Diabetes: a healthcare threat both global and local in scope

Diabetes has been described as the most serious and challenging health problem in the 21st century.

How serious and how challenging? A recent study in The Lancet concludes that the number of diabetes cases worldwide has nearly quadrupled since 1980.

In Ireland, diabetes cases have more than doubled in the past 15 years, according to a study by researchers at UCC. Some 160,000 people are thought to be diabetic, but because Ireland doesn't have a functioning national register, that is only an estimate.

"Type 2 diabetes is the main driver of the epidemic, accounting for approximately 90 percent of all cases," says clinical endocrinologist Dr Ronan Canavan.

“The increasing burden of diabetes is driven primarily by a number of societal factors. These could include levels of obesity, low levels of physical activity, and widening health inequalities.

“However, he adds, “up to half is due to improving life expectancy, with one in 10 women and one in seven men over 70 having diabetes.”

Canavan is the outgoing clinical lead on the HSE National Clinical Programme for Diabetes and a keynote speaker at the Diabetes Summit within the Future Health Summit.

He explains the differences between Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, and Type 2, which was formerly known as adult or mature onset diabetes.

“Type 1 is a chronic condition in which the body does not produce insulin. It is important not to equate it with type 2 diabetes, as lifestyle issues have nothing to do with its onset. It is caused by an autoimmune process where the body’s immune system turns on the insulin-producing cells in the pancreas.

“In Type 2 diabetes, ‘mature’ used to mean being in your 60s or 70s. In type 2, you produce a lot of insulin but your body does not respond to this insulin properly.”

Here in Ireland, the Irish Longitudinal Study on Ageing found a prevalence of type 2 diabetes of 8.4 per cent in adults aged 50 and up. By 2020, the number of people with diabetes in Ireland is expected to rise by a further 30 per cent from 2010 levels.

Unaware diagnosis

“In the past, we used to believe half of people with diabetes were unaware of the diagnosis,” Canavan says. “But increased awareness in the public and in GP practices has meant we are getting better and diagnosing it before serious symptoms develop.

“The proportion of those undiagnosed is falling to between one in three or one in five. This is still quite high, so continued public education on diabetes is very important.”

Diabetes places a significant burden of care on the individual, healthcare professionals and the wider healthcare system. Up to 10 per cent of the national health budget is being spent on the condition and its complications.

“Diabetes is usually the leading cause of blindness in adults, lower limb amputations and advanced renal disease, resulting in transplantation and dialysis,” Canavan says.

The Longitudinal Study on Ageing reported 26 per cent microvascular complications and 15 per cent macrovascular complications among people over 50 with Type 2 diabetes, he describes.

Steps are being taken to meet the various challenges represented by diabetes.

“In the five years since its establishment,” Canavan says, “the HSE National Clinical Programme for Diabetes has worked to improve the quality, access and cost of services for people with diabetes.”

Eye photo

One of its first objectives was to see the establishment of national diabetic retinopathy screening programme.

Once a year since 2013, every known person with diabetes in Ireland has been invited by Diabeticretinascreen.ieto attend to have a digital photograph of the backs of their eyes taken.

This is to look for the earliest signs of diabetes affecting their eyes, as early detection is the best way to prevent progression to more serious eye damage, one of the long-term consequences of the condition.

Unfortunately, only half of those contacted took up the invitation in 2015. Still, numbers are increasing each year as more patients who do take up the invitation find the service very good.

If any diabetes changes are found, they are followed up by an ophthalmologist with the appropriate treatment. This has been factored into the cost of the national screening programme.

The programme has also developed a model of care for diabetic foot care, and resources have been secured to support increased podiatry services to deliver this nationally.

Another positive development has been the recruitment of diabetes integrated care nurses. They work in the community with GP practices to support the rollout of the Diabetes Cycle of Care for type 2 patients.

Close care

The Diabetes Cycle of Care is seen as a stepping stone that will eventually allow patients with a whole range of chronic diseases to receive more care and support close to where they live rather than having to travel to busy hospital sites.

The introduction of the Diabetes Cycle of Care at the end of 2015 was seen as a further improvement in locally provided diabetic care.

“The establishment of the Diabetes Cycle of Care is to be welcomed in that it is a first step in putting managed prevention and care for diabetes in primary care into widespread practice,” says Canavan.

“However, it is recognised by all stakeholders that this is not the full model of care, and a comprehensive contract with GPs is an essential component to the further development of integrated care.”

There is nothing anyone can do to prevent type 1 diabetes, but some relatively small lifestyle changes in terms of diet and exercise may be all that’s required to ward off the potentially catastrophic long-term impact of type 2.

And for those unfortunate to have already developed type 2 diabetes, the sooner it is managed the better.

Risk factors

“People with a family history of diabetes or premature cardiovascular disease are particularly at risk of developing diabetes over a lifetime,” Canavan advises.

“Additionally, if you have other conditions, such as excess weight, being very sedentary, having high blood pressure, or if you are a woman who after a pregnancy had a baby over 4kg, you should be further assessed for diabetes risk with your GP. And, as risk changes as you age, this should be repeated on a regular basis every few years.

“Your GP may suggest a simple blood test to check for diabetes if you fall into these categories.” See futurehealthsummit.com