New JSNA: This is the test site for the new Joint Strategic Needs Assessment

Diabetes

Introduction

Diabetes is a long-term condition that affects an increasing number of people and is known in the majority of cases to be related to poor diet, excess weight and obesity, and too little physical activity. The condition is related to reduced day-to-day health and wellbeing and significantly increases risk of a range of serious complications and premature death. The increasing number of people diagnosed with diabetes has implications for demand for both health and social care services and interventions are needed to target those at risk of developing diabetes and those with diabetes who may go on to develop related conditions.

What do we know?

Diabetes mellitus (commonly known as diabetes) occurs when the body becomes unable to use insulin effectively. Insulin is the hormone responsible for regulating blood sugar (glucose) levels by controlling the flow of glucose into the cells of the body.

There are two types of diabetes mellitus:

  • type -1 diabetes (about 10% of people with diabetes have type-1), usually diagnosed in childhood or young adulthood, is caused by the failure of the pancreas to secrete insulin (the hormone which allows the body's cells to use glucose) and nearly always has to be treated with insulin injections. In most cases, the cause of type-1 diabetes is unknown. This type of diabetes is not related to diet nor weight
  • type-2 diabetes (about 90% of people with diabetes have type-2), occurs when the body cannot make enough insulin or when the insulin it does make does not work effectively.

Being overweight or obese is the main modifiable risk factor for type 2 diabetes. Obese adults are five times as likely to be diagnosed as adults of a healthy weight. Rising prevalence of obesity has led, and is expected to continue to lead, to a rise in the prevalence of type-2 diabetes (Public Health England (PHE, 2014); World Health Organisation (WHO), 2015).

Longer term complications arising from diabetes include: higher risk of heart attack and stroke; neuropathy (nerve damage) in the feet, increasing the chance of foot ulcers and infection, sometimes leading to the need for amputation; diabetic retinopathy (long-term damage to small blood vessels in the retina -the leading cause of sight loss in people of working age in the UK); kidney failure; and depression. Diabetes is associated with lower life expectancy and is a major cause of mortality in the UK and elsewhere. (PHE, 2014; WHO, 2015).

Prevalence of diabetes in Reading

Currently, around 5% of people registered with GP practices in Reading have received a diagnosis of diabetes (Health and Social Care Information Centre, 2015; Public Health England (PHOF), 2015), compared to 6.4% in all of England and 6.5% in local authority areas with similar levels of deprivation to Reading (the 'fifth less deprived' deprivation decile). Prevalence in Reading is rising and is expected to continue to rise. Figure 1 shows the estimated prevalence of diagnosed and undiagnosed diabetes in Reading and England from 2012 through to 2030.

Figure 1: Estimated diagnosed and undiagnosed prevalence of diabetes in Reading and England 2012-2030
Figure 1: Estimated diagnosed and undiagnosed prevalence of diabetes in Reading and England 2012-2030

Source: National Cardiovascular Intelligence Network (NCVIN) (2012). Diabetes Prevalence Model for Local Authorities in England PDFs. PHE, London.

This has implications both for people's health and for health and social care services. There are substantial estimated total costs associated with diabetes, encompassing treatment, loss of productivity, and adult social care and these can be expected to increase dramatically in the next few decades (PHE, 2014).

Prevention of diabetes in Reading

Obesity levels in adults and children and levels of physical activity in Reading are broadly in line with the national average. However, obesity levels nationally have increased steadily over the last 20 years and only 67% of men and 55% of women in England and Wales report that they meet the recommended weekly amount of physical activity (PHE (PHOF), 2016, data from the Active People Survey, and see Obesity - adult and child and Physical Activity sections).

We need to support residents to manage their own lifestyles to ensure healthy weights and active lifestyles in a variety of settings through supporting active transport, accessible leisure services.

Management and Treatment in Reading

A number of measures are used by PHE to monitor how well diabetes is managed in local areas.

  • Good blood sugar control in people with diabetes - patients with diabetes in whom last measurement of blood glucose was within recommended limits;
  • Good blood pressure control in people with diabetes - patients with diabetes in whom last measurement of blood pressure was within recommended limits;
  • Good cholesterol control in people with diabetes - patients with diabetes in whom last measured total cholesterol is within recommended limits; and
  • People with diabetes meeting treatment targets - patients with diabetes meeting all three of the targets above.

In 2012-13 (the most recent year reported by PHE), 34.9% of patients with diabetes met all three targets, slightly below the England average of 36% and an average of 35.9% amongst local authorities with similar levels of deprivation (the fifth less deprived decile). While the percentage of patients with diabetes with good blood pressure and cholesterol control were better or similar to the England average, the percentage with good blood sugar control was significantly below the England and local authority areas with similar levels of deprivation- 58.8% in Reading, compared to 74.9% in England and 65.1% in similar local authorities. This pattern is replicated in both CCGs that operate in Reading (South Reading CCG and North and West Reading CCG).

National and Local Strategies (Current best practice)

Diabetes is a largely preventable disease and the risk of further complications can also be reduced through lifestyle change - especially diet, weight management and increasing physical activity (NHS Choices, 2016).

Obesity, linked with type-2 diabetes, is a national priority. The Government's 'Call to Action' on obesity was published in 2011 and sets out national ambitions relating to excess weight in adults, which it recognises as a major determinant of premature mortality and avoidable ill health (HM Government, 2011).

The 13 quality statements of the 'Diabetes in adults quality standard' (NICE, 2011) were informed by a range of NICE clinical guidelines and the 'National Service Framework for Diabetes' that covered all aspects of diabetes care and prevention. Specifically, it is expected that the high quality care set out in this quality standard will reduce the complications associated with diabetes. NICE guidelines for diabetes include these for children and young people: pregnancy, type-1 diabetes, prevention of type-2 diabetes, risk identification and interventions for individuals at high risk. All aim to improve the prevention, identification and management of those people at risk of developing diabetes and those with the condition.

NICE guidelines on management of type-2 diabetes, the most prevalent and the most preventable form of the disease, recommend an individualised approach to treatment, structured education aimed at developing attitudes, beliefs and knowledge about lifestyle choices, delivered at the time of diagnosis with annual reinforcement, dietary advice and blood pressure management.

What is this telling us?

Diabetes significantly affects the day-to-day lives of those affected and puts them at considerably increased risk of developing a range of serious conditions and of premature death. Diabetes type 2 itself and related conditions are largely preventable through diet, weight management and increased physical activity.

While the proportion of people who are overweight or obese and the levels of physical activity in Reading are similar to the national averages, this must be seen in a national context of dangerous increases in the number who are overweight or obese, and declines in self-reported physical activity.

Although management of diabetes in Reading is similar to the average, management of blood sugar levels is significantly worse than elsewhere. This suggests that more could be done to prevent the development of complications in those who have been diagnosed.

What are the key inequalities?

Deprivation is closely linked to the risk of both obesity and type-2 diabetes. Prevalence of type-2 diabetes is 40% more common amongst people from the most deprived areas compared to the least deprived areas. In addition, people from some black and minority ethnic groups may be more likely to develop type-2 diabetes at a lower body weight than people from white ethnic groups (PHE, 2014).

What are the unmet needs/service gaps?

As well as population-wide interventions to encourage healthy diet, weight management and physical activity (primary prevention), there is some evidence that more could be done locally to target interventions at those at risk of developing diabetes (secondary prevention) and those who have been diagnosed and need support to manage their condition to prevent development of related conditions (tertiary prevention). Both NHS and local authority commissioners should consider how they can encourage and support lifestyle changes and substantially increase the number of people who are helped to reduce their risk of developing diabetes, and, for those who are diagnosed with diabetes, substantially reduce the risk of developing complications. Reading is now a part of the diabetes prevention pilot and this should be actively promoted to address the known risk factors

This section links to the following sections in the JSNA:

Obesity - adult & child

Physical Activity

Common causes of death & disability

References

HM Government (2011). Healthy Lives, Healthy People: a call to action on obesity in England. London, The Stationery Office. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213720/dh_130487.pdf

NHS Choices. Type 2 Diabetes - Treatment. Available at: http://www.nhs.uk/Conditions/diabetes-type2/Pages/treatment.aspx (Accessed 8th March 2016).

NICE (2015). NICE Guidance [NG28]: Type 2 Diabetes in Adults: Management. NICE, London. Available at http://www.nice.org.uk/guidance/ng28 (Accessed 8th March 2016).

Public Health England (2014). Adult obesity and type-2 diabetes. Public Health England. London.

Public Health England. Public Health Outcomes Framework. Available at:  http://www.phoutcomes.info/ [Accessed 8th March 2016].

World Health Organisation (WHO). (2015). Diabetes: Fact Sheet No. 312. Available at: http://www.who.int/mediacentre/factsheets/fs312/en/ (Accessed 8th March 2016).

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