Search results

Type-2 diabetes will not be prevented by repeating past failures

• England has embarked on a national diabetes prevention programme (DPP)
• In the UK, 64% of adults are classed as being overweight or obese
• Obesity is the main risk factor for type-2 diabetes
• Over the past decade diabetes in the UK has increased by 60% and now affects 4m
• Diabetes care consumes about 10% of the NHS’s annual budget of £116.4bn
• Traditional diabetes care and education fail to dent the UK’s diabetes burden
• The national DPP has got off to a slow start
• Type-2 diabetes will not be prevented by repeating past failures
• Lessons can be learnt from Oklahoma

Should we entrust an expensive national diabetes prevention programme to health officials who are failing?

DIABETES is a chronic disease, which occurs when the pancreas does not produce enough of the hormone insulin, or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood (hyperglycaemia). Type-1 diabetes is characterized by a lack of insulin production. Type-2 diabetes is caused by the body's ineffective use of insulin, and often results from excess body weight and physical inactivity

In the video below Sufyan Hussain describes type-2 diabetes; its propensity among certain ethnic groups, and some of its complications. Dr Hussain is a Darzi Fellow in Clinical Leadership, Specialist Registrar and Honorary Clinical Lecturer in Diabetes, Endocrinology and Metabolism at Imperial College Healthcare NHS Trust and Imperial College London. Also in the video are Richard Lane, former President of DUK who draws attention to pre-diabetes, and a patient with type-2 diabetes who describes his diagnosis and family history.
 

      
       (click on the image to play) 
 

The national diabetes prevention programme (DPP)

In March 2015 NHS England, Public Health England (PHE) and Diabetes UK (DUK) launched the NHS Diabetes Prevention Programme, (DPP), with the objective to limit the number of people developing type-2 diabetes. The DPP is an expensive national initiative expected to enrol up to five million people with blood sugar levels so high that they are at risk of the disease. See: Preventing diabetes in high-risk people.
 
“There are too many people on the cusp of developing type-2 diabetes, and we can change that. The growing body of evidence makes us confident that our national diabetes prevention programme will reduce the numbers of those at risk of going on to develop the debilitating disease,” says Professor Jonathan Valabhji, national clinical director for diabetes and obesity at NHS England, and one of the leaders of the DPP.
 

Eye-watering costs for failure

The UK’s record of diabetes care and prevention is poor. Despite £14bn being spent annually by the NHS on diabetes care, and some £20 million annually by DUK on diabetes education and awareness programmes, over the past 10 years people with diabetes have increased by 60%. Those responsible for diabetes care and support have not been held accountable, but continue to provide care and support that is failing to reduce the devastating personal, social and economic burden of diabetes. As a consequence the situation is becoming grave.
 
The latest figures from DUK suggest that the number of people with diabetes has topped four million - 8% of England’s adult population - and is on course to reach five million in less than a decade. In addition, there are currently 5 million people in England at high risk of developing type-2 diabetes. 64% of adults in the UK are either overweight or obese, which is the principal risk factor of type-2 diabetes. According to Professor Dame Sally Davies, the Chief Medical Officer, soaring rates of obesity pose such a threat that they should be treated as a “national risk” alongside terrorism. 

If nothing changes, diabetes treatment costs alone could bankrupt the NHS. Despite these trends and the poor record of prevention and management, health officials leading the DPP confidently say that the new national programme will make a significant impact on the prevention of type-2 diabetes, and save £3 for every £1 spent. Officials however do not produce figures showing what the upfront costs of the programme will be.
 
Duncan Selbie, CEO of PHE and a leader of the DPP, said: “We know how to lower the risk of developing type-2 diabetes: lose weight, exercise and eat healthily  . . . . PHE’s evidence review shows that supporting people along the way will help them protect their health, and that’s what our prevention programme will do.” In 2015-16, the DPP aims to support up to 10,000 people at risk of type-2 diabetes with “motivational coaches”, paid for by the NHS, to provide advice on weight loss, physical activity and diet.

The Public Accounts Committee takes up the cudgels

The Public Accounts Committee (PAC) has expressed serious criticisms of the way in which the DPP is setting about its task of limiting the number of people who develop type-2 diabetes.   

It has said that the DPP is presenting an, "unduly healthy picture" of the state of diabetes services. "It’s not rocket science to tackle diabetes . . . . The NHS and Department for Health have been too slow in tackling diabetes, both in prevention and treatment . . . . . As a priority, action must be taken to ensure best practice in treatment and education is adopted across the board . . . . Taxpayers must have confidence that support is available when and where it is needed," says Meg Hillier, Chair of the PAC.
 

Not keeping pace

The PAC complained that the DPP’s approach lacked urgency, as some 200,000 people are newly diagnosed with diabetes every year, and it stressed that most people would be shocked to know that around 22,000 people with diabetes still die early every year.
 

Public Accounts Committee’s recommendations

The PAC said that the DPP, “will need to move at pace and at scale to stem the rising number of people with diabetes,” and recommended that by April 2016 the programme’s leaders, “set out a timetable to ramp up participation in the national DPP to 100,000 people a year, set out what it will cost, and how the programme will target those areas with the highest prevalence of diabetes. Public Health England should also set out how its other public health activities, such as marketing campaigns, will contribute to preventing diabetes.” The growing frustration of government officials with diabetes care and support is described in: Diabetes Wars
 
The PAC also expressed concerns about the low numbers of people either at risk of or living with diabetes who actually receive education to help them manage their condition. The committee recommended that the DPP, “develop a better and more flexible range of education support for diabetes patients.” Alternative diabetes educational programmes, which employ behavioural techniques to nudge people to change their diets and lifestyles, adhere to medication and get screened regularly, actually exist, but officials responsible for diabetes education turn a blind eye to these, and continue supporting traditional educational programmes that fail. See: Online video education can reduce the burden of diabetes and DUK and HealthPad agree on the importance of diabetes education
 

The Public Accounts Committee should demand more from the DPP

The PAC is right to recommend that the DPP “quickens its pace and increases its scope”; because, over the past 10 years, the NHS has spent more than £100bn on diabetes treatment alone, and DUK has spent some £200 million on education and awareness programmes, yet diabetes in the UK has increased by 60%.
 
Part of the responsibility for raising awareness and encouraging education among people living with diabetes falls to Diabetes UK, the largest and most influential charity for the condition in the UK. In addition to supporting research the charity is mandated to: (i) “Provide relief for people with diabetes and its related complications and to those who care for them, (ii) Promote the welfare of people with diabetes and its related complications and of those who care for them, and (iii) Advance the understanding of diabetes by education of people with diabetes, the health professionals and others who care for them, and the general public.”
 
Each year DUK spends about £20 million on, (i) raising awareness of diabetes, (ii) supporting self-management of the condition, and (iii) improving the quality of diabetes care. Despite this relatively large spend, DUK only manages to reach a relatively small percentage of the millions of people living with diabetes. For example in 2014, only 0.5% of people with diabetes used the DUK care line, the charity sent information packs to only 1.25% of the people with diabetes, only 0.3% signed up for e-learning courses, and only 0.4% of the 5 million people at risk of type-2 diabetes have used the DUK risk calculator. 
 
The PAC is also right to demand more effective and flexible education programmes to propel people to self-manage their condition. Only 16% of people diagnosed with diabetes are offered traditional educational courses, and only 4% of these actually take up the courses. This suggests that there is a crying need for organizations responsible for diabetes education and awareness programmes to increase their understanding of how to engage people and nudge them to change their diets and lifestyles, and improve their use of online communications technology, which makes servicing any number of patient groups, of any size, in any geography, easy and cheap.

More importance should be given to patient outcomes

The PAC should demand more from the DPP, and recommend that it measures and reports annually on the programme’s success in preventing those at risk of type-2 diabetes from developing the condition. “I’ve been struck again and again by how important measurement is to improving the human condition. You can achieve amazing progress if you set a clear goal and find a measure that will drive progress toward that goal . . . This may seem pretty basic, but it’s amazing to me how often it is not done,” says Bill Gates. An earlier Commentary drew attention to the fact that UK diabetes agencies responsible for spending millions each year on diabetes education and awareness programmes which fail, only report on the distribution of services, rather than on the impact those services have had on patient outcomes, which is the most appropriate way of measuring the programme’s effectiveness. See, The importance of measuring the impact of diabetes care.
 

Oklahoma: America’s fattest city

Contrast England’s national DPP with an American prevention programme developed and led by Mike Cornett, the mayor of Oklahoma City, which is known as the “fattest city in America”. Cornett dealt with the challenge very differently.
 

Rejected doctors’ advice

Spurred on by his own weight-loss regime after discovering he was classed as obese, Mike Cornett wanted to transform Oklahoma City into a place where obesity could no longer thrive. While he was aware of the on going debates among clinicians and medical researchers about the best strategies to prevent type-2 diabetes, Cornett was not convinced that traditional health officials had credible answers. On New Year's Eve 2007, Cornett announced that Oklahoma City was going to go on a diet to lose a collective one million pounds.
 
Cornett did not start his prevention strategy by spending money to review evidence from existing diabetes studies; he did not develop a ‘framework’ to be reviewed and sanctioned by an expert panel of clinicians; he neither initiated primary care pilot projects, nor set up demonstrator sites in GPs’ surgeries; and he did not ask doctors to identify people with non-diabetic hyperglycaemia, defined as having an HbA1c of 42 – 47 mm/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG) of 5.5 - 6.9 mmol/mol.  In contrast, all the above was done by England’s DPP.
 

Losing one million pounds becomes a talking point

Having rejected the help of clinicians and healthcare officials, and without spending any money, Cornett started a website, thiscityisgoingonadiet.com, and encouraged citizens to register, and track how much weight they were losing.
 
His awareness campaign took off: churches set up running clubs, schools discussed diets, companies held contests to lose weight; restaurants competed to offer healthy meals. More importantly, people across the City began discussing obesity, which was a crisis spiralling out of control.  More than 51,000 people, 59% of those over 45, signed up to his website and lost weight. By January 2012, Oklahoma City reached its target of shedding one million pounds.  

Cornett was pleased that people had lost weight, but more importantly, he understood that the challenge was not over - it was just beginning. The hidden success of Cornett’s weight loss campaign was that he had successfully engaged an at-risk population. Obesity became a talking point. Mayor Cornett had successfully nudged a city population to change their diets and lifestyles and lose weight. “The message about nutrition and health penetrated Oklahoma City,” says Cornett.

Today, 30% of people in the central Oklahoma region, which includes Oklahoma City, are still obese. Oklahoma City’s obesity rates, while still rising, have been reduced from 6% to 1% a year.  In the lowest income areas of the City, which have the highest rates of diabetes complications, key indicators of diabetes have been reduced by between 2% and 10% in five years, and the City overall has seen a 3% fall in diabetes related mortality rates.

“Changing the health of a community takes a long time - probably a generation,” says Cornett. On 7^th April 2015, Oklahoma State introduced a law relating to diabetes prevention, which demanded “detailed action plans for battling diabetes with actionable items for consideration by the Legislature including, but not limited to, steps to reduce the impact of diabetes, pre-diabetes, and related diabetes complications.” This would not have happened had it not been for the actions and initiative taken by Mike Cornett.

Diabetes and the built environment

Now that a population was engaged, Cornett asked taxpayers for $777 million to fund projects designed to prevent type-2 diabetes in the long term by rebuilding Oklahoma City around the pedestrian rather than the car. The money was forthcoming and Cornett used it to change Oklahoma’s built environment by developing new parks, installing bicycle lanes, reducing driving lanes and introducing buses, creating a boating district, and building pavements, which had not been built for some 30 years. Recent years have seen growing research interest in the relationships between obesity and the built environment. Today, Oklahoma City is a real-time experiment for what happens when you alter the built environment that affects the way people live and behave. 

Takeaways

Preventing type-2 diabetes will not be achieved by a group of academic clinicians and healthcare officials repeating past failures. Preventing type-2 diabetes entails winning the battle against obesity, reducing poverty, and changing peoples’ diets and lifestyles. To do this you first have to engage people and nudge them to change their behaviour.

If the Secretary of State for Health is serious about preventing type-2 diabetes in the UK he would do well to learn from what Mayor Cornett accomplished.  Having done that, he should enlist the help of Mayor Boris Johnson to replace the current leaders of the national DPP.

Online video education can reduce the burden of diabetes

• UK treatment costs for diabetes are £10bn per year and rising fast
• London CCG adopts video education to reduce the burden of diabetes
• Diabetes educational videos delivered directly to patients’ mobiles
• Enhances patient satisfaction yet reduces face-time with doctors
• Videos are peoples’ preferred way to receive healthcare information
• Videos increase knowledge and self-management, and slows complications
• Videos deliver 10 times the response rate of text and graphics

      


Managing My Diabetes is a new, evidence-based service, which offers a smarter and better way to engage and educate people with type-2 diabetes. It’s delivered by video directly to patients’ mobiles, and aims to significantly dent the eye watering, and rapidly escalating personal, financial and societal costs of this preventable condition. A London CCG is an early adopter. 

Dr Seth Rankin, co-chair of Wandsworth CCG’s Diabetes Group, Managing Partner of Wandsworth Medical Centre, and a long time advocate of the use of video in diabetes education, says, “In traditional doctor-patient consultations, patients often don’t absorb important information, and videos help to redress this. Managing My Diabetes engages patients, and provides them with trusted and convenient video information about their condition, which is a necessary prerequisite for any behavioural change”.

In addition to being the preferred format for patients to receive healthcare information, videos generate responses that are 10-times greater than that generated by text and graphics. Further, unlike health professionals, videos never wear out, they can be dubbed in any language, they’re easily and cheaply updated.
 

Importance of a patient user-base

Once people with diabetes are familiar with the initial Managing My Diabetes service, health providers can easily bolt on additional services to help people further manage their diabetes. This follows the model of digital champions such as Google and Facebook, which succeeded by using a simple core service, which successfully built a user base, and then, and only then, offered more services, thus continuously increasing the familiarity of their users with their services; and in turn the intensity with which they use them. Recently, the Department of Health failed to establish an online doctor-patient user-base for a £31m telehealth project, and it failed, see, Lessons from an axed telehealth project. 

Rankin describes the genesis and benefits of Managing My Diabetes:

      

        (click on the image to play the video) 

Video content library

Currently, there is no easy way for people with diabetes to quickly and easily obtain reliable online answers to their FAQs in video formats that they prefer, and there is no easy method for health professionals to post answers to patients’ questions about diabetes in a convenient online video format. 

At the heart of Managing My Diabetes is a content library of some 250 videos contributed by local health professionals, which address patients’ FAQs about managing their diabetes. Each video is between 60 and 80 seconds in duration, which is the average attention span of people seeking online video healthcare information. All videos are linked to bios of the contributors, which help patients judge the validity of the videos. 

Health professionals can cluster and send videos directly to patients’ mobiles to quickly and efficiently address their questions. Also, patients can rapidly access the entire diabetes video content library at any time, from anywhere on any devise. 

Managing My Diabetes is designed to: (i) enhance the connectivity between local health professionals and patients, (ii) increase the knowledge of diabetes among people with the condition, (iii) encourage self-management, (iv) slow the onset of complications, and (v) reduce face-time with doctors. 

Roni Saha, a consultant in acute medicine, diabetes and endocrinology at St George’s University Hospital, London, who contributed a portfolio of educational videos to Managing My Diabetes, describes risks for pregnant women with diabetes: 

       

     (click on the image to play the video) 
 

Traditional diabetes education has failed 

No one knows the true costs of type-2 diabetes, but its treatment costs alone are estimated to be some £10bn per year, and, in 20 years, expected to increase to £17bn; with diabetes complications costing a further £12bn per year. This highlights the pressing need to reduce the burden of the condition, which can be achieved by effective education. 

Traditional diabetes education that cost millions has failed to reduce the burden of diabetes. According to the National Diabetes Audit, less that 2% of people with diabetes attend any form of structured education. Instead, they regularly search the Internet for healthcare information, and use social media to share information they find. This is carried out at lightning speed, 24-7, 365 days a year. 

Health providers must come to terms with the fact that the balance of power has shifted from traditional providers of diabetes education to people living with the condition who are primarily interested in how education affects their outcomes. Failure to provide this link, leads to people disengaging and losing interest. 
 

What do people with diabetes want? 

Understanding the myths and realities about what patients really want from diabetes education is vital to capturing its value. A 2014 study by HealthPad into the efficacy of using videos in diabetes education concluded that there is a significant unmet need for trusted and convenient video educational material to help people manage their diabetes remotely: see: How GPs can improve diabetes outcomes and reduce costs. 
 

Age factor 

Because 63% of people with type-2 diabetes in England are over 60, a question that must be asked is whether delivering educational videos directly to their mobiles is really appropriate. The HealthPad study suggests that it is, and a 2014 McKinsey & Co survey on patients’ opinions of digital healthcare services agrees. Patients over 50 want digital healthcare services as much as younger counterparts. By 2018 smartphone penetration in the UK is expected to be almost 100%. The over 55s are experiencing the fastest year-on-year smartphone penetration, and the difference in smartphone penetration by age is expected to disappear by 2020, and Internet use has shifted from being exceptional to being commonplace.

Mobile devices are ubiquitous and personal, and competition will continue to drive lower pricing and increase functionality. Managing My Diabetes ensures that people living with diabetes will always be part of the doctor-patient network, which increases the variety; velocity, volume and value of educational information patients can receive.
 

Takeaways

Managing My Diabetes has been developed, tested and adopted by a London CCG. It has also a number of clinical champions. The service is designed to be easily and cost effectively embedded in primary care practices, and can be delivered in any language. 

If Managing My Diabetes is to dent the devastating burden of type-2 diabetes it will require national leadership to encourage CCG’s to adopt it, and health professionals to embrace it. Will NHS England and Diabetes UK play this much needed leadership role? If, in five years time, the burden of type-2 diabetes in England has not been significantly reduced, who will be accountable?