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Home » Diabetes, Health

A plan to hold back the diabetes tsunami

Submitted by on 26 Feb 2019 – 16:00

At the time of the IDF/WHO St Vincent Declaration in 1989 (1), there was optimism in Europe that implementation of new understandings on optimal delivery of diabetes care, plus new technologies, and continuing research, could optimise the well-being of the many people afflicted with diabetes. Prof. Philip Home, Professor of Diabetes Medicine at Newcastle University, writes about his plan to conquer diabetes.

The understandings remain, the medication and monitoring technologies have indeed bounded forward, and levels of research across many domains are higher than ever. Indeed for those who have practised in diabetes care for the past four decades, care quality has been transformed, not least with advances in patient education and structured care, the latter partly with electronic support. Paradoxically, the diabetes community is less optimistic than ever.

The problem of course is that society’s adoption of a higher calorie intake with reduced physical activity is promoting a higher incidence of type 2 diabetes, just at a time when the middle- and later-aged population is increasing. Further, these people are surviving in burdened health for longer (due to better glucose, lipid, and blood pressure control).

Type 2 diabetes is a progressive (not a ‘chronic’) disease, meaning that the need for more complex and expensive therapies multiplies the burden further for all parties. Indeed the burden is societal, and not just because of cost, with amarked impact on productivity and employability in later middle age. I know of countries globally where the effect on senior politicians and heads of state has negatively impacted local and indeed international policies.

Primary, secondary or tertiary prevention?

Primary prevention is clearly highly desirable, and has strong overlap with the related conditions of obesity and arterial disease in people who will not develop diabetes. The case for targeting our children is strong, not least because they are the parents of tomorrow, and because they can influence their own parents. The former is important because some feeding behaviours in humans seem to be programmed in the first years of life, and are relatively immutable thereafter.

This probably accounts for why prevention programmes aimed at adults (even after an event such as a heart attack or development of diabetes) have limited efficacy. Indeed, as with tobacco, the impression gained by the practising HCP is that cultural attitudes and fashions have a bigger impact than anything apart from taxation done by governments, who then need to be facilitating rather than programmatic.

However, there is good evidence of success of school initiatives, and the infrastructure for enabling that is of course already in place.

Secondary prevention, attempting to put diabetes into remission, or preventing pre-diabetes hyperglycaemia states from progressing, has also been disappointing. Bariatric surgery can be successful, particularly the more complex and risky gut by-pass operations, but are hardly a general solution, and guidelines often restrict them to people already with complications (ie, to tertiary prevention) for reasons of both cost and health benefit: risk.

More recently, low-calorie diet approaches have been successfully trialled in primary health care, with surprisingly good remission rates (~50 %) at 1 year (2), but long-term efficacy remains to be determined, and this is a research priority. But it will still leave a large population with progressive hyperglycaemia with a high probability of developing burdensome and high cost vascular complications (eg, eye, heart, kidney damage).

Structured diabetes care

The issue then of provision of quality diabetes care cannot be ducked, for both health burden and societal reasons. It is not a simple or inexpensive issue because people progress within the first decade of the condition to insulin therapy, which is a burden to provide, and accordingly is presently marked by considerable clinical inertia. – The good evidence base for structured patient education is notably in contrast to the paucity of its provision to diabetes populations in Europe, even where endorsed and recommended by payers for over a decade, as in the UK by NICE. Structured diabetes care also includes things like annual surveillance for development of retinopathy and for foot problems, both now preventable complications. Further, some newer medications apparently can prevent the decline into end stage renal disease (3), another high cost complication, and one almost usual in type 2 diabetes in older people.

I list these things because it then becomes clear that without national programmes and guidelines, and indeed without plans for their implementation, we are going to continue to fail to deliver to a majority with diabetes the care required to preserve their health, and prevent them becoming a social and cost burden on their communities.

It will also be evident that such programmes need to avoid being hijacked by the promise of population educational initiatives that have a weaker evidence base, and will still currently leave us with a burden that is breaking most health systems.

The views expressed here are those of the author, and do not seek to represent those of any organisation with which he is or was associated.

References:
1. World Health Organisation (Europe) and International Diabetes Federation (Europe),‘Diabetes care and research in Europe: the St. Vincent declaration’, Diabetic Medicine,7, 1990,pp. 360-360.
2. Lean, M.E.J., W.S. Leslie, A.C. Barnes, N. Brosnahan, G. Thom, L. McCombie et al.,‘Primary care-led weight management for remission of type 2diabetes (DiRECT): an open-label, cluster-randomised trial’, Lancet,391, 2018, pp. 541-551. doi: 10.1016/S0140-6736(17)33102-1.
3. Wanner, C., S.E. Inzucchi, J.M. Lachin, D. Fitchett, M. von Eynatten, M. Mattheus et al.,‘Empagliflozin and progression of kidney disease in type 2 diabetes’,N Engl J Med,375, 2016, pp. 323-34. doi: 10.1056/NEJMoa1515920.