This site is intended for Healthcare Professionals only

A long way to go

In-depth bookmark icon off

A long way to go

As a new report focuses on tackling diabetes, we examine the scope of the problem and how pharmacy teams can support patients before and after their diagnosis

 

Just one hundred years ago, there were no such things as insulin injections or diabetes medicines, and there was no easy way of measuring blood glucose levels. Indeed, until the introduction of insulin in 1922, most children with diabetes slipped into fatal comas within a few months of their first symptoms. Their best hope was an extremely restricted diet.

Elizabeth Hughes, the 11-year-old diabetic daughter of an American presidential candidate and New York Governor, controlled her blood sugar by eating just 500 to 800 calories a day and fasting for one day each week. If doctors detected a trace of sugar in her urine, she ate 250 calories a day or less.

Her weight fell from 34kg in 1919 (average for her age and height) to 20kg in the summer of 1922. Fortunately for Elizabeth, she was one of the first people to be treated with insulin. She recovered and lived a full life until her death in 1981.

Thankfully, the prospects for patients with type 1 diabetes (T1D) have changed almost beyond recognition since Elizabeth’s days. In Scotland, for instance, 47 per cent of men and 55 per cent of women with T1D now have an average life expectancy of 70 years. This is still less than in the general population, however, where 76 per cent of men and 83 per cent of women live to be 70.

Figures also show that around 20,000 people with diabetes still die prematurely every year – that’s about one every 30 minutes. A new report from Diabetes UK – State of the Nation: Challenges for 2015 and Beyond – paints a picture of missed opportunities, ‘postcode care’ and the ‘indescribable tragedy’ of widespread avoidable death and disability.

The devil is in the detail

People with diabetes generally use blood glucose monitors, which offer a snapshot picture of their blood sugar levels. But these levels vary over days, weeks and months. As a result, NICE advises everyone with diabetes to have their HbA1c (glycosylated haemoglobin) measured at least once a year. HbA1c measures glucose that is ‘stuck’ to haemoglobin in red blood cells and it indicates a person’s blood glucose levels for the previous two to three months – haemoglobin’s lifespan. In 2012- 13, 94 per cent of people with type 2 diabetes (T2D) had an annual HbA1c check, but only 80 per cent of those with T1D had a check.

This is especially worrying since about 17 per cent of T1D patients and seven per cent of those with T2D have ‘exceptionally high-risk’ HbA1c levels. Over time, dangerously high blood sugar levels poison the body’s cells. This causes debilitating, distressing and disabling complications, such as amputations, heart disease, blindness and kidney damage, which can allow protein (albumin) to ‘leak’ into urine.

The NHS spends about £1 million each hour treating diabetes

Kidney failure directly caused about six per cent of deaths among Scottish people with T1D last year. Kidney disease also contributes to cardiovascular disease, which accounted for 45 per cent of deaths in men and 42 per cent of deaths in women. English figures show that only 74 per cent of people with diabetes had their urine albumin measured in 2012-13. Overall, about 41 per cent of adults with T1D and 62 per cent with T2D received all eight care processes that tackle risk factors linked to death and disability among people with diabetes:

  • HbA1c
  • Blood pressure
  • Cholesterol level
  • Serum creatinine (a measure of kidney function)
  • Urine albumin
  • Foot check
  • Body mass index
  • Smoking status (not recorded for children).

Younger people were especially likely to receive poor care. In 2012-13, only 12 per cent of people aged 12-24 years in England received all of their care processes. All members of the pharmacy team should take every opportunity to emphasise the importance of these basic checks to patients.

Excess weight causes around 90 per cent of T2D cases in the UK 

Patchy treatment

Unfortunately, even those who do have a process recorded are not guaranteed adequate treatment. Indeed, between 2007 and 2012, the number of several potentially avoidable complications from diabetes – including cardiac failure, stroke, renal replacement therapy (dialysis or a transplant) and angina – rose significantly. The Diabetes UK report also highlighted marked ‘postcode’ care.

Speaking at the report’s launch in a packed room at the Houses of Parliament in January, Secretary of State for Health Jeremy Hunt admitted: “There is still a very long way to go and the care we give people with diabetes and the effort we put into prevention needs to improve.” Mr Hunt noted, in particular, that better care would prevent the ‘vast majority’ of the 100 or so amputations that take place every week because of diabetes.

Between 2007 and 2012, the number of these amputations rose by 60 per cent. And despite the fact that childhood obesity rates have started to fall for the first time in 14 years, he described the UK’s levels of childhood obesity as ‘shockingly high’. Excess weight causes around 90 per cent of T2D cases in the UK. “One in 10 children enters primary school clinically obese,” said Mr Hunt. “Two in 10 children leave primary school clinically obese.”

 

A hidden burden

As long ago as the 1920s, doctors recognised that mental, social and family problems contributed to marked fluctuations in blood glucose levels in some people with diabetes. More recently, we’ve realised that depression is twice as common in people with diabetes as it is in the general population, which can undermine self-care and diabetes control.

However, a survey from Diabetes UK found that 68 per cent of people who needed psychological support didn’t receive it. Psychological and emotional support is – or should be – part of the structured education offered to people with diabetes.

Yet in 2012-2013, only 1.1 per cent of people with T1D and 1.6 per cent of those with T2D attended structured education courses. Pharmacy teams can encourage people to take part in education programmes and to ask for the psychological and emotional support they need. “Living with diabetes means never having a single day off from managing your condition,” says Diabetes UK chief executive Barbara Young.

“People with diabetes tell us that coping with your diabetes every hour of every day can be exhausting and stressful. Feeling isolated is also common in people with the condition. But getting the right emotional help can make a real difference and can improve people’s mental health as well as helping improve their physical health outcomes.”

Cause and effect

The relationship between mental illness and diabetes can run both ways. Post-traumatic stress disorder (PTSD) is common after a sexual or physical attack, military combat or a serious physical or mental illness. People with PTSD often report flashbacks, vivid dreams and nightmares about the trauma. They typically avoid places and people that evoke memories of the trauma, refuse to speak about their experiences, feel constantly on guard or emotionally numb and may abuse drugs and alcohol. PTSD may also double the risk of developing T2D.

In a recent study, women experiencing between one and three PTSD symptoms were 40 per cent more likely to develop T2D than those without PTSD. The risk was 50 per cent and 80 per cent higher in women with four to five and six to seven symptoms respectively. This suggests a direct link, although scientists have not yet traced the pathway. Further studies should determine whether treating PTSD reduces T2D risk and help find new methods for detecting at-risk patients.

Not a matter of money

The NHS spends about £1 million each hour treating diabetes, but Barbara Young, chief executive of Diabetes UK, believes that improving diabetes care does not mean spending more. “In fact, better ongoing standards of care will save money and reduce pressure on NHS resources,” she said.

“It’s about people getting the checks they need at their GP surgery and giving people the support and education they need to be able to manage their own condition. Doing this, together with improving diabetes care in hospital, would give people with diabetes a better chance of a long and healthy life, and save the NHS a significant amount of money.”

Numerous studies underline the need to improve care. For example, GPs offer few overweight and obese patients support to lose weight, such as advice, drugs or referral, so there is a key role here for pharmacy teams, who can help by offering advice and support to people who want to lose weight.

A hundred years since the vogue for starvation diets, we are still a long way from fully understanding, let alone defeating, diabetes. While there are some grounds for optimism, everyone – from patients at home to pharmacy teams on the high street to politicians in Westminster – needs to do more.

After all, around 2.7 million people in the UK have been diagnosed with diabetes – that’s more than the population of greater Manchester. Another half a million have undiagnosed diabetes, and every three minutes another person discovers they have this potentially deadly and disabling disease. As Barbara Young remarks: “We all have to act before the number of people with diabetes overwhelms our health and social care systems and consumes an even greater proportion of the NHS budget.”

Copy Link copy link button

In-depth

Share: