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5. BETTER PREVENTION OF TYPE 2 DIABETES, EARLIER DETECTION OF THE DISEASE AND PREVENTING COMPLICATIONS
5.1. PREVENTION
5.1.1. Much of Type 2 diabetes can be prevented. This is one of the single biggest public health challenges facing Scotland, not least because of the obesity epidemic. It is therefore essential that we develop the best possible means of preventing or delaying the onset of Type 2 diabetes and detecting diabetes as early as possible, to prevent complications. This section of the consultation document looks at possible ways of doing so.
5.1.2. Type 2 diabetes mellitus is the most common type of diabetes and accounts for around 86.7% of cases in Scotland. Type 2 diabetes is commoner in older, less active and overweight individuals but genes have an important role in the development of diabetes and many people with Type 2 diabetes have a family history of the condition. After many years of frustratingly limited success, the way in which genes influence the development of Type 2 diabetes is finally being uncovered. Unlike in rare forms of diabetes such as maturity onset diabetes of the young ( MODY), there are a number of different genetic influences which, along with the environmental factors mentioned above, combine to determine if an individual is likely to develop diabetes.
5.1.3. The International Diabetes Federation: a consensus on Type 2 diabetes prevention concludes that, in planning national measures for the prevention of Type 2 diabetes, people at high risk of developing Type 2 diabetes together with the entire population should be targeted simultaneously with lifestyle modification as the primary goal.
5.2. Promoting healthy lifestyles
5.2.1. The Scottish Diabetes survey found over 80% of people with Type 2 diabetes are overweight or obese. 1 Population-level interventions to stabilise and then reverse obesity trends are probably the single biggest factor in reducing the incidence of Type 2 diabetes.
5.2.2. In June 2008, the Scottish Government published Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity (2008/2011). It outlines plans to invest £56m in initiatives set out in the three year plan which are aimed at supporting people to make healthier choices in what they eat, to build more physical activity into their everyday lives and to maintain or achieve a healthy weight. The actions identified in the plan take a themed approach aimed at early years, schools and school age children, adults and workplaces, older people and communities. The Action Plan also sets out the Government's intention to develop a long-term strategy to tackle the rising obesity epidemic.
5.2.3. The Scottish Government is committed to finding innovative ways to tackle diabetes prevention. For example, the Chief Scientist Office recently contributed £200,000 towards the cost of a research project led by Professor Sandra MacRury, clinical professor at the University of the Highlands and Islands Department of Diabetes and Cardiovascular Science in Inverness, looking at the immediate effects of an oat-rich diet. The aim is to develop new dietary plans which could improve diabetes control, delay the need for people with Type 2 diabetes to start tablets or insulin to control their blood sugar, and potentially reduce the risk of some of the complications of diabetes
5.2.4. The Scottish Government aims to increase and maintain the proportion of physically active people in Scotland, and is setting targets to achieve 50% of adults aged over 16 and 80% of all children aged 16 and under who meet the minimum recommended levels of physical activity by 2022. This is being taken forward by education and awareness programmes such as Free to Dance and Take Life On.
5.2.5. A number of Scottish National Prevention Research Initiative ( NPRI) projects are relevant to the prevention of diabetes. For example, there are current projects focusing on bodyweight and lifestyle management programmes; food purchasing behaviour; access to physical activity opportunities; the contribution of neighbourhood environments to ethnic differences in obesity, physical activity and diet; and economic appraisal of the choice and targeting of lifestyle interventions in deprived populations. In addition, NPRI is now in its third call for proposals with a further £12m available to support cross-disciplinary, translational research to develop or test interventions that have the potential to make a major impact on health at the population level.
5.3. Anticipatory Care
5.3.1. Better Health, Better Care committed the Scottish Government to developing a programme of 'Life Begins' checks. This programme will invite people reaching the age of 40 to conduct a web based self assessment through which they can identify which, if any, personal, family and lifestyle issues could pose a risk for their future health and well being. Where needed, people will be signposted to sources of help and given the option of a telephone consultation with a health adviser. There will be a facility for practices to be informed of the outcome of the self assessment, with patient consent.
5.3.2. As regards diabetes, this means that those at risk of Type 2 diabetes due to family history or because of obesity/lifestyle will have this drawn to their attention at age 40 and will be advised as to how they can reduce their risk and/or be tested for unsuspected diabetes. NHS 24 is currently engaged in developing a robust online self assessment programme, complemented by telephone based assistance that would fulfil this commitment.
5.4. TACKLING HEALTH INEQUALITIES
5.4.1. The Scottish Diabetes Survey and a study led by the University of Edinburgh (Wild et al., 2008) has demonstrated a strong relationship between deprivation and Type 2 diabetes incidence. The results of future analyses of these data will be useful to the diabetes Managed Clinical Networks in reviewing and planning services, as well as to health promotion teams in assessing and planning primary and secondary prevention of diabetes and cardiovascular disease. This growing evidence reinforces the importance of tackling inequalities as highlighted by Better Health, Better Care:
Poor mental and physical health is both a cause and consequence of social, economic and environmental inequalities
Figure 2: Data for Scotland 2008 - Type 2 Diabetes and Deprivation
SIMD = Scottish Index of Multiple Deprivation
5.4.2. The Scottish Ministerial Task Force on Health Inequalities produced a report, Equally Well, that recommended the Government commitment to health checks for all at age 40 should be implemented in ways that build on the Keep Well programme, which targets Cardiovascular disease ( CVD) including diabetes. Equally Well highlights Keep Well health checks (see paragraph 5.6.1). These plans are now being taken forward by the Scottish Government, NHS Health Scotland and NHS Boards.
5.4.3. Equally Well also links people living in deprived areas with chronic health conditions associated with obesity, including Type 2 diabetes. Recommendation 29 states that the Government, NHS Boards and other public sector organisations should take specific steps to encourage the use and enjoyment of greenspace by all, with a view to improving health. Public sector organisations should provide materials, resources and training and evaluation of specific initiatives, such as the prescription of 'greenspace use' by GPs and clinical practitioners.
5.5. Cardiovascular disease
5.5.1. Cardiovascular disease is the major cause of death in diabetes, accounting for some 50% of all diabetes fatalities, and significant levels of disability. Recent collaborative work between the British Heart Foundation, Chest, Heart & Stroke Scotland, Diabetes UK Scotland and the Stroke Association has resulted in the emergence of an informal voluntary sector alliance around cardiovascular issues.
5.5.2. SIGN 97 on risk estimation and prevention of cardiovascular disease is directly relevant to diabetes. It has now been reflected in NHS QIS's draft clinical standards for Coronary Heart Disease ( CHD). Among people with diabetes, mortality from heart disease is increased by 300%, and heart failure is up to four times as likely. Effective treatment leads to a reduction in heart failure of over 50%. Stroke risk is up to four times as likely and effective treatment reduces strokes by more than a third. It is therefore essential to make a link between this Action Plan and the revised Heart Disease and Stroke Action Plan. One way of achieving this link would be through the stroke, diabetes and cardiac MCNs working more closely together.
5.5.3. Nearly 1 in 5 people with diabetes are recorded as current smokers. The Scottish Government has committed £33m over the next three years to NHS smoking cessation services and this year invested £3m in a national smoking cessation pharmacy scheme. The Scottish Government is now focussing on preventing children and young people from starting to smoke in the first place. Scotland's future is smoke-free, a smoking prevention action plan was published in May 2008. Backed by £9m over three years, the plan has led to the Tobacco and Primary Medical Services (Scotland) Bill, which will ban the display of tobacco products and the sale of tobacco from vending machines and will introduce a tobacco retailers registration scheme, which could see retailers lose the right to sell tobacco if they continually flout tobacco sales legislation, such as selling tobacco to under-18s.
5.6. Keep Well Programme and ASSIGN
5.6.1. The Keep Well programme is targeted at people living in deprived communities at high risk of developing cardiovascular disease ( CVD), including diabetes. It undertakes screening of 45-64 year olds living within these communities and aims to shift the focus across the NHS and supporting services from treatment of illness to prevention. By early identification of the risk factors associated with CVD, individuals will be referred on to further services, or prescribed drugs, including statins, to reduce their risk of later poor health outcomes. So far, at least 35,000 people have undergone this assessment. The learning and best practice generated by the programme will be disseminated and implemented across the whole of Scotland as anticipatory care becomes part of the normal offer of the NHS.
5.6.2. The Well North programme builds on the momentum of Keep Well to deliver anticipatory care whilst adapting it to fit a rural setting. These remote and rural areas of Scotland pose specific challenges to the delivery of anticipatory care. Well North currently incorporates six projects across NHS Orkney, Shetland, Grampian, Highland and Western Isles that provide interventions to those at risk of preventable serious ill health. This programme is supported by £750,000 from the Scottish Government.
5.6.3. The ASSIGN Risk Calculator enables anticipatory interventions to be targeted effectively at those most at risk of developing serious illness. It is a risk score that calculates an individual's likelihood of developing CVD over ten years, and therefore suitability to receive advice and intervention. Studies have demonstrated that social deprivation is implicated in the development of CVD. ASSIGN factors in social deprivation and family history to improve its accuracy in Scottish circumstances. It is now available to GPs through the internet and has been embedded in a number of Glasgow GPIT systems. SIGN 97 recommends its use as the preferred risk calculation tool in Scotland.
5.7. Diabetes Awareness Campaigns
5.7.1. Government healthy living campaigns such as Take Life On and Eat Well target the general population with supportive messages and information designed to encourage maintenance or achievement of good dietary and physical activity habits. Currently, there is no evidence to show what impact these campaigns have on population groups at risk of Type 2 diabetes. Campaigns targeting at risk groups are therefore an important part of tackling prevention and complication issues. There is currently no Scottish programme to identify and treat impaired glucose tolerance ( IGT) or impaired fasting glucose; i.e. those at highest risk of Type 2 diabetes. In addition to the risk of diabetes, IGT almost doubles the risk of heart disease.
5.7.2. Over the last three years, Diabetes UK has run two UK-wide campaigns, Measure Up and Silent Assassin, which have focused on raising awareness of diabetes risk. Evaluation of the Measure Up campaign, which targeted people at risk of diabetes by raising awareness of waist measurement as a key risk factor, showed that the campaign generated greater awareness in target groups with 10,000 people being tested for diabetes in Scotland. In 2009, Diabetes UK will be rolling out awareness roadshows across Scotland, which will include opportunities for individual risk measurement.
5.8. SCREENING
5.8.1. In July 2006 the National Screening Committee recommended that screening of the general population for diabetes should not be offered as it fails to meet a number of the Committee's key criteria. It does however recommend the introduction of a Vascular Risk Management Programme for individuals at high risk of developing cardiovascular disease and diabetes.
5.8.2. The most recent work on screening for diabetes undertaken in Scotland includes the Health Technology Assessment led by Professor Norman Waugh of Aberdeen University in 2007. The HTA found that although evidence of the benefits of a diabetes screening programme was growing, the viability of such a programme is still essentially uncertain. This was due in part to the lack of certainty of the optimal screening tool, and the lack of a randomised control trial that could demonstrate that screening would be effective in reducing mortality or morbidity.
5.8.3. The Scottish Public Health Network ( SPHN) is currently conducting a Type 2 Diabetes Needs Assessment with an emphasis on screening and prevention. It is expected that by the time the revised Diabetes Action Plan is published, SPHN will have made recommendations on the way forward for screening and prevention.
ISSUES TO CONSIDER
- How do we encourage the prevention of diabetes?
- How do we target at-risk groups?
- What more could be done to tackle diabetes in deprived areas?
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