Dr Suzanne Milligan writes that we do not seem to be heeding the warnings regarding the increase in type II diabetes, and that more needs to be done in terms of screening people who are at risk
On 26 December 2004, a tsunami occurred in the Indian Ocean, which killed approximately 230,000 people in 14 countries. It made headline news. Everyone can remember where they where when they heard about it. Some $7 billion of worldwide aid was donated.
Many people know someone affected by it and no-one ever wants to hear about that level of devastation again. Since then there have been discussions about early warning systems, government collaborations, emergency plans and contingencies to prevent such loss from happening again.
There is another tsunami coming. Metaphorically, the waves will be much bigger than 30 metres high and the shock will read more than 9.3 on the Symbolic Richter scale.
But we have had our early warning and despite us all knowing it is coming, there is no Government plan in place, let alone collaborations. We have no emergency plans and there is certainly not $7 billion of international aid. This tsunami? Type II diabetes.
Obesity
We are aware of the obesity epidemic that is currently taking hold and, of course, obesity is a major risk factor for diabetes. Many people know about healthy diet and lifestyle but few appear to be actually acting on the advice.
Current advertising campaigns regarding food and exercise are in place and while they seem to reach a few people, many are simply either not understanding the importance of the message or are choosing to ignore it.
One wonders if a harder-hitting campaign would be appropriate. Obesity also causes cancer and coronary heart disease, as well as type II diabetes. Perhaps a more shocking warning, such as those on cigarette packets, would now be in order.
This, however, raises the question regarding the ‘Nanny State’. Some critics would argue we should simply just advise people and let them make their own decisions; but, of course, these decisions directly affect the Irish taxpayer with regard to health issues and PSRI contributions.
Other critics would question if we should treat obesity-related, end-stage disease the same way we treat smoking disease. Or should we see them both as preventable illnesses and put the financial pressure back on the patient?
This leads to many ethical questions and, in these cases, doctors differ.
Genetics
There is a genetic discussion as well. Diabetes is more common in African, Afro-Caribbean and Asian people. This leads to the question: should specific racial groups receive earlier counselling for diabetes than the Caucasian Irish population? There are established communities in Ireland, but many are still relatively new and already say they find it difficult to access healthcare for treatment. It seems unlikely that it would be easy for them to present for screening.
Other factors
Some Irish people are at obvious risk. Research would advise screening in certain groups: for instance, those who have a first-degree relative with type II diabetes, anyone with a raised waist measurement (more than 80cm for woman, more than 94cm for a man) and women who had gestational diabetes. But when should these people be screened? And by whom?
These are all valid medical screening options, but the resources are simply not in place to do it.
This only touches on prevention and detection of type II diabetes. What of those patients who already have the disease and do know about it? How can we reduce their complications, morbidity and mortality?
NICE has recently updated its type II diabetes guidelines (1) and has identified many ways to reduce the complications of diabetes. It advises that the first-line treatment of diabetes should be lifestyle changes — reduce weight in the obese patients, stop smoking and increase exercise. These are all very achievable and most of our new diabetics are very able to do this. But, on questioning, they feel it is because they are very shocked to have been diagnosed with diabetes and because they have an intensive discussion with the nurse practitioner.
NICE feels this is very important in diabetes management: a patient-focused, patient-centred approach delivered by a competent health professional seems to give the best results at lifestyle modification. It would be great to have this model rolled out to the whole population; but, again, funding is unlikely. The nurse practitioner has the added benefit of being available for telephone advice and, in doing so, is empowering the diabetic patient to have ownership of the disease and treatment.
NICE advises at least annual monitoring.
Drug treatments
We have a wide range of medications and treatment regimes available to us now and we have guidelines on how to use them. The range of medication is tremendous and with patient determination, the risk of complications, both micro and macro vascular, can be dramatically reduced.
New medications are coming on line and are showing great promise. It is, of course, important to treat co-existing risk factors such as hypertension (to keep BP below 140/80 or 130/80 with complications), hypercholesterolemia and smoking.
The current model
As a GP in the catchment area of a large tertiary hospital, most of our diabetic patients are seen yearly by that hospital. They go about two weeks in advance of their visit for fasting blood tests and are reviewed at the full clinic. Here they are seen by the nurse, who discusses their blood sugar diary, takes their observations and chats about any concerns they may have before they are seen by the doctor for examination. They also have retinal photography, albumin/creatine ratio measurement, foot imprints and lower limb dopplers, if required. This is gold-standard therapy; the problem is it only happens once per year. Yearly monitoring is the minimum standard set out by NICE, but with the massive increase in type II diabetes that is on the way, should we try to find other alternatives before this service reaches saturation point?
Full of enthusiasm following a recent diabetes course, my nurse and I wrote to both of our local hospitals asking if we could duplicate their yearly service in the community — perhaps three or four clinics annually, ensuring the patients would be seen at least three times per year. We had great support from one local consultant.
Budget cuts
As a fully computerised practice, we had no difficulty in identifying our type II diabetic patients and we contacted them for their opinion. They were all very keen to take up such a service. Then, the budget cuts occurred. There simply was no money in the HSE for prevention clinics in GP for diabetes, or anything else.
We are now left with an evidenced-based-protocol, which is ready to go, a nurse and doctor, who are fully up-to-date, and a database of patients who are keen to attend.
Unfortunately, no-one has the money to pay for it.
This is an obvious cost-saver to the HSE, both in prevention of complications of type II diabetes (expensive eye surgery, amputations, reduction of disability) and being very simple to set up. It would run well, as GPs are ideally placed to promote health.
Screening for diabetes is prevalent in our practice. We do a lot of health screening and have many private patients who present for a full health screen. This has fasting blood tests as part of the screen and all people are checked for diabetes with fasting blood glucose. If this shows a high level, we would then arrange for (or do) an oral glucose tolerance test for these patients and, if positive, refer them to the hospital for initial diagnosis and assessment.
Either through health screening or just by fasting blood tests, we would diagnose approximately six-eight new type II diabetics per year. Obviously, if we were to look at all the risk factors and target these patients, we could identify a lot more. This is an area in which we should be investing.
Public awareness
Awareness campaigns would also be effective. Obesity is on the rise; few people are aware that five half-hour walking sessions weekly reduces the risk of diabetes and cardiovascular disease. This is a simple change and can be easily managed by most patients.
Many of our patients who come for screening are amazed to find their cholesterol and fasting blood glucose are high. An intensive month of diet and exercise later, and they are astonished at the results. Many do keep it up and we keep an eye on them every six months.
The Quality Outcomes Framework (2) stated that GPs are ideally placed to do this type of prevention. With the correct funding (and a good nurse), we could identify and assess the at-risk patients and do health promotion and disease prevention at an early stage.
Impending tsunami
So, we are aware of what is coming; this is our early warning. We can reduce the consequences of diabetes effectively, once it is diagnosed. But the best way is to reduce the incidence. Screening and case identification will now stop this impending tsunami.
Call it what you will — tsunami, epidemic or problem — it is coming and the name is irrelevant.
References
1. NICE type 2 Diabetes. The Management of Type 2 Diabetes, May 2009 (2updated April 2010)
2. Department of Health: Quality Outcomes Framework
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