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  • Obesity is one of the most serious global public health challenges of the 21st century and a major cause of type-2 diabetes (T2DM), a life-threatening illness, which costs billions
  • 60% of adults in the UK are either overweight or obese, 74% in the US
  • Low calorie diets and exercise are difficult to sustain and therefore tend to fail as treatment options 
  • Conventional treatments for T2DM have failed to dent the vast and escalating burden of the condition, so interest is increasing in alternative treatment options
  • Bariatric (stomach reduction) surgery is a therapy for obesity, which has been shown to “cure” T2DM
  • In 2016, 45 international health organizations called for bariatric surgery as a treatment for T2DM
  • Is bariatric surgery the biggest step forward in T2DM treatment in 100 years?
 

Weight loss surgery to treat T2DM


It is five minutes to midnight for healthcare systems struggling in vein to reduce the vast and escalating burden of type-2 diabetes (T2DM). Doing more of the same is no longer an option. Given the lack of alternatives, experts are calling for an increase in bariatric surgery because it has been shown to “cure” T2DM.
 
Bariatric surgery not only reduces weight, it also improves glycemic control by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion with a consequent reduction in the symptoms of T2DM.
 
In the video below Kenneth D’Cruz, Senior Consultant Gastroenterological Surgeon at Narayana Health, India describes bariatric surgery, which refers to a range of procedures including gastric bypassgastric sleeve, gastric band, and gastric balloon. Such procedures are often performed to limit the amount of food that an individual can consume, and are mainly used to treat those with a body mass index (BMI) of above 40, and in some cases where BMI is between 30 and 40, if the patient has additional health problems such as T2DM.
 
 
Epidemiology of obesity

Overweight and obesity are principal risk factors of T2DM. In the UK, the number of people classified as obese has doubled over the past 20 years and continues to rise. According to data from the 2014 Health Survey for England, 24% of adults in England are obese and a further 36% are overweight. In 2015, there were 440,288 admissions to England's hospitals for which obesity was the main reason or a secondary factor.
 
Data from the National Child Measurement Programme (NCMP), suggest 10% of children in the UK are obese by the time they start primary school, and 25% are so by the time they finish. 6% of people in the UK are living with diabetes of which 90% have T2DM. Over the past decade the incidence rate of T2DM has increased by 65%.
 
The situation is similar in the US, where 36% of adults are obese, and 6.3% have extreme obesity. Almost 74% of adults are considered either overweight or obese. Over the past 30 years, childhood obesity has more than doubled, and it has quadrupled in adolescents. The percentage of children who were obese increased from 7% in 1980 to nearly 18% in 2012. 9.3% of people in the US are living with diabetes.
 
The World Health Organization warns that obesity is, “one of the most serious global public health challenges of the 21st century”.
 
Causes of obesity

There are many complex behavioural and societal factors that combine to contribute to the causes of obesity. At its simplest, the body needs a certain amount of energy (calories) from food to keep up basic life functions. When people consume more calories than they burn, their energy balance tips toward weight gain, excess weight, and obesity. In the videos below Mohammed Hankir, Department of Medicine, University of Leipzig, Germany, describes what causes obesity, and the relationship between obesity and T2DM:
 
What are the causes of obesity?
 
What is the relationship between obesity and type-2 diabetes?
 
The cost of diabesity

Obesity costs the UK £47bn every year. The medical care costs alone for obesity in the US are estimated to be more than US$147bn. Diabetes treatment and indirect medical costs run to £10.3bn in the UK and US$176bn in the US, representing significant increases over the past five years. The medical costs for an individual with diabetes are typically 2.5 times higher than for someone without the disease. As prevalence of obesity increases these costs will rapidly rise.
 
T2DM prevention and treatment

NHS England, Public Health England and Diabetes UK’s National Diabetes Prevention Program is based upon diet and exercise-induced weight loss, which sometimes remedies insulin resistance. For obese people dietary and lifestyle therapies have limited short-term and almost non-existent long-term success records. According to Professor John Wilding, Head of the Department of Obesity and Endocrinology at the University of Liverpool, UK; the problem with low calorie diets, “is that most people will lose weight, but most people will also regain much of that weight that has been lost.” The UK’s National Institute of Health and Clinical Excellence (NICE) does not support the routine use of low calorie diets.
 
Once an overweight or obese person has T2DM the stakes change. With the limited success of conventional medical therapies, bariatric surgery has become an increasingly popular treatment in the war against obesity and latterly also for T2DM. The 2014 UK National Bariatric Surgery Registry reported that there is good evidence from randomised controlled studies that surgery is superior to medical therapy in improving diabetes control and metabolic syndrome. Surgery lowers the number of hypoglycaemic medications needed, including some people no longer needing insulin. It also means many people living with T2DM going into remission, and it markedly lowers the incidence of T2DM compared to matched-patients not having surgery.
 
NICE guidelines for bariatric surgery as a therapy for diabesity

Concerned about the rising prevalence of diabesity (obesity and diabetes) and the limited success of conventional strategies, in 2011, the International Diabetes Federation endorsed bariatric surgery as a T2DM treatment for obese people. The Federation’s endorsement is a validation of research and medical experience showing that surgery to reduce food intake can alter the biochemistry of the entire body. It also marked the beginning of a major new assault on diabetes.

In 2014, NICE introduced guidelines for bariatric surgery as a treatment option for obese adults, and suggested that it would greatly help T2DM. Current NICE guidelines state that bariatric surgery should be offered to anyone who is morbidly obese (a BMI of 40 or over), to those with a BMI over 35 if they have another condition, such as T2DM, and to those with a BMI of at least 30 with a recent diagnosis of diabetes.
 
In the UK only about 6,500 people each year have bariatric surgery. This is significantly lower than other European countries, which perform on average about 50,000 stomach reduction surgeries each year. Under the NICE guidelines, up to 2m people would be eligible for free bariatric surgery on the NHS, which would cost the taxpayer £12bn.

 
Biggest breakthrough in diabetes care since the introduction of insulin
 
In 2016 a review written by a group of researchers led by David Cummings, an endocrinologist at the University of Washington set out guidelines for bariatric surgery as a treatment option for diabetes. Francesco Rubino, one of the experts behind the guidelines and professor of metabolic and bariatric surgery at King's College London, said: “This is the closest that we have ever been to a cure for diabetes. It is the most powerful treatment to date.” Other doctors who drew up the guidelines said such changes could amount to the most significant breakthrough in diabetes care since the introduction of insulin in the 1920s.
 
The modern Roux-en-Y gastric bypass

The ‘gold standard’ bariatric surgical procedure is the Roux-en-Y Gastric Bypass, which is the most commonly performed bariatric procedure worldwide, named after a 19th century Swiss surgeon César Roux, who first performed the surgery to reroute the small intestine. The modern version of the procedure involves reducing the stomach to a little pouch, to curb eating and appetite, and then connecting that pouch to a lower section of the intestine. By using less of the intestine, fewer nutrients are absorbed, and the patient loses weight.
 
Until recently it has been poorly understood why, after bariatric surgery, a significant proportion of patients with T2DM leave hospital either needing no insulin, or lower doses, before ever losing any weight. Re-plumbing the GI-tract appears to reprogram the body’s hormones and resets its metabolism.

 
Advances in bariatric surgery

Thirty years ago there was little interest in bariatric surgery, which was risky, and not widely practiced. It involved a large, bloody incision, the prising apart of the heavy, fatty abdominal walls with metal arms, which then had to be held in place while the surgeon carried out procedures deep in the gut. Patient recovery times were long, and the risk of complications high.

By the first decade of the 21st century, when obesity became an epidemic in advanced economies the relationship between bariatric surgery and T2DM was given more attention. The medical device industry developed new surgical tools to facilitate blood free minimally invasive procedures for obese people, but researchers were still struggling to understand why bariatric surgery “cured” diabetes.

 
Understanding why bariatric surgery cures diabetes

One of the scientists to discover why bariatric surgery cures T2DM is Blandine Laferrère, an endocrinologist at the New York Obesity Nutrition Research Center at St. Luke’s. Our gut hormone ghrelin signals to our brain that we are hungry and to start eating. Receptors in out GI tract signal to our brain that we are full and to stop eating. In obese people such signalling malfunctions, and leaves them perpetually hungry. According to Laferrère, “It just happened that the surgeons did this type of surgery for weight loss, and that turned out to have a spectacular effect on the remission of T2DM.

Further research was undertaken by Laferrère and influenced by Werner Creutzfeldt, a German doctor who published work on gut hormones that increased stimulation of insulin secretion, which he called an “incretin effect”. According to Laferrère, bariatric surgery, rather than actual weight loss, stimulates the incretin effect, which boosts the production of insulin while lowering the symptoms of diabetes. She concluded that the surgery itself triggered the hormone network, which diet-induced weight loss could not provide.
 
Takeaways

Scientists claim that bariatric surgery is the biggest step forward in diabetes treatment in 100 years, and suggest we are no longer talking about the treatment of obesity, but treatment of diabetes.
 
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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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  • Obesity is common, serious and costly
  • Obese adults in the UK will soar by a staggering 73% to 26m by 2030
  • Obesity generates an annual loss equivalent to 3% of the UK’s GDP
  • Obesity cost NHS England £8bn in 2015
  • The obesity epidemic will only get worse unless we take effective action
  • Innovative research to control appetite could provide a cheap and scalable answer to the obesity epidemic
  • The UK’s obesity crisis should learn from the way AIDS was tackled 

Can the obesity epidemic learn from the way Aids was tackled?
 
Obesity is a common chronic health challenge, which is serious and costly.It is one of the biggest risk factors for type-2 diabetes (T2DM) and together - obesity and T2DM - form a rapidly growing global diabesity epidemic, which today affects some 9m people in England.
 
Experts forecast the incidence rate of obesity will rise sharply, and bankrupt the NHS. Conventional strategies to reduce obesity and prevent T2DM have failed. According to the Mayo Clinic it is common to regain weight no matter what weight loss treatment methods you try, and you might even regain weight after weight-loss surgery. This Commentary suggests that extra resources are urgently needed to accelerate and broaden innovative obesity research.
  
Efforts to tackle obesity are low priority and fragmented
 
Overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance. Risks of coronary heart disease, ischemic stroke, and T2DM increase steadily with raised body mass index (BMI). High BMI also increases the risk of osteoarthritis; sleep apnoea, gallbladder disease, and some cancers. Cancer Research UK predicts that obesity related cancers are expected to increase 45% in the next two decades, causing 700,000 new cases of cancer. Mortality rates will increase with increasing degrees of obesity. It is therefore important that obesity is treated aggressively. According to a 2014 McKinsey Global Institute study, the UK’s Government efforts to tackle obesity are ''too fragmented to be effective'', while investment in obesity prevention is ''relatively low given the scale of the problem''.
 
A multi-generational problem
 
The 2014 Health Survey found that 61.7% of adults in England (16 years or over) are either overweight or obese, and the prevalence of obesity among adults rose from 14.9% to 25.6% between 1993 and 2014. The number of obese adults in the UK is forecast to soar by a staggering 73% to 26m over the next 20 years.

In 2014-15, there were 440,288 hospital admissions in England due to obesity: 10 times higher than the 40,741 recorded in 2004-5. In England one in five children in their first year at school, and one in three in year 6 are obese or overweight. Also, in the past 10 years there has been a doubling of children admitted to hospital for obesity. Over the past three years 2,015 overweight youngsters needed hospital treatment, and 43 of these have had to undergo weight-loss surgery to reduce the size of their stomachs. Today, diabesity is a multi-generational problem, which suggests that far worse is still to come.
 
Costs and spends
 
The UK spends less than £638 million a year on obesity prevention programs - about 1% of the country's social cost of obesity. But the NHS spends about £8bn a year on the treatment costs of conditions related to being overweight or obese and a further £10bn on diabetes.
 
Obesity is a greater burden on the UK’s economy than armed violence, war and terrorism, costing the country nearly £47bn a year, the 2014 McKinsey study found. Obesity has the second-largest economic impact on the UK behind smoking, generating an annual loss equivalent to 3% of GDP. The current rate of obesity and overweight conditions suggest the cost to NHS England alone could increase from £8bn in 2015 to between £10bn and £12bn in 2020.

 
19th century technologies for a 21st pandemic
 
A year after the publication of the McKinsey study, the UK government launched a national Diabetes Prevention Program (DPP) led by NHS England, Public Health England (PHE), and the charity Diabetes UK (DUK). The program offers people at risk of T2DM an intensive personalised course in weight loss, physical activity and diet, comprising of 13 one-to-one, two-hour sessions, spread over nine months, and is expected to significantly reduce the estimated five million overweight and obese people in England, and thereby prevent them from developing T2DM. A previous Commentary predicted that the DPP would fail because it is using a 19th century labour intensive method to address a 21st epidemic.
 
This suggests that the diabesity epidemic will only get worse unless we take more urgent and effective action. A view supported by Majid Ezzati, Professor of Global Environmental Health at Imperial College, London, and the senior author of the most comprehensive review of obesity ever undertaken, and published in The Lancet in April 2016. According to Ezzati, “The epidemic of severe obesity is too extensive to be tackled with medications such as blood pressure lowering drugs or diabetes treatments alone, or with a few extra bike lanes”.

 
Radical action: weight loss surgery
 
The gravity of the UK’s obesity epidemic is demonstrated by the National Institute for Health and Care Excellence (Nice) 2016 suggestion to lower the threshold at which overweight people are offered weight loss surgery. The UK lags behind other European countries in this regard, and experts argue that lowering the threshold would mean the number of people who qualify for weight loss surgery would increase significantly.

According to a report prepared by English surgeons, weight-loss surgery would make people healthier and save the NHS money. The report concluded that after weight loss surgery obese people are 70% less likely to have a heart attack, those with T2DM are nine times more likely to see major improvements in their condition, and also the surgery has a positive effect on angina and sleep apnoea. If all the 1.4m most severely obese people in the UK had weight loss surgery, which costs the NHS around £6,000 per operation, the total cost would be £8.4bn.

 
Weight loss surgery and the brain
 
Initially it was thought that weight-loss surgery worked by reducing the amount of food that can be held by the stomach. However, some patients were found to have elevated levels of satiety hormones, the chemical signals released by the gut to control digestion and hunger cravings in the brain. Patients who had undergone surgery were also found to prefer less fatty foods, which supports the thesis that the hormones also change the patients’ desire to eat, and reinforce the gut brain relationship. This finding reinforces the important link between the gut and the brain on which some of the most promising obesity research is predicated.
 
Gut brain relationship
 
Dr Syed Sufyan Hussain, Darzi Fellow in Clinical Leadership, Specialist Registrar and Honorary Clinical Lecturer in Diabetes, Endocrinology and Metabolism at Imperial College London describes the gut-brain relationship and explains why we eat and why we stop eating:
 

 
Cheap, safe and scalable treatment for obesity
 
The person who has spent most of his professional life searching for cheap, safe and scalable alternatives to weight loss surgery and ineffective weight loss therapies is Professor Sir Steve Bloom, Head of Diabetes, Endocrinology and Metabolism at Imperial College London. Bloom believes that the answer to the UK’s obesity epidemic lies in the gut-brain relationship, and is working on two innovative methods of appetite control, which he and his colleagues believe could significantly reduce the burden of obesity.
 
Method 1: an implantable microchip
 
One method is comprised of a small implantable microchip attached to the vagus nerve to suppress appetite in a natural way. The chip reads and processes both electrical and chemical signatures of appetite within the vagus nerve, and then sends electrical signals to the brain to either reduce or stop eating. Bloom has proven the method’s concept, and in 2013 was awarded €7m from the European Research Council to continue his research. Early findings suggest that chemical rather than electrical impulses are more selective and precise, and the chip reduces both consumption and hunger pangs. All things being equal, it will take another 10 years before this treatment gets to market.
 
Method 2: naturally occurring hormones
 
Bloom is also working on another method to treat obesity, which uses naturally occurring hormones that reduce appetite. Early clinical studies suggest that people will consume 13% fewer calories when they eat a meal after taking the hormones. In 2013 Bloom received £2m from the Medical Research Council to develop this research. One of the significant challenges he faces is hormones normally last only a few minutes in the human body. To overcome this Bloom and his colleagues have had to develop versions of the hormones that can last up to a week before they start breaking down. This suggests that patients could take a single weekly injection to control their appetites. Another approach would be to develop a device, which delivers the hormones continuously. While promising, this method too will take 10 years to get to market.
 
Takeaway: treat obesity the same as Aids
 
Bloom believes that if we approached obesity as we did Aids, the time to develop a cheap, effective and scalable drug for weight control could be cut by half. "The obesity pandemic is the biggest disease that has hit mankind ever in terms  [of] numbers. It is killing more people than anything else has ever killed, . . . . . . . in terms of disease [there are] more deaths from obesity than anything we have known about. The time needed to develop an effective drug could be cut by more than half if conservative checks and balances were loosened. I think we might need to treat obesity in a hurry, and we are being held up. The Aids lobby forced Aids’ drugs on to the market before they had finished testing, but they turned out to be useful and lives were saved. Something similar should be considered for obesity,” says Bloom.
 
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  • National diabetes prevention program (DPP) uses 19th century methods
  • 60% of adults in England are either overweight or obese
  • 5m adults in the UK are at risk of developing T2DM
  • T2DM devastates the lives of millions and costs billions to treat
  • NHS to offer personal trainers to obese people at risk of T2DM
  • There is no evidence that exercise alone can reduce obesity
  • Public Accounts Committee warns that the DPP is insufficient
 
Will the UK’s diabetes prevention program work?
 
Should we entrust the UK’s clinical establishment with preventing type-2 diabetes (T2DM)?

In March 2015 a consortium spearheaded by NHS England, Public Health England (PHE) and Diabetes UK (DUK) - the UK’s clinical establishment - launched the Diabetes Prevention Programme (DPP). A year later, it has come up with Healthier You, an evidence-based program which it hopes will make a significant contribution towards preventing the 5m people in England at risk of T2DM from developing the disease.

 
What will Healthier You achieve?
 
Previous Commentaries have warned that diabetes will not be prevented by repeating past failures. Despite the fact that we know how to avoid and treat T2DM, and despite the fact that over the past decade some £110bn have been spent on diabetes care and education, the incidence rate of the condition has increased by a staggering 65% over the same period. And still each year In England, there are more than 22,000 avoidable deaths, from diabetes-related illnesses.
 
Because the size of the English population at risk of T2DM is so vast, and because Healthier You is using a variant of past diabetes education programs that have failed, it seems reasonable to suggest that while the DPP may have some limited success, it will fail to make a significant reduction to the overall burden of obesity, which devastates the lives of millions and costs billions.
 

Obesity and T2DM are global epidemics

Currently, in England alone some five million people are either overweight or obese, and therefore at high risk of developing T2DM. The economic cost of obesity is £6.3bn, and expected to rise to £8.3bn in 2025 and £9.7bn in 2050. However, this only reflects costs to the health service, and not wider economic consequences for society. In England in 2014, pharmacies dispensed just over half a million items for treating obesity with a net ingredient cost of £15.3 million. All of these prescriptions were for Orlistat, which prevents the body from absorbing fat from food.
 
If current obesity trends persist, one in three people in England will be obese by 2034, and 1 in 10 will develop T2DM. T2DM is a leading cause of preventable blindness, and is a major contributor to kidney failure, heart attack, and stroke. Each year about 120,000 people in the UK are newly diagnosed with diabetes, and there are about 22,000 avoidable annual deaths from diabetes-related causes. In addition to the human cost, T2DM treatment currently accounts for almost 9% of the annual NHS budget: about £8.8bn a year.
 
Similar trends can be seen in the US, where 86 million people are either overweight or obese and therefore have a high risk of developing T2DM. One in every three American adults has prediabetes, a condition that arises when blood glucose levels are higher than normal, but not high enough for a diagnosis of diabetes. There are 30 million Americans living with T2DM, resulting in two deaths every five minutes.

Obesity is a global epidemic. A study published in The Lancet in 2016 found that in the past four decades, global obesity has more than tripled among men and doubled among women. The study says that if current trends continue, 18% of men and 21% of women worldwide will be obese by 2025. According to Majid Ezzati, Professor of Global Environmental Health at Imperial College London, and the study's senior author, “We have transitioned [to] a world in which  . . . .more people are obese than underweight”. 

Diabetes is a global epidemic. Over the past 35 years 314m more people, making a total of 412m, are now living with the condition: 8.5% of adults worldwide. In 2012, 1.5m people died as a result of diabetes, and 2.2m additional deaths were caused by higher that optimal blood glucose.
 
In England, the rising prevalence of obesity in adults has led, and will continue to lead, to a rise in the prevalence of T2DM. This is likely to result in increased associated health complications and premature mortality, with people from deprived areas and some minority ethnic groups at particular risk. Modelled projections indicate that, all things being equal, costs to the NHS and wider costs to society associated with overweight, obesity and T2DM will rise dramatically in the next few decades.
 
Roni Sharvanu Saha, Consultant in acute medicine, diabetes and endocrinology at St Georges Hospital NHS Trust, London describes prediabetes:

 

 

DPP in the news
 
The launch of Healthier You triggered headlines such as, “Personal trainers on the NHS in war on diabetes”, which raised eyebrows and attracted criticism. Despite mounting evidence to suggest that physical activity alone cannot reduce obesity, and despite being attacked by the National Audit Office (NAO) and the Public Accounts Committee (PAC), the NHS, PHE and DUK are convinced that their DPP will be successful. Professor Jonathan Valabhji, national clinical director for diabetes and obesity at NHS England, and one of the leaders of the DPP, says, “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”. Is Valabhji right?

Despite a year of planning and the optimism of the DPP leaders, the UK’s Public Accounts Committee has expressed serious doubts about the way the DPP is setting about its task, and has warned that, "By itself, this [the program] will not be enough to stem the rising number of people with diabetes".

 
Successful pilot studies
 
Behavioral interventions, which nudge people to adopt and maintain a healthy diet and lifestyle, can significantly reduce the risk of developing T2DM. Over the past year, seven demonstrator sites set up by the DPP in England have been testing innovative diabetes educational programs, and have reported the reduction of at-risk people from developing T2DM. One pilot that offered two exercise classes a week, and classroom sessions on diet and lifestyle, found that 100% of its participants lost weight, with more than half reducing their diabetes risk. Intelligence from these studies has informed Healthier You. Three quarters of England’s 211 clinical commissioning groups (CCGs) have already joined forces with local authorities, and will now work with four designated providers to offer personal care to those at high risk of developing T2DM.
 
The service providers
 
The four service providers are: (i) Momenta, which offers weight management for adults, and is part of the Reed Partnership that has already delivered over £0.6bn of publicly funded UK contracts, (ii) Pulse Healthcare, which is part of the ICS Group, an established healthcare service provider that offers health and wellbeing services to local authorities, CCGs and employers, (iii) Health Exchange, which was launched in 2006 as a local authority partnership to provide healthy living advice to local community groups, and (iv) Ingeus, which has evolved from a small Australian rehabilitation company in 1989 to an international provider of employment, training and support services.
 
US has similar diabetes prevention program
 
Healthier You is similar to a US diabetes prevention program, which was developed to improve the health of people at risk of T2DM through improved nutrition and physical activity.  In 2011, through funding provided by the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) awarded the National Council of YMCA America more than $11.8m to enrol eligible Medicare beneficiaries at high risk of developing T2DM in a program that could reduce their risk.
 
Participants in the American program attended weekly meetings with a lifestyle coach who trained them in strategies for long-term dietary change, increased physical activity, and behavior changes to control their weight and reduce their risk of T2DM. After the initial weekly training sessions, participants could attend monthly follow-up meetings to help maintain healthy behaviors.
 
Over the course of 15 months, participants lost about 5% of their body weight, which, if maintained, is enough to substantially reduce their risk of future diabetes. Over 80% of participants attended at least four weekly sessions. When compared with similar people not in the program, Medicare estimated savings to be $2,650 for each participant over the 15-month period, which was more than enough to cover the cost of the program.
 
In 2016, independent experts found that the American program saved money and improved peoples’ health, and recommended its expansion into US Medicare. "This program has been shown to reduce health care costs and help prevent diabetes, and is one that Medicare, employers and private insurers can use to help 86 million Americans live healthier,” says US Health Secretary Sylvia Burwell.
 
The results of the US diabetes prevention program are promising, although there is no recognized evidence to suggest that exercise alone reduces obesity. Further, not enough time has elapsed to assess whether the program permanently changed the behavior of participants, and whether they maintained their initial loss of weight.
  
No evidence to suggest exercise can tackle obesity

Despite Healthier You’s emphasis on personal trainers, there is no evidence to suggest that exercise has a role in tackling obesity. A 2015 British Journal of Sports Medicine editorial suggests that it was time to “bust the myth” about exercise. According to the Mayo Clinic,Studies have demonstrated no or modest weight loss with exercise alone, and that, an exercise regime is unlikely to result in short-term weight loss”. The benefits of exercise are on insulin sensitivity and aerobic fitness, not weight loss. Exercise is a good way to keep weight off, but a bad way to lose weight. To put it in perspective, exercise burns calories, but substantially less than people often think. For example, 1lb of fat is 3,500 calories, and to burn 1lb of fat you would need to run about 40 miles.
 
19th century methods for a 21st century epidemic

The US experience and the English pilot studies suggest that Healthier You is likely to produce some improvement in the overall situation, but research suggests that this will more likely come from diet rather than exercise. The logistics and scale of the problem are so great that Healthier You is unlikely to have more than a relatively small impact. One-to-one life coaches are expensive, difficult to scale, and costly to administer. Successfully engaging a substantial proportion of the vast and rapidly growing English population at risk of developing T2DM, and nudging them to change their diets and lifestyles will require 21st century technologies. That the DPP has chosen 19th century labour-intensive methods to deal with a 21st century epidemic raises doubts about its efficacy.  Let us explain.
 
Not well planned

Healthier You’s 2016 objective is to identify 22,000 people at high risk of T2DM out of a population of 26m across 27 geographic regions of England, and offer them an intensive personalised course in weight loss, physical activity and diet, comprising at least 13 one-to-one, two-hour sessions, spread over nine months, which is estimated to cost £320 per person, or some £7m each year for the cost of the coaches alone.  

By 2020, the DPP expects to have rolled out Healthier You to the whole country, and each year thereafter expects to recruit 100,000 at-risk people found to have high blood sugar levels. At this rate, it will take 50 years, at a minimum annual cost of some £35.2m, to provide 26 hours of personal coaching for the 5m people at risk of T2DM in England. In addition to the cost, the logistics of effectively delivering and accounting for such a program is a significant challenge. The four designated service providers are expected to join forces with the 211 English CCGs, which are the cornerstone of NHS England, and with several thousand local authorities to deliver each year 2.6m hours of one-to-one personal coaching to 100,000 people at risk of T2DM drawn from an adult population of some 50m, and spread across nearly 60 geographic regions in England. A significant percentage of the beneficiaries will be in full time employment and therefore have time constraints. Another complexity is that each CCG commission’s primary care for an average of 226,000 people, and there are some 8,000 GP practices, which ‘own’ the patient data.

Moreover, the £35.2m annual cost estimate does not include the administrative costs associated with identifying and triaging the 5m at-risk people to recruit annually 100,000 people most at risk who will be offered personal coaching, and monitoring the impact this will have on patient outcomes. It seems reasonable to suppose that Healthier You will be difficult to manage, given that the current NHS primary care infrastructure is at breaking point, with a shrinking pool of overworked and demoralised GPs. It will also be extremely expensive as well as wholly inadequate for the scale of the problem. Recently, Dr Maureen Baker, chair of the Royal College of General Practitioners, said: “Rising patient demand, excess bureaucracy, fewer resources and chronic shortage of GPs [are] resulting in worn-out doctors, some of whom are so fatigued that they can no longer guarantee to provide safe care to patients.

 
Simple arithmetic
 
Did the leaders of the DPP not only over emphasize the potential impact of exercise on obesity, and their ability to manage the program and underestimate the program's costs; but also get their arithmetic wrong in planning the roll out of Healthier You? The DPP leaders must have known that each year for the past 10 years there have been some 100,000 new diagnoses of T2DM. Even if we assume that: (i) there will be no future increase in the incidence rates of obesity and T2DM, (ii) by 2020 Healthier You will be 100% effective in recruiting its annual target of 100,000 at risk people, (iii) Healthier You will be 100% successful in changing the diets and lifestyles of the 100,000 people it recruits each year, and (iv) the annual death rate from diabetes-related causes will remain constant; the conclusion is unavoidable that although the DPP will be spending a minimum of £35m a year to deploy personal trainers, there will still be millions of overweight and obese people, and the incidence rate of T2DM will still be vast and escalating. The T2DM epidemic will not have been dented.
 
 Accountability
 
The UK’s Secretary of State for Health says, “We will be looking closely at the results of this programme.” Does this mean that its leaders will be accountable? To date, the UK government’s record on making people accountable for diabetes care and education is poor.

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 Healthier You’s effectiveness.  See, The importance of measuring the impact of diabetes care. 

 
Takeaways
 
What will Healthier You achieve?  Given the success of the English pilot studies and the success of the similar American diabetes prevention program, it seems reasonable to expect Healthier You to produce some improvement in the overall situation. However, the scale of the problem is so vast, its management infrastructure so weak, and the impact of exercise on obesity so little, that Healthier You is unlikely to have more than a relatively small impact. The size of the UK population at risk of T2DM is so great that much more modern and efficient tools are needed to get to grips with the problem and make a real difference. A future Commentary will be devoted to describing some of the technological advances being made to tackle obesity and T2DM.
 
Preventing T2DM is too important to be entrusted to our well-resourced clinical establishment that has failed to dent the large and rapidly rising burden of the condition. Preventing T2DM requires leadership and an efficacious strategy, which in the short term, innovates and leverages the use of mobile technologies to engage millions of at-risk people, and nudge them to become permanently enthusiastic about changing their diets and lifestyles; in the medium term, recruits corporates, educational establishments, restaurants, and faith groups into the overall prevention strategy; and in the long term, promotes changes in our environment so that we are obliged to live healthier lives. 
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