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  • 1. Diabetes Diabetes occurs when the body either fails to make enough insulin or no longer responds to it as it should.1 There are two main types of diabetes: type 1 and type 2. Type 1 diabetes occurs when the body fails to make insulin in sufficient quantity. This is usually caused by an abnormality in the body’s immune system that leads to the destruction of the cells in the pancreas that make insulin. Type 2 diabetes occurs when the body fails to respond to insulin as it should. If inadequately controlled, diabetes can cause a variety of complications. Principally, these affect blood vessels and thus the blood supply to various organs in the body. The complications of diabetes therefore include increased risk of heart attack, kidney failure, blindness, inadequate blood supply to the extremities (especially the feet) that can lead to ulceration and gangrene, and inadequate blood supply to nerves, especially in the extremities, leading to loss of touch and pain sensation. It is thus a potentially serious condition. The risk we face Diabetes is a relatively common condition. Barnet GPs have identified some 14,000 people with this condition,2 although the actual number is likely to be higher. This is shown in Figure 1, which also shows that there is considerable variation throughout London in the burden of diabetes. This is predominantly because of differences in the Black and minority ethnic makeup in different areas. A major risk factor for type 2 diabetes is obesity: an obese woman is 12.7 times as likely to develop diabetes as a woman who is not obese and an obese man is 5.2 times as likely to do so as a man who is not.i Unless we can curb the year-on-year rise in obesity in Barnet then the number of people with diabetes, and thus the number of people at risk of complications and death as a consequence, will continue to rise. Diabetes is not only associated closely with obesity. It becomes more common with age and is more likely to occur in someone if one or more of their close family has diabetes, and in women who developed glucose intolerance during pregnancy. There is also a condition called ‘pre-diabetes’ (which is also referred to as ‘impaired glucose tolerance’ and ‘impaired fasting glucose’. This is an asymptomatic condition characterised by higher than normal blood glucose levels and insulin resistance. Without intervention and appropriate treatment, people with pre-diabetes are at risk of developing type 2 diabetes within10 years.ii The risk factors for pre-diabetes are similar to those for type 2 diabetes. There is evidence that by identifying and treating pre-diabetes with lifestyle change and – as necessary – drugs, type 2 diabetes can be prevented or delayed and the risk of complications associated with the condition, such as cardiovascular disease, can be reduced.iii,iv,v 1 Much of the food we eat is converted by the body into glucose. This is needed by body cells for them to function properly. Insulin is a hormone that enables glucose to transfer from the blood stream into cells 2 Source: Barnet PCT Quality and Outcomes Framework 2007
  • 2. Proportion of people with diabetes (%) 6 Estimated additional prevalence 5 QoF-reported prevalence 4 Figure 3 1: The 2 1 0 Lambeth Kensington & Chelsea Southwark Bromley Ealing Enfield Richmond & Twickenham Haringey Bexley Hillingdon Islington Havering Westminster Sutton & Merton Wandsworth Newham Lewisham Greenwich Barking & Dagenham Waltham Forest City & Hackney Harrow Tower Hamlets Barnet Redbridge Kingston Hammersmith Camden Hounslow Brent Croydon estimated prevalence of diabetes in London PCTs compared with the QoF-reported prevalence in March 2007 Source: Healthcare for London Report – Diabetes Care. July 2008 The relationship between diversity and deprivation and diabetes Diabetes is more common in Asians and Blacks, and amongst African Caribbeans it is more common in women than in than in men, as shown in Table 25. The average age at diagnosis of diabetes is also lower in people of African Caribbean origin, the risk of death from diabetes is between three and six times higher, and there is a greater susceptibility to the cardiovascular and renal complications of diabetes amongst them. In addition, Bangladeshi men are nearly six times more likely to develop diabetes than the general population and African Caribbean women four times as likely to do so (noting that this is an ethnicity and gender difference: African Caribbean men are only 2.5 times as likely to develop diabetes as the general population. The average age at diagnosis of diabetes is also lower in people of African Caribbean origin, the risk of death from diabetes is between three and six times higher, there is also a greater susceptibility to the cardiovascular and renal complications of diabetes.vi Table 1: Standardised risk ratios for diabetes by ethnic group and gender in 1999 Men Women General 1.0 1.0 population Irish 1.4 1.0 Indian 3.0 2.9 Pakistani 5.4 5.6 Bangladeshi 5.8 5.8 Black Caribbean 2.5 4.2 Chinese 1.4 2.1 Source: Health Survey for England, 1999, Department of Health There may be an association between deprivation and diabetes, but this is more likely to be a reflection of the fact that obesity is more common amongst people who live in deprived areas.
  • 3. Local targets There are no specific PCT performance targets for diabetes other than in relation to screening for diabetic retinopathy.3 However, in collaboration with a wide variety of experts on the subject, the Healthcare Commission has identified a number of measures that might be used to assess the quality of diabetes control in groups of patients. The glycosylated haemoglobin level is one such measure and reflects the level of diabetes control over the preceding few weeks. In contrast, testing for glucose in the urine or checking the level of glucose in the blood only shows what is happening at that point in time. Figure 2 shows the proportion of people with ‘tightly controlled’ diabetes as measured by their glycosylated haemoglobin level. In comparison with most other parts of London, Barnet GPs (who are the ones predominantly caring for people with diabetes) in collaboration with GP practice nurses, diabetes nurse specialists and hospital doctors are providing a good service. Figure 2 The proportion of patients with diabetes who have a record of HbA1c and in whom this is 7.5 or less in the previous 15 months 70% 65% 60% 55% 50% 45% tto Ha g & To Hil ham k e et ns it uth n Ea g k n H on h th En ey Tw Ba st Is gey w on La am Mw en n Ki ham H ton av n ou g e & Cro th on Fu rk av ea W db w en m ac s Fo ld C eth nd Ch m er ds nt tm ge N ling Te let in Ke ersm So de n ic ag o H g to rro R nslo re am fie ic rn or G wha a a an Bre st l hi ac er g d Le er t D yd H ra on els es rid w m er h in h & w s b lh ey am in am in w ng is n m lin e o H w lin ar e Br re & e Lo & n W al & Su gt W g Key things that need to be done in d on rk m Ba hm am ity The key activities required are: ic H C R continuing to identify people with diabetes and impaired glucose tolerance (‘pre-diabetes’)  and to manage this effectively; to increase the proportion of people with diabetes in whom the last HbA1c measurement in  the last 15 months is 7.4% or less; to enable people with diabetes to manage their own condition more effectively;  to maintain the current high coverage of diabetic retinopathy screening; and  to encourage and enable people to avoid and to address lifestyle risk factors that increase their likelihood of developing diabetes. 3 Diabetic retinopathy is the most common cause of acquired blindness in people of working age. The main damage caused by diabetes is to the lining of blood vessels (hence the increased risk of heart attack and stroke). This blood vessel damage affects many parts of the body, including the blood vessels supplying the retina.
  • 4. i National Audit Office Tackling obesity in England. National Audit Office. London, 2001 ii Prediabetes: Prevention and treatment for your diabetes (Accessed 8 August 2006) http://www.dlife.com/dlife.com/dLife/do/ShowContent/prediabetes/treatment.html iii Tuomilehto J, Lindstrom J, Eriksson JG et al.: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Eng J Med, 2001;344:1343-1350 iv The Diabetes Prevention Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Eng J Med, 2002; 346:393-403 v Buanan TA, Xiang AH, Peters RK et al: Preservation of pancreatic (beta) cell function and prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high-risk Hispanic women. Diabetes, 2002;51:2796-2803 vi Department of Health. National Service Framework for Diabetes. Department of Health. London. 2001