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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
 

Breaking the cycle of ineffective diabesity services
 
People are eating themselves to death, and our healthcare systems are failing to stop it. Not more so than in Mexico, where 70% of the population is overweight and 33% obese; both risk factors of type-2 diabetes (T2DM), which kills 70,000 Mexicans each year.
 
The situation is not that different in the UK, which has the highest levels of obesity in Western Europe: 64% of adults in the UK are either overweight or obese, and the incidence rates of diabetes have more than trebled over the past 30 years. Each year, in the UK diabetes kills 22,000 people unnecessarily, and leads to 7,000 avoidable lower limb amputations.
 
The two countries differ however in their respective responses to the epidemic of obesity and diabetes (diabesity), which is the subject of this Commentary. While the UK’s diabetes establishment appears to be locked into a cycle of ineffectiveness, the Fundación Carlos Slim (FCS), is re-engineering the way Mexico’s primary healthcare system delivers its services in order to prevent and reduce the vast and escalating burden of diabesity. The FCS’s endeavours have important lessons for the UK, and indeed other countries battling with a similar epidemic.  
Diabesity a global challenge
Diabesity is no longer a disease of rich countries; it is increasing everywhere. An estimated 422m adults were living with diabetes in 2014, compared to 108m in 1980. The global prevalence (age-standardized) of diabetes has nearly doubled since 1980, rising from 4.7% to 8.5% in the adult population. This reflects an increase in associated risk factors such as being overweight or obese. Uncontrolled diabesity has devastating consequences for health and wellbeing, and it also impacts harshly on the finances of individuals and their families, and the economies of nations.


Mounting frustration with the UK’s diabetes establishment

Although there is consensus about what needs to be done to prevent and enhance the management of obesity and T2DM, and although each year NHS England spends £10.3bn on diabetes care, and £4bn to treat obesity, the prevalence rates of the conditions continue to rise, and the UK’s diabetes establishment seem unable to do anything about it.
 
This ineffectiveness has caused mounting frustration with the diabetes establishment on the part of the UK government’s National Audit Office (NAO) and the Public Accounts Committee (PAC). Numerous official inquiries into adult diabetes services have found no evidence to suggest that T2DM prevention and care are effectively managed, and failure to do so leads to higher costs to the NHS as well as less than adequate support for at risk people and those with the condition.
 
Damning official inquires into adult diabetes services
A 2015 NAO report into adult diabetes services found, “that performance in delivering key care processes and achieving treatment standards [recommended by the National Institute for Health and Care Excellence (NICE)], which help to minimise the risk of diabetes patients developing complications in the future, is no longer improving . . . . There are significant variations across England in delivering key care processes, achieving treatment standards and improving outcomes for diabetes patients, (and)  . . . There are still 22,000 people estimated to be dying each year from diabetes-related causes that could potentially be avoided”. 
The 9 basic processes for diabetes care
The nine NICE recommended basic processes of diabetes care are: (i) blood glucose level measurement (HbA1c), (ii) blood pressure measurement, (iii) cholesterol level measurement, (iv) retinal screening, (v) foot and leg checks, (vi) kidney function testing (urine),  (vii) kidney function testing (blood), (viii) weight check, and (ix) smoking status check.
No strong national leadership and depressingly poor progress
When the Public Accounts Committee (PAC) reported on adult diabetes services in 2012 it found that, "progress in delivering the (NICE) recommended standards of care and in achieving treatment targets has been depressingly poor. There is no strong national leadership, no effective accountability arrangements for commissioners (local healthcare providers), and no appropriate performance incentives for providers." Four years later, a 2016 PAC inquiry into adult diabetes services reported that nothing of significance had changed. The Committee was concerned, “that performance in delivering key care processes and achieving treatment standards is no longer improving”, and it challenged, “the Department of Health, the NHS and Public Health England on their lack of progress in improving patient care and support”.
 
The UK’s cycle of ineffective diabesity services
The NAO and the PAC inquiries appear to have identified a cycle of ineffectiveness among the UK’s diabetes establishment, which manifests itself in a familiar scenario. Here is a stereotypical picture.
 
Each year, after the publication of the latest prevalence data for obesity and diabetes, Diabetes UK, a leading charity, “calls on the government to do more”, the National Clinical Director for Obesity and Diabetes at NHS England makes a defensive statement usually emphasising the positive aspects of diabetes services. NHS England continues to spend £14.3bn each year on the treatment of diabesity. There continues to be little improvement in the 20,000 plus unnecessary annual diabetes-related deaths, and 7,000 avoidable amputations. Diabesity services continue to be inflexible and process, rather than outcomes driven. Nothing of substance changes, prevalence rates and eye-watering costs continue to rise, and no one is accountable.
 
This cycle of ineffectiveness reflects a dearth of national leadership among the diabetes establishment.
 
The Fundación Carlos Slim (FCS) appears successfully to have broken a similar cycle of ineffectiveness for the prevention and treatment of diabesity in Mexico. The Fundación used the weaknesses in Mexico’s primary healthcare system as an opportunity to re-engineer the prevention and treatment of diabesity with an innovative program called Casalud. The name is derived from two Spanish words: “casa” (house) and “salud” (health): ‘Homehealth’.
 
In 2008, when the FCS launched the Casalud program, the primary care services of both the UK and Mexico were similar in in their inflexibility, and in emphasising treatment processes and service delivery rather than value-based healthcare. This emphasis results in weak primary care systems, which contribute to the increased prevalence of diabesity.
 
We will draw lessons from the Casalud program, but before doing so let us consider the grounds for a comparison between the healthcare systems of the UK and Mexico.
 


UK and Mexico compared

In both countries the prevalence of obesity and T2DM are high and increasing. Both governments’ healthcare systems are struggling to effectively cope with the vast and growing burden of diabesity. Mexico’s Seguro Popular, which is roughly equivalent to NHS England, serves about 57m people: which includes 60% - 34m - of Mexico’s poorest non-salaried workers employed in the informal sector. Mexico’s population is younger than the UK’s. The median age of Mexico’s 129m citizens is 29 years, whereas in the UK, which has a population of 65m, the median age is 40 years.
 
Both the UK and Mexico struggle with structural challenges associated with the supply and competence levels of health professionals. These manifest themselves in significant local variations in the effectiveness of diabesity prevention and treatment, and in lengthy waiting times for GP consultations.
 
Annual foot checks in the UK and Mexico
In England for instance, standard annual recommended foot checks for people with diabetes vary as much as 4Xs depending on where you live. Each year 415,000 or 13.3% of people with T2DM do not receive foot checks, which increases their risk of amputation, and fuels the 7,000 avoidable lower limb amputations carried out each year. Similarly in Mexico, 60% of people with diabetes fail to have their feet examined during primary care consultations, and between 86,000 and 134,000 diabetes-related amputations occur each year.
 
Responding to the recent English findings, Professor Jonathan Valabhji, the National Clinical Director for Obesity and Diabetes at NHS England said; “It is very important as many people as possible receive their foot checks at the right time – currently each year 85% of people with diabetes receive these foot checks.”
 

Leadership to break the cycle of ineffective healthcare services
In contrast to the UK’s diabetes establishment, the Casalud program provides strong, well-coordinated national leadership, and effective accountability and performance incentives for local healthcare providers. It does not however, deliver direct healthcare services; these are provided by the state. Instead Casalud concentrates on fostering the implementation and use of innovative technology, which it has designed to enhance patient centred primary care, extend healthcare into communities and homes, encourage self-management, engage in prevention programs, and enhance the competence and capacity of healthcare professionals within Seguro Popular.
 
For the Casalud program to stand a chance of being supported by the Mexican government, and implemented nationally, the FCS understood that it was essential to collect convincing performance data in its pilot program. From its inception therefore, the Casalud program developed and agreed with the relevant healthcare agencies a suite of performance measures, data collection protocols and reporting systems. This helped the Fundación to secure the backing of key national and regional healthcare agencies.
 
The FCS chose a social franchising model for the Casalud program, which uses commercial best practice to achieve socially beneficial ends, rather than profit. This makes the program significantly different to the endeavours of some UK public and non-profit bureaucracies, which provide diabesity services.
Some common aspects of bureaucracies
Here we briefly describe some common aspects of bureaucracies, which suggest that over time, bureaucratic organizations may become ineffective diabesity service providers. Bureaucracies are machine-like organizations characterised by hierarchical authority, a detailed division of labour, and a set of rules and standard procedures, which staff are obliged to follow. Rules provide a means for achieving organisational goals, but the following of the rules sometimes displaces the actual objective of the organisation, and organisational objectives become secondary. This is encouraged by the fact that people in bureaucracies tend to be judged on the basis of observance of rules and not results. For example, in an organisation, say committed to diabetes services, performance may be judged on the basis of whether expenditure has been incurred according to rules and regulations. Thus, expenditure becomes the criterion of performance measurement, and not the results achieved through expenditure. Bureaucracies almost completely avoid public discussion of its techniques, although there may be some discussion of its policies. This secrecy is believed to be necessary to prevent “valuable information” from leaking out, and going to competitors. “Trained incapacity” is a term sometimes applied to bureaucracies to describe training and skills, which have been successful in the past, but are unsuccessful under present changed conditions. Inadequate flexibility, in an evolving environment such as healthcare, will result in ineffectiveness.
 mHealth platform embedded with bespoke tools
The Casalud program avoided bureaucratic traps that result in ineffectiveness by developing a flexible mHeath platform (the use of mobile phones and other wireless technology in medical care) with an embedded suite of proprietary software, which connects patients to health providers, nudges people to self-manage their own health, and to become integral members of local care teams. The platform is used for mobile screening, providing patients with their own individual healthcare dashboards, online healthcare education, supply chain monitoring, standardizing electronic patient records, and big data strategies. It also acts as an entry point for patients, support for health professionals to identify at-risk people, make early diagnosis, and quickly begin diabesity management, and structure follow-up with patients over time.
 


The Casalud program’s successful pilot

In 2009, the FCS began a 3-year pilot of its Casalud program in 7 Mexican states, which resulted in improved patient knowledge about diabesity, enhanced self-management among people with the condition, increased clinician knowledge of diabesity prevention and management, and improved clinical decision-making.
 
The FCS used performance data from its pilot to secure a partnership with the Mexican Ministry of Health to extend the Casalud program to 120 primary care clinics serving 1.3m people across 20 Mexican states - 4 to 10 clinics in each state. Also, the performance data was successful in getting the Casalud program adopted as an integral component of the National Strategy for the Prevention and Control of Pre-obesity, Obesity and Diabetes. So, within three years the Casalud program went from a relatively small charity-backed start-up to a significant component in a nationally supported healthcare system.
 
It is reasonable to assume that this was partly due to the leadership provided by the FCS, and partly due to setting, collecting and reporting appropriate performance indicators. The FCS acted similarly to a lead institution in a commercial endeavour, and successfully recruited key contributing partners who were prepared to share the costs of the program’s national rollout. The FCS covers the cost of all the software development, and the training of healthcare professionals for the Casalud program. All the software is owned by the FCS, and licensed free-of-charge to the Mexican government. The federal government covers the cost of all computer hardware used in participating clinics, and local state governments cover the cost of Casalud’s operations, which include such things as laboratory tests and medications.
 


The 5 components of the Casalud program

To better understand the Casalud program and its contribution to enhanced diabesity services we review its five components: (i) proactive prevention and detection of diabesity, (ii) evidence-based management of diabesity, (iii) supply chain improvements, (iv) capacity-building of healthcare professionals, and (v) patient engagement and empowerment. Each component has an on-going monitoring system associated with it, which informs the FCS on the status of the program’s implementation.
 
1. Proactive prevention and detection of diabesity
Previous attempts in Mexico at community based screening for diabesity have failed. However, the FCS insisted that a national screening strategy was important for reducing the burden of diabesity, but understood its case would need to be supported by appropriate performance data, which would require systematic collection and reporting. To help achieve this the FCS developed two online risk assessment tools, which capture, assess and report data on peoples’ risk factors of diabesity.
 
One of these tools is used in clinics, and the other, which is portable, used in homes and communities. Both screen and categorise people as, (i) healthy, (ii) at risk of diabesity, and (iii) already diagnosed as obese or with T2DM. Screening allows local healthcare professionals to suggest personalised lifestyle changes to individuals either to help them reduce their risk of diabesity or to improve their management of the condition. Each participating clinic has a screening goal. Screening data are collated and reported weekly on a pubic system, which incentivizes the clinics in their screening endeavours.
 
Having a portable device means that populations, which previously did not have access to healthcare are included in the screening. While this increased the number of reported people with diabesity, over time it lowered healthcare costs because early detection reduced the use of urgent care facilities. This proactive component of the Casalud program and the performance data resulted in the support of federal healthcare officials who saw the advantages of using technology to integrate communities, families, and patients into a continuum of care. The tools also extended care to people and communities that previously had little access to healthcare, and encouraged patients to use technology to manage their own health, which health authorities appreciated.
 
2. Evidence-based diabesity management
The second component of the Casalud program is an evidence-based diabesity management system, which is supported by more software developed by the FCS. This includes agreed international best practice protocols for diabesity prevention and management, a digital portfolio for health professionals, electronic monitoring of patients in order to improve the accuracy and reliability of performance measurements and patient data. Such data are used to improve the quality of clinical decision-making.

Examples of the data collected and reported are the percentages of people with T2DM and their corresponding laboratory test results. Casalud’s study found that out of 961,733 patients with T2DM, only 20% had an HbA1c (blood glucose) measurement. Further, only 40.7% of patients with an HbA1c measurement had their HbA1c levels under control (below 7%).  All data are made available at the national, state and clinic levels, and are thereby expected to empower healthcare providers to base their health policy decisions on the areas of most need.
 
3. Supply chain improvement
Mexico like other emerging countries suffers from an inconsistent supply of medicines and laboratory tests, which is a significant obstacle to optimal disease prevention and management. Drug supply decisions in Mexico are centralized and made at a state or federal level. This is different to the UK, and other developed countries.
 
This component of the Casalud program uses a proprietary online information system that standardizes metrics for stock management at the clinic level to improve the supply of medicines and laboratory tests. The software is made available on mobile phones to make it easy for health professionals to ensure that stock levels are adequate for clinics to provide a quality service. In addition, Casalud uses these data to raise awareness with federal and state healthcare officials of inefficiencies in supply chains, which could fuel complications and increase healthcare costs. Prior to Casalud there was no accurate and systematic way to assess and report on the supply of medicines and laboratory tests.
 
4. Capacity building for healthcare professionals
Casalud’s forth component is an interactive platform to develop the capacity of healthcare professionals through online education, which leads to diplomas conferred by national and foreign universities. The FCS partnered with Harvard University’s Joslin Diabetes Center, and Mexico’s National Institute of Medical Sciences and Nutrition to develop courses that certify competence in key areas of diabesity prevention, diagnosis and management. One course is designed to update doctors’ knowledge of diabesity, and the other is a practical course developed by faculty of the Joslin Diabetes Center in which health professionals solve real-life cases to test their knowledge in practical settings.
 
Certificates act as non-monetary incentives for health professionals, and to promote competition between clinics and health professionals. This helps to increase participation in the program, improve the quality of care, encourage openness and transparency, and increase collaboration between clinics.
 
Software developed by the FCS assists local clinics to capture data on the characteristics of the participating healthcare professionals, their baseline knowledge, and improvements after each course. These data are aggregated to choose a clinic of excellence for each state, and a national clinic of excellence; both of which are publicly recognised awards, and help with Casalud’s national rollout strategy.
 
Further, performance data are contributed to the National Strategy for Improving Skills and Capacity of Healthcare Personnel, which obliges all Mexican healthcare institutions to engage in formal online training that is, personalized, linked to a continuing education program, validated by academic institutions and independently monitored. Casalud’s capacity building component fulfils all of these criteria.
 
5. Patient engagement and empowerment
With the help of the Joslin Diabetes Center, the Mayo Clinic, and Mexico’s National Nutrition Institute, this component has two mobile applications, which assess patient engagement, knowledge of diabesity, and confidence and skills in order to help them understand their health, begin to self-monitor their condition, interpret their own results, and implement beneficial lifestyle changes. A specific app for people with T2DM allows them to schedule medicines and appointment reminders, input glucose and weight measurements, and receive immediate personalized feedback and educational messages from health professionals.

However, the FCS changed its approach following evidence from the program’s pilot, which suggested that due to the characteristics of the patient population – elderly, rural, and with limited access to and familiarity with technology – mobile technology alone would not lead to a high percentage of patient engagement. So, Casalud implemented a suite of in-person interactions and activities, which are thought to be more appropriate for the specific patient population.

Such a change may not be necessary in the UK and other developed countries. In the UK for instance, the growth trend in smartphone ownership is present in all age groups, and fastest among 55-64 year olds, which jumped from 39% in 2014 to 50% in 2015. While those aged over 55 are more likely to own a laptop the gap is closing. Among younger age groups, 90% of those aged 16-24 now owns a smartphone.
 


Takeaways

Although the Casalud program has encountered challenges associated with Mexico’s patchy technological infrastructure, entrenched attitudes of some health professionals, and fragmentation and lack of uniformity of its primary healthcare system; the program has been successful; not least because of its flexibility and speed of adjusting to prevailing conditions. In 2015 a Brookings Institution research paper concluded that, “Casalud has made significant strides in transforming care delivery in Mexico”. 

Casalud’s development and implementation continues. It is an innovative program, which employs appropriate technology and evidence-based knowledge to re-engineer Mexico’s public sector primary healthcare system by encouraging patient self-management to reduce the country’s vast and increasing diabesity burden.
 
Casalud provided leadership and seed money to secure financial support from and create consensus between the federal and state governments, and obtain local support from clinics, healthcare professionals and patients. The program is on-going and warrants consideration from the UK’s diabetes establishment, and those of other countries wrestling with the burden of diabesity.
 
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  • It is one of the most serious global health challenges of the 21st century
  • It causes high incidence of morbidity, disability and premature mortality
  • It affects 30% of children and 62% of adults in the UK
  • It costs the UK £47bn a year
  • For 40 years official statistics have under-reported its main cause
  • Doctors have neither been able to reduce nor prevent it
  • Behavioural scientists are well positioned to reduce it
  
A major 21st century health challenge is under-reported for 40 years
 
A 2016 study by the UK’s Behavioural Insight Team (BIT) found that, for the past 40 years, official UK statistics have under-reported the main cause of it. The Office for National Statistics failed to pick up the fact that people consistently under-report the principal cause of it. “Such a large underestimate has misinformed policy debates, and led to less effective strategies to combat it,” says Michael Hallsworth, co-author of the study. Jamie Jenkins, head of health analysis at the Office for National Statistics, replied, “We are actively investigating a range of alternative data sources to improve our understanding of the causes of obesity”.
  
Obesity should be treated like terrorism

Although we know how to prevent obesity, it devastates the lives of millions and costs billions. In the UK obesity affects 33% of primary school children, and 62% of adults. Its prevalence among adults rose from 15% to 26% between 1993 and 2014. In 20 years, obese adults are expected to increase to 73%.
 
The UK spends £640m on programs to prevent obesity. Each year, the NHS spends £8bn treating it, and obesity has the second-largest overall economic impact on the UK; generating an annual loss equivalent to 3% of GDP. 
 
The World Health Organization warns that obesity is, “one of the most serious global public health challenges of the 21st century”. The UK’s Health Secretary says obesity is a “national emergency”, and the UK’s Chief Medical Officer argues that obesity should be treated similarly to “terrorism”.
 
Here we suggest how behavioural science rather than doctors can help to reduce and prevent obesity.
 

Vast, persistent and growing

Although we know how to address obesity, there are few effective interventions in place to reduce it. According to a 2014 McKinsey Global Institute study, the UK Government’s efforts to tackle obesity are, ''too fragmented to be effective'', while investment in its prevention is, ''low given the scale of obesity''. Being obese in childhood has both short and long-term consequences. Once established, obesity is notoriously difficult to treat. This raises the importance of prevention. Obese children are more likely to become obese adults, and thereby have a significantly higher risk of morbidity, disability and premature mortality. The global rise in obesity has led to an urgent call for action, but still its prevalence, which is significant, is rapidly increasing.
 

The incidence of certain cancers is significantly higher in obese people, and is expected to increase 45% in the next two decades. Professor Karol Sikora, a leading cancer expert, describes the association, but says we do not know the reasons why, and Dr Seth Rankin, Founder and CEO of the London Doctors Clinicsuggests that virtually every health problem known to mankind is made worse by obesity:

 

Prof. Karol Sikora - Cancer linked to obesity


Dr Seth Rankin - Can being overweight lead to health problems?
 
 The success and growth of Nudge Units

A previous Commentary drew attention to the fact that obesity is connected with a relationship between the gut and brain. Gut microbiota are important in the development of the brain, and research suggests that an increasing number of different gut microbial species regulate brain functions to cause obesity. Notwithstanding, the UK’s Behavioural Insight Team (BIT), which started life in 2010 as a government policy group known as the "Nudge Unit", revolutionized the way we get people to change their entrenched behaviours, and this has important implications for public policy strategies to reduce and prevent obesity.
 
Under the leadership of David Halpern, the BIT has been very successful and has quadrupled in size since it was spun out of government in 2014. Now a private company with some 60 people, the Nudge Unit permeates almost every area of government policy, and also is working with Bloomberg Philanthropies on a US$42m project to help solve some of the biggest problems facing US cities. The UK’s Revenue and Customs (HMRC) has set up its own nudge unit, and nudge teams are being established throughout the world.
 
The genesis of Nudge Units

It all started in 2008 with the ground-breaking publication on behavioral economics, Nudge: Improving Decisions About Health, Wealth and Happiness, written by US academics Cass Sunstein and Richard Thaler. Their thesis suggests that simply making small changes to the way options are framed and presented to people “nudges” them to change their lifestyles without actually restricting their personal freedoms. Politicians loved the thesis, not least because it was cheap and easy to implement, and ‘Nudge’ became compulsory reading among politicians and civil servants. “Nudge Units” were set up in the White House and in 10 Downing Street to improve public services and save money by tackling previously intractable policy issues.
 
Nudging people to change

The UK’s Nudge Unit has, among other things, signed up an extra 100,000 organ donors a year, persuaded 20% more people to consider switching energy provider, and doubled the number of army applicants. Now it is turning its attention to health and healthcare, and already has implemented behavior change strategies that motivate individuals to initiate and maintain healthier lifestyles. The Unit’s strategies that have demonstrated self-efficacy and self management are examples that can be further incorporated into lifestyle change programs, which help people maintain healthy habits even after a program ends and thereby be a significant factor in reducing and preventing obesity.
 
Takeaway
 
Doctors understand the physiology of obesity, but they do not understand the psychology of people living with it. Doctors are equipped to treat the morbidities and disabilities associated with obesity, but ill-equipped to reduce and prevent it. The sooner the Nudge Unit is tasked with reducing and preventing obesity the better.
 
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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 7th 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.
 

 
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