What do we want? The best National Illness Service in the world, with ring-fenced financing? We argue till the cows come home about the politics of the NHS: how to fund it, how to organise it, whether parts of it should be privatised or not, and what is the place, if any, of private health insurance and private hospitals. It’s a political hot potato: governments can be elected or not depending on the public’s view of who might look after our NHS the best. People on all sides of the debate are worried about the spiralling costs, as our population ages, and as more and more expensive interventions become available. Should this or that cancer drug be made available, when the benefits are unclear? How do we cope with the increasing demands of dementia?
At the same time, there is one condition, type 2 diabetes, which accounts for 10% of the NHS spend, and it’s almost COMPLETELY AVOIDABLE. Diabetes is the health epidemic of today. It kills, and maims – blindness, kidney failure, and amputations are common complications. It greatly increases the chances of heart attacks and strokes. It inflicts untold grief, ill-health and loss at a personal level, and is blowing our health and social security budgets out of the realm of affordability.
Incidence is rising dramatically. In England, the cost1 of diabetes drugs and treatments rose by 56.3% from £513.9 million in 2005/6, to £803.1 million in 2013/14. Diabetes-related societal costs are huge as well: according to 2012 estimates, absence from work accounted for £8.4 billion per year, early retirement £6.9 billion per year, and social benefits a further £0.152 billion per year.
If we tackled type 2 diabetes properly, a lot of this enormous problem would simply go away. But it is not up there in the public consciousness, like smoking, or Alzheimer’s, breast cancer, or even heart disease.
We know what to do -the subject is extremely well researched- but we don’t do it? Why? That’s the reason I’m writing this post. Let’s have a National Health Service, not a National Illness Service.
What is diabetes?
There is a huge amount of detailed information on the internet about diabetes. An excellent place to start is the leading UK diabetes charity, Diabetes UK2.
In brief, diabetes is a disease where the body cannot adequately process glucose, the basic energy providing chemical that the body uses to function. Glucose is derived from our food: all carbohydrates, whether sugars or starches, are digested in the intestine to form glucose, which is transported around the body by the blood, and taken into cells to be converted into energy. The hormone insulin, secreted by the pancreas gland within the abdomen, controls this action of cell glucose uptake.
There are two types of diabetes:
In Type 1 diabetes the body is unable to produce any insulin. Its causes are not fully understood, but it is not a self-inflicted problem associated, for example, with poor diet or being overweight. It accounts for about 10 per cent of all adults with diabetes. Management of the condition is not easy, and it is for life. It is treated by daily insulin doses, taken either by injections or via an insulin pump, and sufferers have to engage in careful monitoring of their diet, exercise, and blood sugar levels. Type 1 diabetes can develop at any age, but usually appears before the age of 40, and especially in childhood. It is the most common type of diabetes found in childhood. There is no explosion in the incidence of Type 1 diabetes, but research continues to develop better understanding and better treatments. This post is not about Type 1 diabetes.
Type 2 diabetes usually appears in people over the age of 40, though in South Asian people, who are at greater risk, it often appears from the age of 25. It is also increasingly becoming more common in children, adolescents and young people of all ethnicities. Type 2 diabetes accounts for about 90% of all people with diabetes, and rising. In Type 2 diabetes there is not enough insulin (or the insulin isn’t working properly), so glucose builds up in the blood. There is an explosion of epidemic proportions in the incidence of Type 2 diabetes, and it is getting worse year on year. Type 2 diabetes is the focus of this article.
What causes Type 2 diabetes?
There are 4 main risk factors:
- Heredity – susceptibility to type 2 diabetes runs in families.
- Age – if you’re over 40 (or 25 for certain ethic groups) the risk goes up
- Ethnicity – being of South Asian, Chinese, African-Caribbean or black African origin carries increased risk of type 2 diabetes.
There isn’t anything much you can do about the first three. Incidence of number 4, overweight, has greatly increased in the UK in recent years, and it is this epidemic of overweight and obesity which has driven the surge in diabetes.
Prevalence of obesity among adults aged 16+ years 3 Health Survey for England 1993-2013 (3-year average)
Obesity is defined as a BMI>30. BMI (Body Mass Index) is weight (kg) / height squared (m)2, so for an adult woman of average height of 5ft 5”, it equates to a weight of 180lbs (just under 13 st). Overweight is defined as having a BMI between 25 and 30. BMI is a fairly crude measure, and is less accurate as an indicator for people who are very tall or very short, or people such as athletes whose muscle mass might be high. It is also age related. Another useful indicator is the ratio of waist measurement to height, which has the advantage of addressing the most dangerous form of excess weight, that carried around the abdomen – the men’s (traditional)“beer gut”. A healthy indicator here is to have a waist/height ratio of <0.5. Go on, get out the tape measure!
There is a lot talked about high sugar consumption, especially sugary drinks and sweets, but there is little evidence of a direct causal link between sugar consumption and type 2 diabetes. However, high intake of sugary drinks and sweets is linked to high calorie intake, and the quantity can be surprisingly high. One 12oz can of Coca Cola contains about 39g of sugar (10 teaspoons worth), or 140 calories, and does not cause a satiation feeling (feeling full up, as one would after eating a meal). So it is possible to drink large quantities of sugary drinks and not have any sensation or appreciation of the quantity of calories being consumed – dangerous, especially if it’s a regular habit!
In the end, if the number of calories consumed is greater than the number expended, the laws of physics apply, and there will generally be a gain in weight. The body will lay down the extra calories as fat store. It is a function of our evolutionary history as a species that laying down fat is what we do: people who were able to store fat efficiently were better able to last out times of food shortage, long harsh winters, etc, and those are the people who preferentially survived to be our ancestors. Once we have attained a given weight, our bodies seem programmed to fight to maintain that weight: once we have become overweight, it is extraordinarily difficult to lose it again in a sustainable way.
This is particularly important for children: once children become overweight, and the worse the overweight becomes, the harder it is for the individual ever to recover to a healthy weight during their entire life. The excuse “it’s only puppy fat” is a dangerous illusion.
There are countless diets and systems for weight loss out there, and maybe one will work for you. Perhaps you’ve tried a few. But for most adults, even those with great personal motivation, weight loss is a temporary success, and once the diet is over the weight goes back on again, often to a slightly higher weight than before the diet. This leads to a sort of ratchet effect- you’ll probably have heard the aphorism “dieting makes you fat”. The obvious best approach is not to become overweight in the first place, but, if one has done so, there really is no substitute for a long term slowly-slowly approach of sensible diet plus exercise, rather than dramatic campaigns of abrupt weight loss.
Being overweight has many downsides: feeing unattractive or unhappy about one’s appearance, finding moving about and exercise more difficult, finding everyday tasks a little harder, and getting more tired more quickly. There are direct health risks too: overweight is associated with elevated risk of heart disease, some cancers (endometrial, breast, colon, kidney, gallbladder, and liver), stroke, sleep apnea and breathing problems, and joint problems (knees and hips), and of course, the subject of this article, type 2 diabetes.
All the doctors I speak to tell me that if there’s one thing they could do to make a huge difference to people’s health and life quality, it would be to reduce overweight. An interesting book to read on this topic is by a GP called Dr. John Briffa: “Escape the Diet Trap”4. It’s well worth a read. It recognizes from his first-hand experience, including of many well-motivated patients, that sustained weight loss is very difficult, but achievable and worthwhile.
Diet is one part of the equation. The other is exercise. It is harder and harder for children to get reasonable amounts of everyday exercise. Schools have greatly reduced their extra-curricular sporting activities, as teachers face litigation if a child is injured, and as playing fields are sold off. Even in private sports clubs, parents who would in the past have willingly run a team find it very difficult, with the hassle of going through CRB/DBS checks makes it harder to take children in cars to away fixtures. Cycling is much more dangerous than it used to be, with increased traffic. The huge increase in sedentary entertainment – TV, computer games – makes it harder for parents to get their children out of the house doing stuff. Fewer and fewer children walk to school, as evidence by the big difference in peak-time traffic between term time and when the kids are off school. Our lifestyle seems to conspire against exercise, and it is killing us.
What to do about it?
Government can do this. That’s what it’s for.
If we take smoking as an analogy, although we haven’t completely won the battle, public opinion has moved enormously in the past 10 years, and smoking has declined markedly. Most smokers admit that they are taking risks with their health and would like to be able to stop. We need to achieve a similar level of public awareness about overweight and diabetes.
There is no shortage of well-researched information on how best to assess whether an individual has a problem with overweight; data is readily available to assist clinical judgement, for all ages of children, as well as for adults. There is also established practice on how to intervene most effectively once an individual has been identified as having an overweight problem. The NHS’s own publications cover this very well, for children5 and adults6. It is arguable whether we need to engage in more detailed pilot study work for any of the proposals below, though establishing of ever more robust data through control studies is always a great idea.
- We need a hard-hitting TV campaign about Type 2 diabetes, to increase understanding of the problem, why achieving and maintaining a healthy weight is important, and why allowing children to get overweight is probably condemning them to a life of relative ill-health and low life expectancy. Hard hitting means real cases, with gruesome pictures to grab the attention.
- Direct action by Government to discourage consumption of “empty calories”, eg taxation on sugary drinks. The BMA has recently advocated just such a move7 . We should put our voices behind the proposal. The soft drinks industry will counter, much as the tobacco industry did against anti-smoking legislation, as it has a lot to lose. It is a powerful lobby, with enormous resources. Coca-Cola’s funding of the Global Energy Balance Network8 is a recent example of this strategy, and it will take a determined Government to avoid being deflected.
- Address the overweight issue directly in schools, as tackling the problem as early as possible is the most effective, before people have become “fat adults”. Inclusion of health and diet education as part of the schools national curriculum (in Personal, Social, Health and Economic education, or PSHE) is essential, but it does not go far enough. Schools already have educational attainment targets, with published league tables. We need annual weight monitoring and recording for all school pupils from age 5 up, with some proportion of a school’s budget related to the percentage of pupils who are in the “healthy weight” range. There would of course be objections, just as there are for GCSE league tables, for example because it’s not a level playing field (no, it isn’t), or claims of intrusiveness (no, it isn’t), or fear of being seen to scapegoat overweight children (no, it mustn’t be). These objections can be managed. It would focus some attention in schools to concentrate on the sort of things which impact weight and which schools can influence through their policies and priorities: content/ quality of PSHE teaching, school meals /diet, exercise & sport provision. What doesn’t get measured doesn’t get done.9
- More resources in NHS allocated to prevention rather than treating ill health. This is an area where Government policy can and should make a difference. We already have age-related health screening for very specific conditions such as colon cancer, breast cancer, and even abdominal aortic aneurism. How about weight/BMI screening, annually, for everyone, with advice counselling for those who have a problem? Sounds draconian, shades of Big Brother perhaps, but it would certainly bring overweight to the fore of public consciousness. In Germany, for example, if you don’t attend your 6-monthly dental check-up, any treatment required you have to pay for in full. A sanction which might work in UK is to provide free prescriptions for those who attend their annual weight screening, and everyone else has to pay – children and pensioners included. The mindset we should seek to establish is that the NHS is a partnership between the individual citizen and the healthcare system: for the citizen to benefit from the healthcare system, he/she must be prepared to participate actively in managing their own health; if they do, everything is provided, but if they don’t, then they have to contribute to the cost of treatment. I must be clear here – what I am suggesting is not that overweight people (or smokers, for that matter) should be discriminated against by being made to pay. I am advocating that participation in screening for everyone should be incentivized. The aim is not to introduce some sort of hurdle to make healthcare less widely available; it is to expand participation of the individual in pre-emptive health care – helping to prevent problems before they arise. An added benefit of my proposal would be to generate epidemiological data to understand health v weight better, and to provide individual personal data tracking- a useful tool in managing health. This is a big step, so it might be wise to work towards it by carrying out pilot control studies, so that there is strong evidence, before roll-out, that the expected benefits will accrue in practice.
- Government policy should focus on getting us out of our cars where possible. A key example is cycling, not just for leisure/sport, but as a means of getting to and from school or work. Investment in more safe cycle-ways, segregated from motor traffic, is an enabler which has to be led at national level. It is happening, but not fast enough. The levels of cycling in the UK compare poorly to those in other EU countries. According to a survey10 by the European Commission, only 4% of UK respondents cycle daily. Along with Luxembourg and Spain, this is the lowest percentage of all EU 28 countries, except for Cyprus (2%) and Malta (1%). Yet addressing this problem is a win-win-win: lower road congestion/ lower vehicle-related pollution/ better fitness/ lower incidence of weight-related ill-health.
If you think this makes sense, join the campaign. Write to your MP, and reference this post. Spread it on social media. Let’s make the change from a National Illness Service to a National Health Service.
4 Escape the Diet Trap, Dr John Briffa (ISBN: 9780007447763)