Analysis… A response to Type 2 diabetes
UK: With diabetes threatening public health and weighing heavy on European health systems, Professor Kevin Fenton, of Public Health England, details the efforts being made in England to tackle the problem.
Driven by increases in overweight and obesity, unhealthy diet and physical inactivity, the prevalence of Type 2 diabetes is on the up across Europe, leading to increasing engagement with the matter amongst decision makers and health policy leaders
In England, Public Health England (PHE), the government agency charged with improving health and wellbeing and reducing health inequalities, is moving to tackle the diabetes epidemic with the National NHS Diabetes Prevention Programme. As 80% of all cases of Type 2 diabetes are preventable, the programme is focused on intensive lifestyle change interventions. Initially, 10,000 people at high risk of developing Type 2 diabetes will be targeted, with a national rollout following; seven demonstrator sites are pioneering the first phase of the programme. Initiatives on a variety of schemes, from weight loss to physical activity and from cooking to nutrition, are being advanced under the programme in the hope that effective public health interventions will be gleaned.
Indeed, PHE argues that a successful national programme for England could save tens of thousands of lives and millions of pounds for the UK’s healthcare system.
Speaking to PEN, PHE’s director of health and wellbeing, Professor Kevin Fenton, provides an insight into the diabetes challenge and the public health response required.
What are the key trends around Type 2 diabetes and the wider health challenges in England today?
For us in England, and certainly across the United Kingdom, diabetes is actually a very serious public health issue. We estimate that it affects nearly 3.2 million people in England, and there are 4.6 million at high risk of developing diabetes in the near future. This has huge cost implications for us as a nation in terms of premature mortality and the contribution of diabetes towards cardiovascular disease, including heart attacks and strokes, but also in terms of microvascular disease, leading to amputations and other complications including blindness. It really has a huge impact on the NHS budget, of which we believe 10% is driven by diabetes in the country.
Not only do we have a huge current and potential burden on the population, but we know that diabetes is largely preventable, as well. This is the call to action that we are putting in place here in England: to really get the nation to focus first of all on the obesity epidemic that is driving high rates of Type 2 diabetes and, specifically, on what more we can do to better manage diabetes.
While there is a clear impact on health issues, what wider impact does the disease have on society at large?
The clinical conditions are significant: blindness, strokes, heart attacks and other serious conditions, impacting hugely on the individual as well as their family. That has an effect on health and social care services. On a population level, the number of adults with Type 2 diabetes will continue to rise, reaching almost 9.5% of the adult population by 2030. We also know that the population level is not randomly distributed, because of the concentration of both obesity and diabetes within population sub-groups such as minorities. We see this driving health inequality, too. Whether at the individual, family or community level, the impacts of this disease are quite prevalent.
In terms of helping to inform and drive your work in this area, how important are co-operation and exchange with other countries?
Co-operation is incredibly important as one of the things we are keen to do in England is to move at pace and at scale when it comes to addressing the diabetes epidemic. We are already reaching out to other countries that have implemented a structured programme to manage pre-diabetes and are looking at ways that they have worked to bend the epidemic curve by intervening earlier. Programmes such as this have been implemented in the United States and in the state of Victoria in Australia.
We are already collaborating with international partners, and when we look at the potential across Europe, there are huge opportunities. In part this is because there are other countries in western Europe facing similar challenges. They have already been reaching out to us to learn about our approach, what we are hoping to learn, and how we plan on translating the evidence into action. We are implementing the programme and it will generate lots of experience of the implementation and scaling of different approaches. Our European partners have said that they would like to learn from us in terms of how such a large scale programme can be implemented quickly.
Thus, we are learning as we are doing, and we are sharing as we are learning. That is going to be really important for us with our European partners moving ahead.
What role are key stakeholders playing in terms of engaging with efforts?
The success of a programme such as the diabetes prevention programme has so many components within it. These include identifying those at risk and the pre-diabetic individuals, linking them into lifestyle management programmes, and then monitoring their outcomes and keeping them engaged in terms of their health and wellbeing after the intervention, meaning that reliance on a range of stakeholders is needed – general practitioners, colleagues who are commissioning the lifestyle management services, and other stakeholders who are involved with providing peer, social and mental support, and counselling.
From day one, we have been working with a number of partners on the programme, and as we are moving towards implementation in the first year, we are focused on seven pioneer sites and will be scaling up in the years ahead. It is key that we are working in partnership with NHS England and the NGO Diabetes UK. Alongside Public Health England, these organisations are then informed by a wider stakeholder group involving local government, other third sector providers, business sector colleagues and those working in the academic sector, as evaluation is important. A wider tier of stakeholders includes members of the public who we are taking along with us as we develop and market the programme. Here we are looking at our social media efforts.
This is a very deliberate programme of engagement that we implemented from day one and have been scaling up as the programme continues.
How are you ensuring that the programme can adapt and evolve to have the greatest impact over the coming years?
One of the things we have been keen to do with the design of the programme is to go back and conduct a systematic review of the evidence in order to understand what the effective components of a diabetes prevention programme are. We have been looking to what lessons can be learnt from the Australians and the Americans given the fact that they began this journey before us. From this literature review, we have been able to determine the core components of an effective programme and its successful implementation.
We are building those factors in as we develop our efforts. One of the key lessons we have learnt from the United States is to try not to be too prescriptive in having the same programme in every locality across the country and to instead set overarching parameters, core principles and outcomes, then let local partners look at local assets and local relationships to design a programme that can reach those outcomes. We are also looking to use performance management or support systems to help the localities reach the result outcomes. That is a key lesson that we have been able to bring to the design of the programme that will enable greater ownership and then a greater level of effectiveness.
We are also developing a suite of structured process outcome indicators to help us understand how the programme is being designed, developed and implemented. This will help us to understand if we are meeting the key indicators for success. That systematic evaluation is a part of what we do for all of our prevention programmes.
In terms of research, how important a role does this play in helping to combat Type 2 diabetes and develop public health policies?
Our academic partners are key for us as we embark on this programme. We didn’t want to simply take the American and Australian approach and move towards implementation; there is a huge research agenda here. We use research to inform the implementation of the programme and have some approaches that we can use to structure this in a phased way. That will enable us to learn about the effectiveness of the programme in the real world setting.
That application of good science methodology can help us to carry out a better job of implementation.
Further, there are already many questions being generated amongst colleagues designing the programme on the pioneer side: is it appropriate and acceptable in the English context?; what are we doing to identify individuals at risk?; and what are the key structural and contextual issues that those who are pre-diabetic are faced with, so that the programme can take account of this?
Such questions are already emerging as we are considering implementation in England. Having a parallel research track to stimulate understanding of the issues is going to be important. We are hoping that by building in research alongside implementation we will be able to contribute to the global literature, and especially the European literature, which we think will be of enormous benefit to our European partners.
Amidst worrying signs that the diabetes epidemic will continue to worsen, are you confident that it can potentially be brought under control in the future?
The reality is that the diabetes epidemic is being driven by obesity in the population. With current projections, we will continue to see an increase in those who are overweight or obese for the foreseeable future. We haven’t yet peaked with the epidemic curve of adult obesity. That is worrying. Unless we begin to bend that curve, we are likely to continue to experience increased pressure as a result of Type 2 diabetes, but I think that there is room for optimism.
One, there is a recognition that if we are going to address this epidemic there is no simple magic bullet; we are going to have multiple approaches being implemented at scale, with strong leadership at all levels – national and local – to get to where we need to get to.
I am pleased that with the new government in the UK, it is clear that diabetes and obesity are going to be key health priorities. We have a secretary of state for health who is very keen to push forwards on diabetes and obesity. That means we will have the political leadership in place to push through some of the changes that we need.
So there is some room for optimism; people are now looking at obesity not just as a health threat but as an economic threat to the country. This is an opportunity for us to think about what all parts of government need to do to address the epidemic. For the first time we are having very different conversations with our colleagues in the Department for Education, the Treasury and other government departments which are beginning to see the impact of diabetes upon their agendas, as well.
This is a ‘health in all policies’, cross-department approach.
Finally, at the local level, we are beginning to have very different conversations with individuals, families and in local government around tackling this issue. In England we have a major programme designed to help families and children reduce their sugar intake. Children are ingesting far more sugar than they should, largely from fizzy drinks. We have programmes now in England on education awareness, helping families to switch to healthier diets. Indeed, there is a new awareness of the health harm of sugar.
But while there may be a few developments to be optimistic about, we need to be cautious moving forward.
Professor Kevin Fenton
Director of Health and Wellbeing
This article first appeared in the seventh edition of Horizon 2020 Projects: Portal, which is now available .
