Diabetes

1. Public Health Module
Venue
Date
Unit: Public Health Aspects of Diabetes
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© 2010

2. 2
Course Aims
This unit will:
– Explore how common diabetes is;
– Familiarise students with the risk factors of diabetes
– Explore the efficacy interventions for the prevention and
management of diabetes
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Outline
Part I: DIABETES AS A PUBLIC HEALTH PRIORITY
1. What is diabetes?
2. Classifying diabetes
3. Epidemiology - how common is diabetes?
4. Risk factors and consequences
Part 2: PREVENTING AND MANAGING DIABETES
1. Primary prevention of diabetes
2. Secondary prevention
3. Screening in diabetes
4. Self care
5. Monitoring diabetes care
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4. What is health?
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WHO Definition ‘a state of complete
physical, mental and social
well-being and not merely
the absence of disease or
infirmity’
Antonovosky: Salutogenic model
‘sense of coherence’
Seedhouse and Duncan: Achievement of potential
Empirical Lack of health
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5. What is public health?
‘the science and art of preventing disease, prolonging life and
promoting health through the organized efforts of society’
C.E.A. Winslow, 1920
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6. The wider determinants of health
Source: Dahlgreen and Whitehead, G and
Whitehead M (1991)
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7. The challenge for public health
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8. Statistical description of nation’s health
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Census data
Health Inequalities data
Infant Mortality Rates
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1. What is diabetes?
Diabetes results from reduced production of the hormone
insulin, resistance of body tissues to the effect of insulin,
or both.
The result is abnormally high levels of glucose in the blood and
widespread disturbances to metabolism.
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History
• 30-90AD: Diabetes named by Greek Physician Aretaeus: means ‘a flowing
through’ to describe its constant thirst, excessive urination and weight loss
• Japanese name: 'Shoukachi', the thirst disease
• 1600s: Professor Thomas Willis of Oxford University describes urine in
diabetes mellitus as ‘wonderfully sweet’, distinguishing it from
diabetes insipidus
• 1889: Oskar Minkowski and Joseph von Mering of University of Strasbourg
remove a dog’s pancreas - it produces diabetes
• 1921: Banting & Best isolate insulin, successfully treats a patient,
transforming diabetes to a treatable, chronic condition
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11. The Healthy Body
3. Insulin triggers
liver to take up
glucose and turn
into glycogen
1. Glucose,
produced from
carbohydrates,
released into
bloodstream
2. The pancreas
produces insulin,
also released into
the bloodstream
4. Insulin
enables cells to
take up glucose
Source: Diabetes UK, Diabetes and the Body animation (www.diabetes.org.uk/Guide-to-diabetes/Introduction-to-diabetes/What_is_diabetes/Diabetes-and-the-body/)
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2. Classification
• The WHO recognises several types of diabetes
• Type 1
• Type 2
• Gestational diabetes
• Other types
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13. I. Type 1 Diabetes
The
pancreas
unable to
produce
insulin
Accounts for ~15%
of diabetes in
the UK
Mainly diagnosed in
children/young
adults
Characterised by
insulin deficiency
Symptoms develop
quickly
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In type 1 diabetes, no insulin is available so cells are unable to take in
glucose
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Symptoms of type 1 diabetes
• Frequent and excessive urination
• Thirst
• Dehydration
• Tiredness
• Urinary or genital tract [eg thrush] infections
• Blurred vision
• Symptoms develop quickly
• Can progress to ketoacidotic coma
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Type 2 diabetes
• Characterised by insulin resistance, though may also have
deficiency [Used to be classified as Non-insulin dependent
diabetes (NIDDM) but can require insulin]
• Similar acute symptoms to type 1
• Compared with type 1, often develops gradually
• Some have no symptoms at diagnosis
• Milder forms: can be controlled by diet, and exercise
• Accounts for ~85% of diabetes in the UK
• Mainly diagnosed in older adults though increasingly seen in
younger age groups too
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II. Type 2 diabetes
Fat deposits affect cells’ insulin (i) sensitivity.
They are less able to take in glucose (g)
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III. Gestational diabetes
• Excess blood glucose during pregnancy (both diabetes mellitus and
impaired glucose regulation)
• Increased risk of diabetes related complications in pregnancy
• Health consequences for the baby include increased risk of
• birth complications: caesarean sections; still births and
perinatal deaths
• very high birth weight babies
• birth defects
• obesity and diabetes in the child.
• For the mother:
• increased long term risk of type 2 diabetes (30% as opposed to
10% in the general population)
• higher risk of diabetes-related complications in
subsequent pregnancies
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IV. Other types
• Monogenic diabetes
• 1-2% of all diabetes, affecting 20,000-40,000 in UK
• Usually develops in under 25s
• Due to a single gene mutation
• Runs in families – affected person has 50% chance of
passing on
• Currently 6 types of monogenic diabetes recognised
• Some types managed by diet and exercise alone
• Often initially misdiagnosed as type 1 or type 2 diabetes
• Diagnosing correctly can help
• inform which treatments are most appropriate
• give some idea of how the diabetes is likely to progress
• affected families understand their risk of diabetes and/or risk to
their children
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Diabetes insipidus
• Moderately rare condition - affects 1 in 25,000
• Symptoms of excessive urination
• Distinct from diabetes mellitus:
• not related to production or sensitivity to insulin
• Urine not sweet
• related to function of vasopressin hormone in the pituitary gland
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21. Classifying glucose regulation
Normoglycaemia
(low risk of
diabetes/CVD)
FPG: ≤ 6.0mmol/l
Impaired glucose
regulation
(higher risk of
diabetes/ CVD)
FPG: >6 to <7mmol/l
Diabetic
(high risk of CVD)
FPG: 7.0 + mmol/l
“Healthy” “Diabetic”
Diabetes
Low risk
Risk
Glucose levels
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3. Long term impact of diabetes
• Diabetes is an important cause of death and disability
• Diabetes is a leading cause of blindness, renal failure and
neuropathy in the UK
• Life expectancy is reduced on average by 20 years in those
with Type 1 diabetes and up to 10 years in Type2 diabetes
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Retinopathy
Common cause of
blindness in people
of working age in West
Nephropathy
20% of all ESRD
Erectile Dysfunction
May affect up to 50%
Macrovascular
2–4 x increased risk
of CVD, 75% have
hypertension
Foot Problems
15% develop
foot ulcers; 5–15% need
amputation
Source: The Audit Commission. Testing
Times. A Review of Diabetes Services in
England and Wales, 2000.
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‘Macrovascular’ complications
cardiovasular diseases
• Biggest cause of death in diabetes:
• 75% of deaths in people with diabetes caused by
cardiovascular disease
• People with diabetes have:
• 2x risk of death from heart disease
• 1.5-4x risk of stroke
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‘Microvascular’ complications
Nerves (neuropathy):
– affects up to 60-70% of people with diabetes
– symptoms include tingling or burning, pain, numbness
– increases the chance of foot ulcers and limb amputation
– other conditions e.g. erectile dysfunction
Eyes (retinopathy):
– biggest cause of blindness in working aged adults in UK
– long-term damage to the small blood vessels in the retina
– after 15 years of diabetes, ~ 2% of people become blind, and about
10% develop severe visual impairment
Kidneys:
– Disease detected by protein in the urine
– affects 30% of people with diabetes
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26. Source: Yorkshire & Humber Public
Health Observatory 2008
Deaths from diabetes
~ 2700 death certificates with diabetes
as cause of death pa
~26,000 deaths from the diseases
caused by diabetes pa
So death certificates underestimate
diabetes attributable deaths.
Variations by area too:
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Cost of diabetes
• Diabetes is a clinical area of high expenditure
• eg in one year, October 2007 to September 2008, there were
31.9 million NHS items prescribed = £581.2 million
• ~ 5% of total NHS spend is used for the care of people
with diabetes
• The growth in expenditure on prescribing for diabetes is
greater than any other major clinical area
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4. Prevalence of diabetes
• Current prevalence
• Trends
• Models
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29. Global impact
• Diabetes accounts for estimated 5.2% all world mortality
• 80% deaths occur in low & middle income countries
• Prevalence increasing fastest in these countries
Source: WHO
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30. Diabetes prevalence in England
• 2.1 million on
diabetes registers
• BUT 25% in coronary care
have undiagnosed
Type 2 DM
• Y&H PHO modelling
estimates:
• another 400,000+
not diagnosed
• The estimated prevalence of
diabetes (diagnosed and
undiagnosed) is 4.82% of
population of England
• prevalence varies by area
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31. Trends
• Diabetes expected to rise in
England to 6.5% by 2025
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32. Diabetes UK
Silent Assassin Campaign
What do these images say to you about diabetes?
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5. Risk factors
• Why consider risk factors?
• Type 1 v 2
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34. Type 1
• Highest prevalence in
northern European
populations
• Strong familial link – genetic
factors
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6
4
2
0.3
0 5 10 15 20 25 30 35
identical twin
sibling
father
mother
no family
members
Family
member
affected
% risk of type 1 diabetes
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35. Relative risks of type 2 diabetes
• Population factors:WB
• Family history;
• Age;
• Socioeconomic
circumstances;
• Ethnicity
• Modifiable risk factors
• Obesity;
• Exercise;
• Smoking
0 5 10 15 20 25
OBESITY
age
ethnicity
socioeconomic
factors
SMOKING
Risk
factor
RR
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36. Obesity
• BMI = weight (kg)/height (m)2
• BMI categories:
• In the Nurses Health Study, compared with women
with a BMI or 23 or less, diabetes was
• nearly 40 times higher with a BMI of 35+
• 20 times higher with a BMI or 30-34.9
Underweight Normal Overweight Obese Morbidly obese
<18.5 18.5-24.9 25-29.9 30-39.9 40+
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Ashwell shape chart
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Physical activity, obesity and the risk
of diabetes
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<25
25-29.9
30+
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
<2.1
2.1-4.6
4.7-10.4
10.5-21.7
21.8+
2.1
1.6
1.5
1.6
1.0
6.9
6.3
5.1 5.4
4.8
16.8
15.8
13.0 12.9
10.7
Relative
risk
Physical Activity (Metabolic Equivalent Hours/week)
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39. Age
Prevalence of doctor-diagnosed diabetes, by age
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Ethnicity
• In England, compared with the general population,
rates of diabetes are:
• 3-4 x higher Bangladeshi, Pakistani and Indian men
• 5 x higher in Pakistani women
• 3 x higher in Bangladeshi and Black Caribbean women
• 2.5 in Indian women
• When assessing risk of diabetes, need to consider ethnicity, &
also need to consider gender
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41. Deprivation
Age adjusted prevalence of
known diabetes by fifths of
deprivation score
• Mortality and morbidity are
increased by socio-
economic deprivation
• The complications of
diabetes have been
shown to be more prevalent
in areas of high
socioeconomic deprivation
J Epidemiol Community Health 2000;54:173-177
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Other risk factors
• Smoking:
• small relative risk compared to obesity, but of public health
importance given prevalence of smoking, particularly in poorer
socioeconomic groups
• Physical health problems
• Mental health
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Diabetes and gender
• Risk factors affect men and women differently
• Risk of death from heart disease linked to diabetes is greater in
women than men:
• Is diabetes more harmful to women? and/or
• Is treatment better for men? and/or??
• Gestational diabetes: numbers of diabetes cases in women of
childbearing age increasing
• Risk factors: family history; pre-pregnancy obesity; advanced
maternal age; gestational diabetes in previous pregnancy;
ethnic background; large baby (≥ 4.5 kg) in a previous
pregnancy; smoking
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Part 1 summary
• Diabetes is a chronic condition
– It can lead to CVD, kidney failure, limb amputation and blindness
• Type 1 and type 2 diabetes share similar symptoms but different
public health implications
• Type 2:
– 85% of diabetes in UK
– Obesity most important modifiable risk factor.
– more common in people over 40 years, Pakistani, Bangladeshi, Indian
and African Caribbean populations
• Women and poorer socioeconomic groups more at risk of diabetes
complications and death from diabetes
• Problems assessing the health burden of diabetes because:
– ~20% with type 2 diabetes remain undiagnosed
– diabetes seldom recorded as cause of death but its complications –
heart disease, stroke, renal failure – are leading causes of death.
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Exercise: ‘Westport’ PCT’s local diabetes
Needs Assessment
• ‘Westport’ PCT needs to understand the current impact of
diabetes on its population – prevalence, health consequences
and effects on services - and to forecast the impact of diabetes
in the future
• From what you’ve learnt in the module so far, how would
you find out about the impact of diabetes on your local
population?
• What sources of data could you access?
• What information would you collect specifically? Who would you ask?
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Part 2: Preventing and managing diabetes
1. Primary prevention of diabetes
2. Secondary prevention
3. Screening in diabetes
4. Self care
5. Monitoring diabetes care
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1. Primary prevention
• Three strategies for primary prevention-
• Upstream- whole population
• Midstream- special high risk groups e.g. children, elderly
• Downstream- high risk ‘individuals’
• Type 2 prevention Government priority in England:
“The NHS will develop, implement and monitor strategies to reduce the risk of
developing type 2 diabetes in the population as a whole and to reduce the
inequalities in the risk of developing type 2 diabetes.”
Standard 1 of the Diabetes National Service Framework, 2003
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Population measures
• Reducing obesity
• Increasing physical activity
• Choosing health: choosing a healthy diet and choosing activity
– 5-a-day
– 5-a-week
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Identifying high risk individuals
• Why?
– Can target interventions to those most at risk
• How?
– Risk assessment considering
» Weight (BMI, waist circumference)
» Blood pressure
» Cholesterol
» Blood glucose
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NHS Health Check WB46
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51. Interventions for high risk individuals
• Lifestyle interventions significantly reduce progression rates
to diabetes in prediabetic individuals
• Trials have shown that sustained lifestyle changes in diet
and physical activity can reduce the risk of developing
type 2 diabetes
Study Country % risk
reduction
Diabetes Prevention Programme
(Tuomilehto et al, 2001)
Finland 58
DAQing (Pan et al, 1997) China 46
Diabetes prevention programme (Knowler et
al, 2002)
America 58
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Programmes for high risk
• Medications & non-drug interventions to:
– reduce blood pressure
– lower cholesterol (eg statins)
– manage blood glucose
• Community referrals for programmes on:
– exercise
– weight management
– smoking cessation
• Specialist referrals for bariatric surgery?
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53. Exercise: theory…
• Chief Medical officer Report
2004: ‘5 a week’ call
for action
• At least 30 minutes exercise
5 times a week can improve
health, prevent diabetes and
reduce overweight
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…reality?
And…people with diabetes less likely to meet
exercise recommendations
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target high risk or provide for the whole population?
In public health, there is often debate about whether to target
high-risk individuals or offer population wide strategies to
promote health and prevent disease
Think of some of the pros and cons of these contrasting
approaches for lifestyle interventions to adopt healthier diets
and take more exercise to prevent diabetes
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Exercise 2: Encouraging healthy eating
and regular exercise
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3. Screening
• Primary prevention
– To identify people at increased risk of disease
• Secondary prevention
– To identify early stages of disease
NSC found no evidence to implement national screening
for diabetes in UK.
Better strategy to:
– optimise management of blood pressure and hyperglycaemia in people with
known diabetes; and
– ensure universal screening for eye disease
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4. Self care and self management
DESMOND for type 2 diabetes
• Diabetes Education and Self Management for Ongoing and
Newly Diagnosed patients
• Group sessions to help new patients to
– identify their own health risks
– develop behaviour and health goals tailored to their
own circumstances
• Evaluation found:
– greater weight loss & smoking cessation
– improvements in beliefs about illness
– No change in HBA1c
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5. Monitoring diabetes care
• Why?
– To find out if services delivered as intended
– To find out whether services reaching groups that need them
• How?
– Local monitoring, checks, visits, feedback
– National data
• Monitoring against targets: access
• Patient survey: patient experience
• Hospital admissions & procedures: outcomes
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NCHOD admissions and procedures
Age standardised rates of emergency hospital admissions
for diabetic coma and ketoacidosis, by region
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15
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30
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Regions in England
diabetic
coma
and
ketoacidosis
emergency
hospital
admissions/resident
population
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Part 2 summary
• Type 2 diabetes is preventable
• Complications of diabetes can be avoidable
• Interventions aim to:
– encourage healthy eating and regular exercise
– reduce blood pressure, cholesterol and improve glucose regulation
– reduce complications
• Programmes in England to improve diabetes care focus on
identifying high risk individuals, rewarding quality services,
screening for retinopathy
• Monitoring indicates room for improvement in access
and effectiveness
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Exercise 3: Shaping your local services
‘Westport’ PCT’s public health department has been asked to
recommend how Nowhere should develop its diabetes services.
• How would you assess the impact of diabetes services
provision locally?
• From what you’ve learnt in the module, how would
you decide on your top priorities for diabetes in your
local area?
• Think about:
– Prevention vs treatment
– Evidence based programmes vs learning through doing
– National policy priorities and targets
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