Public Health Module Venue Date Unit Public Health

Course Aims WB 3 This unit will: – Explore how common diabetes is; – Familiarise students with the risk factors of diabetes – Explore the efficacy interventions for the prevention and management of diabetes 2 LTPHN/JS © 2010

Outline WB 3 Part I: DIABETES AS A PUBLIC HEALTH PRIORITY 1. 2. 3. 4. What is diabetes? Classifying diabetes Epidemiology - how common is diabetes? Risk factors and consequences Part 2: PREVENTING AND MANAGING DIABETES 1. 2. 3. 4. 5. 3 Primary prevention of diabetes Secondary prevention Screening in diabetes Self care Monitoring diabetes care LTPHN/JS © 2010

WB 5 What is health? 4 WHO Definition ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ Antonovosky: Salutogenic model ‘sense of coherence’ Seedhouse and Duncan: Achievement of potential Empirical Lack of health LTPHN/JS © 2010

WB 6 What is public health? ‘the science and art of preventing disease, prolonging

The wider determinants of health Source: Dahlgreen and Whitehead, G and Whitehead M (1991)

The challenge for public health 7 LTPHN/JS © 2010 WB 7

WB 8 Statistical description of nation’s health Census data Health Inequalities data Infant Mortality

1. What is diabetes? WB 9 Diabetes results from reduced production of the hormone insulin, resistance of body tissues to the effect of insulin, or both. The result is abnormally high levels of glucose in the blood and widespread disturbances to metabolism. 9 LTPHN/JS © 2010

History 10 WB 9 • 30 -90 AD: Diabetes named by Greek Physician Aretaeus: means ‘a flowing through’ to describe its constant thirst, excessive urination and weight loss • Japanese name: 'Shoukachi', the thirst disease • 1600 s: Professor Thomas Willis of Oxford University describes urine in diabetes mellitus as ‘wonderfully sweet’, distinguishing it from diabetes insipidus • 1889: Oskar Minkowski and Joseph von Mering of University of Strasbourg remove a dog’s pancreas - it produces diabetes • 1921: Banting & Best isolate insulin, successfully treats a patient, transforming diabetes to a treatable, chronic condition LTPHN/JS © 2010

The Healthy Body WB 14 1. Glucose, produced from carbohydrates, released into bloodstream 2. The pancreas produces insulin, also released into the bloodstream 3. Insulin triggers liver to take up glucose and turn into glycogen 4. Insulin enables cells to take up glucose Source: Diabetes UK, Diabetes and the Body animation (www. diabetes. org. uk/Guide-to-diabetes/Introduction-to-diabetes/What_is_diabetes/Diabetes-and-the-body/) 11 LTPHN/JS © 2010

2. Classification • 12 The WHO recognises several types of diabetes • Type 1

I. Type 1 Diabetes The pancreas unable to produce insulin WB 16 Accounts for ~15% of diabetes in the UK Mainly diagnosed in children/young adults Characterised by insulin deficiency Symptoms develop quickly 13 LTPHN/JS © 2010

WB 17 In type 1 diabetes, no insulin is available so cells are unable

Symptoms of type 1 diabetes 15 • • Frequent and excessive urination Thirst Dehydration Tiredness Urinary or genital tract [eg thrush] infections Blurred vision Symptoms develop quickly • Can progress to ketoacidotic coma LTPHN/JS © 2010 WB 15

Type 2 diabetes WB 17 • Characterised by insulin resistance, though may also have deficiency [Used to be classified as Non-insulin dependent diabetes (NIDDM) but can require insulin] • Similar acute symptoms to type 1 • Compared with type 1, often develops gradually • Some have no symptoms at diagnosis • Milder forms: can be controlled by diet, and exercise • Accounts for ~85% of diabetes in the UK • Mainly diagnosed in older adults though increasingly seen in younger age groups too 16 LTPHN/JS © 2010

II. Type 2 diabetes Fat deposits affect cells’ insulin (i) sensitivity. They are less

III. Gestational diabetes 18 WB 20 • Excess blood glucose during pregnancy (both diabetes mellitus and impaired glucose regulation) • Increased risk of diabetes related complications in pregnancy • Health consequences for the baby include increased risk of • birth complications: caesarean sections; still births and perinatal deaths • very high birth weight babies • birth defects • obesity and diabetes in the child. • For the mother: • increased long term risk of type 2 diabetes (30% as opposed to 10% in the general population) • higher risk of diabetes-related complications in subsequent pregnancies LTPHN/JS © 2010

IV. Other types WB 22 • Monogenic diabetes • • 1 -2% of all diabetes, affecting 20, 000 -40, 000 in UK Usually develops in under 25 s Due to a single gene mutation Runs in families – affected person has 50% chance of passing on Currently 6 types of monogenic diabetes recognised Some types managed by diet and exercise alone Often initially misdiagnosed as type 1 or type 2 diabetes Diagnosing correctly can help • inform which treatments are most appropriate • give some idea of how the diabetes is likely to progress • affected families understand their risk of diabetes and/or risk to their children 19 LTPHN/JS © 2010

Diabetes insipidus WB 23 • Moderately rare condition - affects 1 in 25, 000 • Symptoms of excessive urination • Distinct from diabetes mellitus: • not related to production or sensitivity to insulin • Urine not sweet • related to function of vasopressin hormone in the pituitary gland 20 LTPHN/JS © 2010

WB 23 Classifying glucose regulation “Healthy” “Diabetic” Normoglycaemia Impaired glucose Diabetic (low risk of regulation (high risk of CVD) diabetes/CVD) (higher risk of FPG: 7. 0 + mmol/l diabetes/ CVD) FPG: ≤ 6. 0 mmol/l FPG: >6 to <7 mmol/l Risk Low risk 21 Glucose levels LTPHN/JS © 2010 Diabetes

WB 12 3. Long term impact of diabetes • Diabetes is an important cause of death and disability • Diabetes is a leading cause of blindness, renal failure and neuropathy in the UK • Life expectancy is reduced on average by 20 years in those with Type 1 diabetes and up to 10 years in Type 2 diabetes 22 LTPHN/JS © 2010

WB 12 Retinopathy Common cause of blindness in people of working age in West Macrovascular 2– 4 x increased risk of CVD, 75% have hypertension Nephropathy 20% of all ESRD Erectile Dysfunction May affect up to 50% 23 LTPHN/JS © 2010 Foot Problems 15% develop foot ulcers; 5– 15% need amputation Source: The Audit Commission. Testing Times. A Review of Diabetes Services in England Wales, 2000.

WB 12 ‘Macrovascular’ complications cardiovasular diseases • Biggest cause of death in diabetes: • 75% of deaths in people with diabetes caused by cardiovascular disease • People with diabetes have: • 2 x risk of death from heart disease • 1. 5 -4 x risk of stroke 24 LTPHN/JS © 2010

WB 13 ‘Microvascular’ complications Nerves (neuropathy): – – affects up to 60 -70% of people with diabetes symptoms include tingling or burning, pain, numbness increases the chance of foot ulcers and limb amputation other conditions e. g. erectile dysfunction Eyes (retinopathy): – biggest cause of blindness in working aged adults in UK – long-term damage to the small blood vessels in the retina – after 15 years of diabetes, ~ 2% of people become blind, and about 10% develop severe visual impairment Kidneys: – Disease detected by protein in the urine – affects 30% of people with diabetes 25 LTPHN/JS © 2010

Deaths from diabetes ~ 2700 death certificates with diabetes as cause of death pa ~26, 000 deaths from the diseases caused by diabetes pa So death certificates underestimate diabetes attributable deaths. Variations by area too: Source: Yorkshire & Humber Public Health Observatory 2008 26 LTPHN/JS © 2010 WB 25

WB 26 Cost of diabetes • Diabetes is a clinical area of high expenditure • eg in one year, October 2007 to September 2008, there were 31. 9 million NHS items prescribed = £ 581. 2 million • ~ 5% of total NHS spend is used for the care of people with diabetes • The growth in expenditure on prescribing for diabetes is greater than any other major clinical area 27 LTPHN/JS © 2010

4. Prevalence of diabetes • Current prevalence • Trends • Models 28 LTPHN/JS ©

WB 25 Global impact • Diabetes accounts for estimated 5. 2% all world mortality • 80% deaths occur in low & middle income countries • Prevalence increasing fastest in these countries Source: WHO 29 LTPHN/JS © 2010

Diabetes prevalence in England • 2. 1 million on diabetes registers • BUT 25% in coronary care have undiagnosed Type 2 DM • Y&H PHO modelling estimates: • another 400, 000+ not diagnosed • The estimated prevalence of diabetes (diagnosed and undiagnosed) is 4. 82% of population of England • prevalence varies by area 30 LTPHN/JS © 2010 WB 27

Trends • Diabetes expected to rise in England to 6. 5% by 2025 31

Diabetes UK Silent Assassin Campaign WB 29 What do these images say to you

5. Risk factors • Why consider risk factors? • Type 1 v 2 33

Type 1 • Highest prevalence in northern European populations • Strong familial link –

WB 31 Relative risks of type 2 diabetes • Population factors: WB • Family history; • Age; • Socioeconomic circumstances; • Ethnicity • Modifiable risk factors • Obesity; • Exercise; • Smoking 35 LTPHN/JS © 2010

WB 32 Obesity • BMI = weight (kg)/height (m)2 • BMI categories: Underweight Normal Overweight Obese Morbidly obese <18. 5 25 -29. 9 30 -39. 9 40+ 18. 5 -24. 9 • In the Nurses Health Study, compared with women with a BMI or 23 or less, diabetes was • nearly 40 times higher with a BMI of 35+ • 20 times higher with a BMI or 30 -34. 9 36 LTPHN/JS © 2010

WB 34 Ashwell shape chart Take Care 37 LTPHN/JS © 2010 OK Take Care

Physical activity, obesity and the risk of diabetes 18. 0 16. 8 16. 0 15. 8 14. 0 13. 0 12. 9 10. 7 10. 0 8. 0 6. 9 6. 3 5. 1 4. 0 5. 4 4. 8 30+ 25 -29. 9 <25 2. 0 0. 0 2. 1 <2. 1 1. 6 2. 1 -4. 6 1. 5 4. 7 -10. 4 1. 6 10. 5 -21. 7 Physical Activity (Metabolic Equivalent Hours/week) 38 LTPHN/JS © 2010 Bo Ma dy Ind ss (kg ex /m ²) Relative risk 12. 0 1. 0 21. 8+ WB 33

WB 34 Age Prevalence of doctor-diagnosed diabetes, by age 39 LTPHN/JS © 2010

WB 35 Ethnicity • In England, compared with the general population, rates of diabetes are: • • 3 -4 x higher Bangladeshi, Pakistani and Indian men 5 x higher in Pakistani women 3 x higher in Bangladeshi and Black Caribbean women 2. 5 in Indian women • When assessing risk of diabetes, need to consider ethnicity, & also need to consider gender 40 LTPHN/JS © 2010

WB 36 Deprivation • Mortality and morbidity are increased by socioeconomic deprivation Age adjusted prevalence of known diabetes by fifths of deprivation score • The complications of diabetes have been shown to be more prevalent in areas of high socioeconomic deprivation J Epidemiol Community Health 2000; 54: 173 -177 41 LTPHN/JS © 2010

Other risk factors WB 37 • Smoking: • small relative risk compared to obesity, but of public health importance given prevalence of smoking, particularly in poorer socioeconomic groups • Physical health problems • Mental health 42 LTPHN/JS © 2010

Diabetes and gender WB 38 • Risk factors affect men and women differently • Risk of death from heart disease linked to diabetes is greater in women than men: • Is diabetes more harmful to women? and/or • Is treatment better for men? and/or? ? • Gestational diabetes: numbers of diabetes cases in women of childbearing age increasing • Risk factors: family history; pre-pregnancy obesity; advanced maternal age; gestational diabetes in previous pregnancy; ethnic background; large baby (≥ 4. 5 kg) in a previous pregnancy; smoking 43 LTPHN/JS © 2010

Part 1 summary WB 40 • Diabetes is a chronic condition – It can lead to CVD, kidney failure, limb amputation and blindness • Type 1 and type 2 diabetes share similar symptoms but different public health implications • Type 2: – 85% of diabetes in UK – Obesity most important modifiable risk factor. – more common in people over 40 years, Pakistani, Bangladeshi, Indian and African Caribbean populations • Women and poorer socioeconomic groups more at risk of diabetes complications and death from diabetes • Problems assessing the health burden of diabetes because: – ~20% with type 2 diabetes remain undiagnosed – diabetes seldom recorded as cause of death but its complications – heart disease, stroke, renal failure – are leading causes of death. 44 LTPHN/JS © 2010

WB 41 Exercise: ‘Westport’ PCT’s local diabetes Needs Assessment • ‘Westport’ PCT needs to understand the current impact of diabetes on its population – prevalence, health consequences and effects on services - and to forecast the impact of diabetes in the future • From what you’ve learnt in the module so far, how would you find out about the impact of diabetes on your local population? • What sources of data could you access? • What information would you collect specifically? Who would you ask? 45 LTPHN/JS © 2010

WB 42 Part 2: Preventing and managing diabetes 1. 2. 3. 4. 5. 46

1. Primary prevention WB 43 • Three strategies for primary prevention- • Upstream- whole population • Midstream- special high risk groups e. g. children, elderly • Downstream- high risk ‘individuals’ • Type 2 prevention Government priority in England: “The NHS will develop, implement and monitor strategies to reduce the risk of developing type 2 diabetes in the population as a whole and to reduce the inequalities in the risk of developing type 2 diabetes. ” Standard 1 of the Diabetes National Service Framework, 2003 47 LTPHN/JS © 2010

Population measures WB 43 • Reducing obesity • Increasing physical activity • Choosing health:

WB 45 Identifying high risk individuals • Why? – Can target interventions to those most at risk • How? – Risk assessment considering » » 49 LTPHN/JS © 2010 Weight (BMI, waist circumference) Blood pressure Cholesterol Blood glucose

NHS Health Check 50 LTPHN/JS © 2010 WB 46

WB 47 Interventions for high risk individuals • • Lifestyle interventions significantly reduce progression rates to diabetes in prediabetic individuals Trials have shown that sustained lifestyle changes in diet and physical activity can reduce the risk of developing type 2 diabetes Study Country Diabetes Prevention Programme (Tuomilehto et al, 2001) Finland 58 DAQing (Pan et al, 1997) China 46 Diabetes prevention programme (Knowler et America al, 2002) 51 % risk reduction LTPHN/JS © 2010 58

Programmes for high risk • Medications & non-drug interventions to: – reduce blood pressure – lower cholesterol (eg statins) – manage blood glucose • Community referrals for programmes on: – exercise – weight management – smoking cessation • Specialist referrals for bariatric surgery? 52 LTPHN/JS © 2010 WB 48

Exercise: theory… WB 48 • Chief Medical officer Report 2004: ‘ 5 a week’ call for action • At least 30 minutes exercise 5 times a week can improve health, prevent diabetes and reduce overweight 53 LTPHN/JS © 2010

…reality? And…people with diabetes less likely to meet exercise recommendations 54 LTPHN/JS © 2010

Exercise 2: Encouraging healthy eating and regular exercise WB 50 target high risk or provide for the whole population? In public health, there is often debate about whether to target high-risk individuals or offer population wide strategies to promote health and prevent disease Think of some of the pros and cons of these contrasting approaches for lifestyle interventions to adopt healthier diets and take more exercise to prevent diabetes 55 LTPHN/JS © 2010

3. Screening WB 53 • Primary prevention – To identify people at increased risk of disease • Secondary prevention – To identify early stages of disease NSC found no evidence to implement national screening for diabetes in UK. Better strategy to: – optimise management of blood pressure and hyperglycaemia in people with known diabetes; and – ensure universal screening for eye disease 56 LTPHN/JS © 2010

4. Self care and self management DESMOND for type 2 diabetes WB 56 • Diabetes Education and Self Management for Ongoing and Newly Diagnosed patients • Group sessions to help new patients to – identify their own health risks – develop behaviour and health goals tailored to their own circumstances • Evaluation found: – greater weight loss & smoking cessation – improvements in beliefs about illness – No change in HBA 1 c 57 LTPHN/JS © 2010

5. Monitoring diabetes care • Why? – To find out if services delivered as intended – To find out whether services reaching groups that need them • How? – Local monitoring, checks, visits, feedback – National data • Monitoring against targets: access • Patient survey: patient experience • Hospital admissions & procedures: outcomes 58 LTPHN/JS © 2010 WB 59

NCHOD admissions and procedures 59 LTPHN/JS © 2010 WB 61

Part 2 summary WB 63 • Type 2 diabetes is preventable • Complications of diabetes can be avoidable • Interventions aim to: – encourage healthy eating and regular exercise – reduce blood pressure, cholesterol and improve glucose regulation – reduce complications • Programmes in England to improve diabetes care focus on identifying high risk individuals, rewarding quality services, screening for retinopathy • Monitoring indicates room for improvement in access and effectiveness 60 LTPHN/JS © 2010

Exercise 3: Shaping your local services WB 64 ‘Westport’ PCT’s public health department has been asked to recommend how Nowhere should develop its diabetes services. • How would you assess the impact of diabetes services provision locally? • From what you’ve learnt in the module, how would you decide on your top priorities for diabetes in your local area? • Think about: – Prevention vs treatment – Evidence based programmes vs learning through doing – National policy priorities and targets 61 LTPHN/JS © 2010