Wednesday 2 September 2015

Epidemic of diabetes threatens to bankrupt the HNS

Bees on an artichoke flower in my vegetable garden

The lives of plants and animals are intriguing, but it is human life that never ceases to provide us with an endless supply of drama and humour. Newspaper headlines are, I think, generally intended to be serious, but the shock factor often becomes ridiculous. Like so many things in life, do not take them too seriously but try to identify the facts behind the scary headlines.

We are told that the number of people in the UK with diabetes has increased by an astounding 60% in ten years. In another twenty years or so we might all have diabetes. If this is true then there must be a very obvious cause. I have previously suggested that the main cause of diabetes is a visit to the doctor.

As usual the message is vicim-blaming. The epidemic is due to us becoming obese (another epidemic) and eating too much sugar. Surely our diet and other aspects of lifestyle cannot have changed so dramatically during such as short time. But obesity, although generally and officially viewed as the sign that the Grim Reaper will shortly visit us, is not the disadvantage made out.

And then there is the warning that this epidemic of diabetes will bring about the bankruptcy of the NHS. What on earth does this mean? Do people actually believe this?

"Bring down the NHS" - how could this possibly happen? How would we possibly replace it? Will we transfer pay for the million people who work in the NHS into welfare unemployment benefits for them? Will the hospitals close down?

First we must ask ourselves, is there really an epidemic of diabetes? Well, we don't know. In fact it is now difficult to know what diabetes is - ask experts to define it! 

Diabetes mellitus (DM) means "plentiful sweet urine". It has been known for a long time, since before chemical testing for glucose, when tasting of the urine was necessary. The WHO gave a clear definition of diabetes in about 1983 and it has never removed this definition. It is "a condition in which a random blood glucose is in excess of 11mmol/l on at least two occasions." 

But there is a continuum of blood glucose, like height or weight, and the problem is to define the cut-off between normal and abnormal (disease state). A cut-off point is decided by a committee (e.g. World Health organisation – WHO) rather than by a bio-scientific marker. In more recent years it has been considered that a cut-off of 11mmol/L is too high and thus too many people with unknown and unexpected diabetes might be missed by medical surveillance. Perhaps a cut-off level of 8.5 mmol/L might be in the public interest, and by applying this the number of people with with diabetes is increased enormously "at a stroke", of the pen of a committee. 

However things have moved on further and now people tell me that they have been diagnosed as having diabetes ("having become a diabetic" to use common but unfortunate language) without any knowledge of blood glucose.

The new measure is not the level of free glucose in the blood, which can vary from minute to minute, but the amount of glucose attached to proteins in the blood, and in particular to haemoglobin. The measure is HbA1c, and it is usually expressed as a percentage  the percentage of haemoglobin in the blood to which glucose is attached. Once again there is no specific demarcation between those with and without diabetes but a continuum, and an arbitrary cut-off is necessary to define the "normal".  

HbA1c has been used for several years as a measure of control of diabetes, but it has now come into use as a method of diagnosis. 

However for the purpose of population screening it is a much more expensive test than measuring glucose. Many responsible for public health suggest that blood glucose is best used for identifying diabetes. Public Health England (PHE) suggests, as quoted in The Guardian (26 August 2015), that 5 million people might have high blood glucose levels. It also suggests that "many of those who become diabetic suffer complications such as blindness and foot amputation". The reality is that "many" is just a tiny proportion, although it is very serious for those afflicted.

There is clearly a great effort being made in the UK, and probably in other countries, to identify as many people as possible with diabetes, with financial rewards for the diagnosing doctors. 

And so a combination of case-finding and redefinition of diabetes to include a much greater proportion of the population has inevitably led to a sudden and great increase in the number of people with diagnosed diabetes - that is, a pseudo-epidemic. It is simply not known whether the true incidence of diabetes is rising.

The reason behind the great effort to identify and treat people with diabetes is to prevent the associated diseases of the circulation. These are:
  • disease of the large arteries (atherosclerosis),  macro-vascular disease. This would lead to heat attack (MI, deaths already reducing dramatically), stroke, and major failure of blood supply to the limbs, possibly resulting in leg amputation;
  • disease of the small arteries, micro-vascular disease. This is more specific for diabetes and it causes damage to the retina (blindness should now be averted by laser therapy), kidney failure (a major problem in ethnic South Asians living in the UK), and damage to the nerves supplying the feet, with subsequent painless ulceration that might result in amputation of a foot or the front part of it.
These micro-vascular diseases occur also in people with Type 1 diabetes and are more closely associated with a high blood glucose. However these conditions affecting only the minority of people diagnosed with Type 2 diabetes.

There are two predictable and significant consequences of the diagnosis of diabetes being applied to an individual. One is worry and the other is an increase personal health insurance premiums. Is early diagnosis by population screening worth-while? 

This was investigated by the UK medical Research Council, in Cambridge. It looked at 15,089 people between the ages of 40 and 69 years, who had a high risk (top 25%) of developing Type 2 diabetes. They were invited to screening and were compared to 4137 people who were not invited. Follow up was for an average of 9.6 years and after this time there was no significant difference in outcome between the two groups.

This lack of benefit of screening has not deterred diabetes evangelism, and indeed population screening continues to expand in a variety of ways. This important research project was effectively a waste of time and it has been ignored (even though it received a prize of the research project of the year).

However the outcome measure in this study was death, and this is easy to measure for a large population sample. If we are concerned about reduction in morbidity (illness) within the population, such as visual deterioration, kidney disease, or foot amputation,  data collection over a period of ten years for almost 20,000 people becomes a very major and a very costly process, unfortunately prohibitively so.

We are therefore dealing with population screening to identify a large number of people with hitherto undiagnosed diabetes knowing that only a very small proportion might benefit, and this precise proportion is not known or predictable. 

We might just remember that Type 1 diabetes is the result of a failure of insulin production by the Islets of Langerhans in the pancreas. Treatment with insulin is essential. A major feature of  Type 2 diabetes is an increased amount of insulin in the blood, but there is resistance to its effect. The nature of insulin resistance is far from fully understood, but it means that insulin production within the body must increase. A high blood sugar will only occur when the limit of insulin production has been reached, in other words a relative rather than absolute deficiency of insulin.

Professor Edwin Gale of Bristol University has suggested that Type 2 diabetes is a disease in search of a definition. He goes on to suggest that the term Type 2 diabetes is not a specific disease as its influence on different people varies greatly. In some it is associated by a number of serious and more specific disease processes, but in others it appears to do no harm. If diabetes is to be defined by blood glucose levels then we would be intellectually more honest if we were to use the term "idiopathic hyperglycaemia", which simply means an elevated blood glucose of unknown cause.

In other words we have a great deal yet to understand about diabetes. Rather than the present overall protocol  approach, further understanding will hopefully lead to a more individualistic approach to people with a high blood sugar.

But what about the economic catastrophe that is predicted? Could diabetes possibly "bankrupt" the NHS? The answer is clearly "No". The UK NHS is strictly cash limited by the government. An increased spending on diabetes will need to be balanced by reduced spending on other aspects of health care, unless the government produces additional funding.

Identifying more people with diabetes does not itself cost any money, apart from to the sufferers who must pay higher insurance premiums and who might experience restrictions on employment. The health costs arise from the regular surveillance of so many people (perhaps 10% of the population) by a doctor, or increasingly by a specialist nurse and a clinical team. The regular assessment includes blood tests, retinal screening, foot inspection, blood pressure control, cholesterol management, pharmaceuticals. These all necessitate recruitment of large numbers of staff, and if part of a national programme these become mandatory. Of course there are continual demands for more staff, especially from pressure groups such as Diabetes UK. 

An increased number of people with diabetes is of great financial benefit to the people who treat diabetes. This is true in a salaried NHS, but even more in a health system in which the physician is paid by item of service. "Patient mongering", increasing the number of patients from previously well population, becomes essential for maintaining and increasing income. As Gale indicates, formal guidelines for the masses is in the financial interests of the providers. We must be careful that health systems are designed for the benefit of the patients rather than for the benefit of the providers of care. 

The management of diabetes is increasingly driven by protocols, rigid guidelines, especially when treatment is nurse-led. This becomes expensive because it is not targeted on those individuals who are at particular risk.

The idea of diabetes detection is that the serious vascular diseases will be reduced by the identification of people with high blood glucose, which would then be followed by intensive and effective treatment. We should expect therefore that if the case-finding is effective, then NHS costs will go down, not up!

It is in the interests of most people that disease incidence should be reduced, and this would include diabetes. Early diagnosis is not prevention. If we wish to reduce the incidence of diabetes and its associations ("complications") then we might try to encourage the consumption of less food. This is generally not a successful venture and it is based on a great oversimplification of body size and shape. An expansion of this subject can be found in the book "Curvology - the origins and power of female body shape" by David Bainbridge.

There is another approach that might be helpful. This is the association between diabetes, obesity and low levels of vitamin D. I will expand on this in a future post.


Simmons RK et al

Screening for type 2 diabetes and population mortality over 10 years (ADDITION- Cambridge): a cluster randomised controlled trial. 
Lancet 2012; 380: 1741-48.

Gale EAM. 

Is Type 2 Diabetes a category error? 
Lancet 2013; 381, 1956-57.

Sunset over Baie de la Somme, France, August 23rd 2015