The Mexican Connection
A Special Report 

• People are eating themselves to death and our healthcare systems and governments are failing to stop it
• Obesity and type-2 diabetes (diabesity) kills thousands unnecessarily, and threatens the stability of healthcare systems around the world
• In the UK there is mounting frustration with the diabetes establishment’s failure to make inroads into the prevention and management of diabesity
• Mexico is re-engineering the way primary care delivers its services in order to prevent and reduce the burden of diabesity
• There are lessons from Mexico for healthcare systems challenged by the diabesity epidemic

Behavioural Science provides the key to reducing diabetes

• Behavioural techniques can help reduce the burden of all chronic non-commuicable diseases

• Each year hundreds of millions are spent on diabetes education that fails

• Each year Diabetes UK (DUK) calls on the government to “do more”

• Each year the personal, social and fiscal burden of diabetes increases

• Wandsworth CCG is implementing a new pathway of care for diabetes

• The new pathway of care benefits from behavioural science

• DUK should advocate behavioural techniques that change behaviour

To reverse the diabetes epidemic, and slow the vast and escalating cost of the condition, Diabetes UK (DUK) should promote behavioural science techniques for diabetes education such as those, which are now being implemented by Wandsworth CCG.
 

Current strategies are failing

According to DUK diabetes is the fastest growing health threat of our times, current care models are not working, and the condition is currently estimated to cost the UK £23.7bn annually. This figure is set to rise to £40bn by 2035 if nothing changes.
In August 2015 Barbara Young, CEO of DUK, warned that diabetes is being allowed to spiral out of control. “With a record number of people now living with diabetes in the UK, there is no time to waste: the government must act now,” she said.

The poor state of diabetes education and care in England is leading to avoidable deaths, record rates of complications, and huge costs to the NHS: 1.2 million more people have diabetes now than a decade ago (a 60% increase), and DUK has warned that its cost could, “bankrupt the NHS”. 

DUK, NHS England, and Public Health England (PHE) spend millions on diabetes education, prevention and screening programs, which have failed to dent the burden of the condition.
 

Diabetes

Diabetes is a chronic condition and, if poorly managed, can lead to devastating complications, including blindness, amputations, kidney failure, stroke and early death. To prevent, detect, and slow the progression of complications, best-practice guidelines say that people living with the condition should regularly receive nine checks, which include: weight, blood pressure, eyes, HbA1c, urinary albumin (indicates kidney function), feet, serum cholesterol (level of cholesterol in the blood), smoking, and serum creatinine (indicates kidney function). Official audits of NHS care in England and Wales show that some 33% of people with diabetes do not receive these checks.

Effective education and care save money

Earlier in 2015 Barbara Young said, “Better on-going standards of care will save money, and reduce pressure on NHS resources. It’s about people getting the checks they need at their GP surgery, and giving people the support and education they need to be able to manage their own condition”.

A better approach

DUK needs to adopt and advocate tried and tested behavioural principles that will lower the risk of T2DM, propel those living with T2DM into self-management, and slow the onset of devastating and costly complications.

Behavioural scientists have generated a set of principles about how people engage in judgments and decision-making, and these have been successfully used by policy makers to explore, understand, and explain existing influences on how people behave, especially influences, which are unhelpful, with a view to removing or altering them. 
 

Tried and tested by governments

The Obama Administration in the US uses behavioural techniques to ‘nudge’ people to make better choices for themselves and enhance public policy. Soon after Prime Minister Cameron took office in 2010, he established the “Behavioural Insight Team” to ‘nudge’ the long-term unemployed into work. If it is good for the White House and 10 Downing Street, it should be good enough for DUK.

Cameron’s Nudge team, which is now well established, found that if staff at job centres texted details of vacancies to the unemployed, they achieved little. But, if they added a greeting such as “Hi Pat”, they produced a better response; and if they signed their name, “Best of luck, John”, the unemployed felt they were dealing with a local friend who wanted the best for them, and they would be more inclined to respond positively. Behavioural techniques such as these have been shown to successfully nudge people to take the right decisions about their health.

“The NHS should consider adding such techniques to its armoury of strategies to reduce the burden of diabetes”, says Dr Ana Pokrajac, Diabetes Consultant at West Herts Hospitals NHS Trust, and DUK Clinical Champion for Diabetes.
 

An important precedent - Wandsworth CCG’s new pathway of diabetes care

Wandsworth Clinical Commissioning Group (CCG) has recently adopted personalized behavioural techniques, following similar principles used in the US and UK, to help make dietary and lifestyle changes in their patients living with T2DM. Wandsworth health professionals are developing and implementing a fully automated new pathway of care for diabetes based on behavioural techniques, which they piloted in 2014, to help reduce the burden of the condition. The pathway is expected to go live in November 2015.

Dr Seth Rankin, the co-chair of Wandsworth CCG’s Diabetes Group says, “We are implementing the first phase of a new and innovative pathway of care for people living with T2DM, which we piloted last year. See; "How GPs can improve diabetes outcomes and reduce costs" The new pathway is aimed to change peoples’ behaviours, and to encourage people to eat healthier diets, lose weight, exercise, stop smoking, educate themselves about the condition, regularly monitor their blood and glucose levels, get their kidneys and feet checked regularly, and attend screening sessions. Behaviours that, in time, we expect will lower the risk of T2DM, propel those living with the condition into self-management, and slow the onset of devastating and costly complications”.

“The fully automated pathway, borrows from behavioural science and is predicated on a rich content library of short 60 second videos, which are clustered and sent by GPs directly to peoples’ smart phones. All the videos have been contributed by local Wandsworth CCG health professionals, and most are accompanied by personalized texts”, says Rankin. 

Figure 1 describes Wandsworth CCG’s fully automated new pathway of care for people with T2DM.
 

Figure 1: Wandsworth CCG’s new pathway of care for T2DM

Diabetes education in need of a new pathway of care

In 2015, the DUK’s State of the Nation Report called on CCGs to set themselves performance improvement targets and implement diabetes action plans. The charity also urged CCGs to ensure that all people with diabetes have access to the support they need to manage their condition effectively, and that the local health system is designed to deliver this. 

“The medical community, including commissioning organisations, need more specific guidance about using technology and behavioural techniques if they are to prevent those at risk from getting T2DM, and reduce the burden of diabetes. Examples like the Wandsworth CCG’s initiative illustrates the strong potential of applying these techniques,” says Dr Sufyan Hassain, Darzi Fellow in Clinical Leadership, Specialist Registrar and Honorary Clinical Lecturer in Diabetes, Endocrinology and Metabolism, Imperial College Healthcare NHS Trust, and Imperial College London.

Below, as part of Wandsworth CCG’s new pathway of care, Roni Shavanu Saha, Consultant in Acute Medicine, Diabetes and Endocrinology at St George’s University Hospital, London provides some dietary tips for people with T2DM:

     
          (click on the image to play the video) 

 

Excursus: behavioural techniques 

Behavioural scientists have generated a set of principles about how people engage in judgments and decision-making. DUK can learn from this. For example, we are strongly influenced by who communicates information (see the illustration above about the long- term unemployed); we are motivated by incentives; we are also influenced by comparisons, and by what others do; we go along with pre-set options, for example defaults; our acts are influenced by subconscious cues, and our emotional associations can shape our actions, we seek to live up to our public commitments; and we act in ways that make us feel better about ourselves. Here are some examples, but first we describe nudge theory.
 

Nudge theory

'Nudge' theory was proposed originally in US 'behavioural economics', and was introduced to policy makers in 2008 by Richard Thaler and Cass Sunstein in their book, ‘Nudge: Improving Decisions About Health, Wealth, and Happiness’. The behavioural principles the authors describe have been adapted and applied widely to enable and encourage change in people, and groups, and have been successfully used to motivate people to lose weight, take medications, exercise, and stop smoking. Let us explain.
 

The influence of others

People are influenced by what others do, and by who it is who communicates information. This knowledge is being used in the US to change the health behaviours and decisions people make. Thus, Wandsworth CCG’s new pathway of care for diabetes uses videos of local health professionals to speak directly to people living with T2DM via their smartphones to nudge them into changing their behaviours. The time individuals spend watching the videos, the frequency viewed, and whether they share the videos, can easily be compared with data across the same indices for their peer group, and the comparisons fed back to individuals. By giving people information about their exercise and lifestyle choices relative to others in their peer group nudges them to change their behaviour and become healthier. 
 

Defaults

Nudge strategies have been used successfully to change health behaviours and decisions through the use of defaults. This exploits the insight that people tend to go with the flow of current options (i.e. defaults). Health providers can pre-set options that promote health and wellbeing and reduce costs, requiring those who want to go against the grain to “opt out”. This has been used successfully in the US by the Center for Disease Control and Prevention, which developed guidelines recommending that opt-out HIV screening with no separate written consent be routine in all healthcare settings. 

Defaults have also been successful in presumed consent for organ donation unless someone has opted out. Austria, France, Poland and Portugal have such systems, and 90 to 100% of their citizens are thus donors, compared to only 5 to 30% in countries that do not use the donor default strategy. Also, defaults have been successfully used in preventative care. In the US, doctors nudge their patients toward regular screenings by giving them a default appointment date and time. Patients must opt out of the appointment. 
 

Memories and subconscious cues

Behavioural science tells us that people are influenced by novel, personally relevant examples and explanations, and such knowledge is being successfully used to change people’s health behaviours and decisions. Emotional associations are embedded in peoples’ memories, and invoking these in images and videos shapes peoples’ decisions and behaviours. Cues can be used to encourage people to make healthier choices through reminders. Nudgesize, a smartphone application, reminds its users to get their daily exercise. Reminders have also been used to nudge people to schedule their screening appointments. 
 

Commitment and ego

Another thing we learn from behavioural science is that we seek to be consistent with our public promises and commitments, and we behave in ways that makes us feel better about ourselves. Several websites take advantage of the fact that people want to honour their public commitments. These allow users to commit themselves to achieve certain goals, such as losing weight, exercising, stop smoking, or eating a healthier diet. One example is Stickk.com, a website where users enter into binding commitment contracts by choosing a goal, such as losing weight in a given time, and appointing a referee to confirm the truth or falsity of their reports. Stickk users, who attach stakes to their goals, enter their credit card information, and if a person fails to achieve his goal, then the card is charged for the agreed amount pledged. According to Stickk it has over 56,000 contracts valued at some US$5.5m; 141,003 workouts occurred that might not have otherwise happened, and 1.1m cigarettes were not smoked that otherwise would have been.

According to a 2005 study reported in the Journal of Geriatric Physical Therapy, commitment strategies have significant influence over peoples’ behaviours even without any financial stakes attached. The study described how 84% of exercisers who signed a contract met their goal, compared to only 31% in the control group who did not sign a commitment pledge. This and similar examples suggest that part of the effectiveness of commitment strategies comes from ego, and our desire to be perceived by others as strong willed and consistent. Ego plays a role in the effectiveness of many nudges. 
 

Conclusion: the way forward

The best chance of impacting on the vast and rising incidence and cost of diabetes in the UK lies in the promotion by DUK of behavioural techniques of diabetes education such as those, which are now being implemented by Wandsworth CCG. 

• 16% of Mexico’s population has type-2 diabetes (T2DM) and each year it kills 70,000
• Mexican mothers feed their children sugary beverages from birth and create soda addicts
• In 2014 a national sugar tax on fizzy drinks was introduced, but sales on untaxed sugary beverages increased
• The Carlos Slim Foundation (CSF) takes fundamental action to dent Mexico’s T2DM epidemic
• The CSF collaborates with MIT’s Broad Institute to conduct the largest and most comprehensive genomic study on T2DM in Mexican populations
• Three years later CSF announces the discovery of the first common genetic variant shown to predispose Mexicans to T2DM
• Findings could lead to improved diagnostics and new therapies for T2DM, say experts
• The Broad Institute and the CSF make their genomic studies and other data freely available to scientists worldwide
• Organizations with bureaucratic walls that restrict the free-flow and sharing of knowhow and information significantly impede the advancement of our understanding and management of globally important chronic conditions such as T2DM

Each year, T2DM related complications kill 70,000 Mexicans. In 2015, there were 11m people with diabetes in Mexico - almost 12% of its adult population - projected to rise to some 16m by 2035. Mexico has one of the world’s highest rates of childhood obesity, a significant contributory risk factor of T2DM. The prevalence of overweight or obese children and adolescents between 5 and 19 years is 35%. This is believed to be the result of mother’s feeding their babies sugary drinks: partly because of the lack of clean water, and partly cultural since many Mexicans consider chubby babies to be good. According to Dr. Salvador Villalpando, a childhood obesity specialist at the Federico Gomez Children's Hospital in Mexico City, “about 10% of Mexican children are fed soda from birth to six months, and by the time they reach two it's about 80%." Mexico has become the No. 1 per capita consumer of sugary beverages, with the average person drinking more than 46 gallons per year: nearly 50% more than the average American.
 
Over the last 20 years, the prevalence of T2DM in Mexico, a country with a population of 122 million, has increased rapidly. The Mexican health system is struggling to effectively adapt to the diabetes burden facing the nation. Healthcare spending represents approximately 6% of GDP and is divided near equally between the public and private sectors. The former, supports mostly low-income non-salaried workers, accounting for about 60% of those in work: some 30m. The latter, is an employer-based scheme linked to salaried workers.

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Sugar tax

So acute is the problem of T2DM in Mexico that in January 2014, the government introduced a 10% tax on sugar-sweetened beverages. Research published in the British Medical Journal in 2016 suggests that the tax resulted in a 6% reduction in the purchases of taxed beverages in the first year, increasing to 12% by the end of the second year. The study also reported increases in purchases of untaxed beverages. Findings are disputed by the drinks industry. “Fizzy drinks only account for 5.6% of Mexico's average calorie consumption so can only be a small part of the solution to obesity and diabetes,” says Jorge Terrazas of Anprac; Mexico's bottled drinks industry body.
  

Carlos Slim Foundation and diabetes

The obesity epidemic, aging population and escalating health costs have increasingly strained resources and exacerbated Mexico’s diabetes burden, which the CSF is intent to reduce. In 2010 the Foundation formed an association with MIT’s Broad Institute. With an investment of US$74m it formed the Slim Initiative in Genomic Medicine for the Americas (SIGMA). It was a natural fit because Slim knows just how big data strategies transformed retail businesses and also cancer research and therapies; and the Broad Institute specialises in developing big genomic data sets and making them available to molecular scientists in premier research centres throughout world in order to transform medicine. From its inception SIGMA set out to systematically identify genes underlying diabetes.
 
The development of T2DM depends on complex inheritance-environment interactions along with certain lifestyle behaviors. Previous HealthPad Commentaries have described such complexities. One described the lifetime research endeavors of Professor Sir Steve Bloom, Head of Diabetes, Endocrinology and Metabolism at Imperial College London, on obesity and the gut-brain relationship.
 
SIGMA believed that having access to genomic research undertaken by a network of world class scientists holds out the possibility of discovering fundamental aspects of the biological mechanisms linked to T2DM. And this could form the basis for more effective diagnostics and new and improved therapies for the condition. Until recently, only a select group of specialists had full access to such data. The CSF was also mindful that their relationship with the Broad Institute would help build Mexico’s capacity in genomic medicine.
 

T2DM risk gene found in Latin Americans

A major focus of SIGMA’s 2010 research agenda was to identify the genetic risk factors that contribute to the significantly higher incidence rate of T2DM in Mexico compared with the rest of the world. SIGMA conducted the largest and most comprehensive genomic study to date on T2DM in Mexican populations, which involved scientists at 125 institutions in 40 countries, and resulted in the discovery of the first common genetic variant shown to predispose Latin American’s to T2DM.

Findings show that people who carry the higher risk version of the gene are 25% more likely to have diabetes than those who do not. People who inherit copies of the gene from both parents are 50% more likely to have diabetes. The higher risk-form of the gene is present in half of the people with recent Native American ancestry, including Latin Americans. The elevated frequency of this risk gene in Latin Americans could account for, as much as 20% of the populations’ increased prevalence of T2DM. The gene variant also is found in about 20% of East Asians, but is rare in populations from Europe and Africa.
 

Doing science with one eye closed

"Most genomic research has focused on European or European-derived populations, which is like doing science with one eye closed,” says Eric Lander, Professor of Biology at MIT and President and Founding Director of the Broad Institute, who went on to say, “There are many discoveries that can only be made by studying non-European populations." José Florez, a principal investigator of the SIGMA study adds, “By expanding our search to include samples from Mexico and Latin America, we’ve found one of the strongest genetic risk factors discovered to date, which could illuminate new pathways to target with drugs and a deeper understanding of T2DM.”
 

The impact of evolutionary science on healthcare systems

Roger Kornberg, Professor of Medicine at Stanford University who won the 2006 Nobel Prize in chemistry, "for his studies of the molecular basis of eukaryotic transcription", describes how human genome sequencing and genomic research fundamentally changed the way healthcare is organized and delivered. “Genomic sequencing enables us to identify every component of the body responsible for all life processes. In particular, it enables the identification of components, which are either defective or whose activity we may wish to edit in order to improve a medical condition,” says Kornberg.
 

 

Website helps translating genomic discoveries into therapies

Three years following their discoveries; the CSF launched SIGMA 2 with a mandate to complete its genetic analysis of T2DM, improve diagnostics, and develop therapeutic roadmaps to guide the development of new treatments. SIGMA 2 also planned to ramp up scientific capabilities in both the US, and Mexico by developing a unique resource. In 2016 SIGMA 2 created a website of open-access genetic data on T2DM. The site contains data available from all the SIGMA studies, plus information on major international data networks, including more than 100,000 DNA samples, and the complete results of 28 large genome association studies. Scientists throughout the world have free access to these data.
 

The importance of the open exchange of information

The new web portal represents a breakthrough, because it allows scientists throughout the world access to genetic information, and this is expected to accelerate progress of our understanding and treating diabetes. “The open exchange of information is essential for scientific progress, but it is not always easily achievable. This site not only helps us to overcome this barrier – by allowing access to patient data from around the world – but also will allow directing scientists to the most prevalent genetic risk factors among the populations of Latin America and others who have been underrepresented in large-scale genomic studies,” says Lander who believes that, "It is essential that the benefits of the genomic revolution are accessible to people throughout the Americas and the world."

“The SIGMA project has been a story of total success. Our extraordinary partners, both in Mexico and the US, have made it possible to make historic advances in the understanding of the basic causes of T2DM. We hope that through our contributions we will be able to improve the ways in which the disease is detected, prevented and treated,” says Roberto Tapia-Conyer, CEO of the CSF.
 

Takeaways

 
So, for an investment of US$25m a year for three years SIGMA made a significant discovery, which could beneficially affect the diagnostics and treatment of T2DM, and it also enhanced Mexico’s capacity for genomic research. Such success was due, in part, to the leadership of a 77-year-old Mexican businessman intent on solving problems, who thought globally, partnered with world-class institutions, understood and supported the potential of big data strategies and genomic research, and stood shoulder-to-shoulder with Eric Lander against healthcare organizations, which build and defend bureaucratic walls that significantly restrict the open access of knowhow and data.
 

• Detecting pancreatic cancer early is a significant advance
• 80% of people with pancreatic cancer are diagnosed late
• Only 3% of pancreatic cancer patients survive 5 years after diagnosis
• 12% of pancreatic cancer is associated with obesity
• MD Anderson blood test is 100% accurate at detecting pancreatic cancer
• Urine test 90% accurate at detecting pancreatic cancer
• Both tests could be in the clinic in a few years

Liquid biopsies are poised to detect pancreatic cancer early, which is a significant advance.

This is important because the clinical symptoms arise late in people with this cancer. Eighty per cent of people with the disease are diagnosed when it has already spread, so they are not eligible for surgery to remove the tumour, which currently is the only potential cure. Only about 3% of patients diagnosed with pancreatic cancer survive five years after diagnosis.
 

The pancreas is an organ that sits close behind the stomach, and has two main functions: (i) producing digestive enzymes, which break down food so that it can be absorbed, and (ii) producing insulin, which regulates blood sugar levels. Pancreatic cancer occurs when cells are produced in the pancreas in an uncontrolled fashion. This can lead to a number of health risks. Almost half of all new cases of cancer of the pancreas are diagnosed in people aged 75 and over, and is uncommon in people under 40. This year, an estimated 48,960 adults in the US and some 9,000 in the UK will be diagnosed with pancreatic cancer. It is estimated that 40,560 US deaths, and about 9,000 deaths in the UK from this disease also will occur this year. Those at higher risk include people with a family history of the cancer, heavy smokers, and obese people. There is some suggestion that pancreatic cancer is a risk for people over 50 who are newly diagnosed with diabetes.
 

Pancreatic cancer and diabetes

Type-2 diabetes is considered to be associated with pancreatic cancer, but it is not altogether clear whether diabetes is a risk factor or a symptom. Two studies published in 2011; one in the British Journal of Cancer, and the other in the Annals of Oncology confirm the hypothesis that, “increased BMI and abdominal obesity are associated with increased pancreatic cancer risk.” One of the studies estimates that about 12% of all pancreatic cancers in the UK are attributable to overweight and obesity. Fatty tissue in overweight people produces more hormones and growth factors than those in people of a healthy weight. High levels of some of these hormones, including insulin, which is produced in the pancreas, can increase the risk of pancreatic cancer.

Dr Roni Sharvanu Saha, a consultant in acute medicine, diabetes and endocrinology at St George's Hospital, London, opines on the possible relationship between diabetes treatment and pancreatic cancer, and says that, “the jury is out” about the link. 


            
                

Blood test for pancreatic cancer 

Pancreatic cancer is devastating, it usually shows no signs or symptoms, and presents late. Being able to detect the disease early is considered life enhancing for patients. Scientists from the University of Texas MD Anderson Cancer Center believe they are close to developing a blood test to detect pancreatic cancer, which they describe as "a major advance". Early results, published in 2015 in the journal Nature, showed the test was 100% accurate. Experts said the findings were striking and ingenious, but required refinement before they could be used in the clinic.
 

Major advance

A wall of fat marks the boundary of every cell in the human body. The MD Anderson test hunts for tiny spheres of fat, called exosomes, which are shed by the cancers. Scientists looked for unique signatures of cancer in these fatty exosomes, and noticed that a protein called proteoglycan glypican-1 was found in much higher levels in people with pancreatic cancer. Further blood tests on 270 people showed it was 100% accurate at distinguishing between cancers, other pancreatic disorders and healthy tissue.

The need for such a test is huge. According to Dr Raghu Kalluri, one of the MD Anderson researchers, the test is, "not too far" from the clinic. "We think the ability to identify and isolate cancer exosomes is a major advance and provides the possibility of immensely benefiting our patients," says Kalluri.
 

Urine test for pancreatic cancer

Scientists from Barts Cancer Institute, Queen Mary College, London, have developed a simple urine test to detect pancreatic cancer. The UK-Spanish study, published in Clinical Cancer Research in 2015, showed that out of 1,500 proteins found in the urine samples of 500 people, three were seen to be at much higher levels in the pancreatic cancer patients. This provided a "protein signature" that could identify the most common form of the disease, and distinguish between this cancer and the inflammatory condition chronic pancreatitis, which can be hard to tell apart. The signature was found to be 90% accurate. More research is now planned, and scientists will focus particularly on people whose genes put them at particular risk of pancreatic cancer.
 

Advantages of urine over blood 

Lead researcher, Dr Tatjana Crnogorac-Jurcevic, said: "We've always been keen to develop a diagnostic test in urine as it has several advantages over using blood. It's an inert and far less complex fluid than blood, and can be repeatedly and non-invasively tested.  We're hopeful that a simple, inexpensive test can be developed, and be in clinical use within the next few years."

"For a cancer with no early stage symptoms, it's a huge challenge to diagnose pancreatic cancer sooner, but if we can, then we can make a big difference to survival rates," says co-author and Director of Barts Cancer Institute, Professor Nick Lemoine.
 

Takeaways

Although there is a significant amount of work still to do before these tests appear in clinics, the levels of accuracy reported by the researchers are striking, and suggest that, in principle, a liquid biopsy has been found for this devastating cancer, which is good news for patients suspected of having the disease.