventative. These drugs fall into many categories, such as alpha glucosidase Inhibitors (slow carbohydrate digestion), incretin mimetics, and thiazolidinediones (reduce insulin resistance), to name but a few. With diabetes, the old adage – that prevention is better than cure – is a huge understatement.

Although to many, healthy lifestyle choices are common sense and almost intuitive, the NHS is preparing to roll out a diet, weight loss and exercise programme that has been shown to reduce the diabetes risk for a quarter of those who take it up. However implementing these recommendations into real world settings is a challenge for many.

Most people understand that in order to reduce risk of developing diabetes or reduce complications associated with diabetes they need to lose weight, exercise and eat healthily, but can find it difficult to maintain, so therefore patient support is critical. Mobile applications and web-based technology can be useful in self-management, and particularly for lifestyle changes in patients with diabetes.

A review of internet-based interventions highlighted that they were focused on management of glycaemic controls and drug titrations and rather than lifestyle changes, and that in this respect they lacked behaviour theory and educational components (5). This comes as a surprise as the lifestyle choices could be both cause and cure for the disorder. Promisingly, they found the tools available demonstrated improvements in behavioural, physiological outcomes as well as improved knowledge and self-efficacy. This suggests that utilisation of the almost ubiquitous smartphone as a motivational and educational tool may hold promise for managing type-2 diabetes for individual and peer-to-peer support using social media.

Another school of thought believes that a more drastic method is required: bariatric surgery. A recent study demonstrated that half of the type-2 diabetes patients who had weight loss surgery were cured for at least two years (6). Overall they were less likely to have heart problems (a common side-effect of uncontrolled diabetes), and reported improved quality of life and even those who weren’t cured were able to better manage their symptoms. In fact, so effective is this approach that NICE guidelines have reduced the threshold for consideration for surgery from a BMI of 35 with concurrent health to a BMI of 30-35 (7).

Clearly, in order to slow this wave of diabetes something must change, whether it is a more aggressive pre-symptomatic diagnostic phase with education and behavioural therapy, or decisive action regarding surgery at early stage or more effective symptomatic treatment. Technology must be embraced, so that patients can self-manage, self-motivate and prevent diabetes and its deleterious complications before NHS resources are overwhelmed with what is largely a preventable disease.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. http://www.bbc.co.uk/news/health-33932930.
  2. Wise J. A third of adults in England have “prediabetes,” study says. BMJ. 2014;348:g3791. Epub 2014/06/12.
  3. Yudkin JS, Montori VM. The epidemic of pre-diabetes: the medicine and the politics. BMJ. 2014;349:g4485. Epub 2014/07/17.
  4. Ussar S, Griffin NW, Bezy O, Fujisaka S, Vienberg S, Softic S, et al. Interactions between Gut Microbiota, Host Genetics and Diet Modulate the Predisposition to Obesity and Metabolic Syndrome. Cell metabolism. 2015;22(3):516-30. Epub 2015/08/25.
  5. Cotter AP, Durant N, Agne AA, Cherrington AL. Internet interventions to support lifestyle modification for diabetes management: a systematic review of the evidence. Journal of diabetes and its complications. 2014;28(2):243-51. Epub 2013/12/18.
  6. Arora T, Velagapudi V, Pournaras DJ, Welbourn R, le Roux CW, Oresic M, et al. Roux-en-Y Gastric Bypass Surgery Induces Early Plasma Metabolomic and Lipidomic Alterations in Humans Associated with Diabetes Remission. PloS one. 2015;10(5):e0126401. Epub 2015/05/07.
  7. http://pathways.nice.org.uk/pathways/obesity – path=view%3A/pathways/obesity/surgery-for-obese-adults.xml&content=view-node%3Anodes-people-with-recent-onset-type-2-diabetes.

 

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