HealthPad | obesity

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7 years, 7 months ago

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A major 21st century health challenge is under-reported for 40 years

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behavioural science

behavioural techniques

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obesity

obesity prevention

It is one of the most serious global health challenges of the 21^st 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 21^st 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 21^st 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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7 years, 10 months ago

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Can the obesity epidemic learn from the way Aids was tackled?

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behavioural techniques

chronic disease prevention

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.

19^th century technologies for a 21^st 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 19^th century labour intensive method to address a 21^st 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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7 years, 11 months ago

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Will the UK’s diabetes prevention program work?

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commentary

diabetes prevention

diabetes prevention program

National diabetes prevention program (DPP) uses 19^th 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.

19^th century methods for a 21^st 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 21^st century technologies. That the DPP has chosen 19^th century labour-intensive methods to deal with a 21^st 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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8 years, 2 months ago

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

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

Diabetes and the built environment

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

Takeaways

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

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