What is Diabetes?
In type 1 diabetes, the pancreas does not produce enough insulin. Insulin is a hormone which allows the cells in our body to take in glucose and utilise it to create energy via the electron chain system in the Krebs cycle.
In type 2 diabetes, the pancreas does produce enough insulin but due to weight and lifestyle choices, the cells in the body do not respond to insulin properly. They become what is known as insulin resistant. Insulin resistance occurs as a result of a higher level of abdominal fat which is metabolically different to subcutaneous fat. Abdominal fat is resistant to the antilipolytic effects of insulin, resulting in the release of excessive amounts of free fatty acids which in turn lead to insulin resistance. This leads to increased levels of circulating glucose.
Which type of diabetes is most prominent?
Out of the two types of diabetes, type 2 is by far the most prevalent. It accounts for about 90% of all diabetes cases, whereas type 1 diabetes accounts for approximately 10%.
In the case of type 2 diabetes, when there are excess levels of sugar, the pancreas makes extra insulin to make up for it. Over time, the pancreas isn’t able to keep up and can’t make enough insulin to keep the blood glucose at normal levels. Type 2 diabetes usually appears in adults, however, it is frequently being diagnosed in younger overweight people and certain ethnic groups. The risk of its development can be reduced by making changes in lifestyle. Ethnicity and gender also play a big role as diabetes is five times more likely to develop in Pakistani women, two and a half times as likely in Indian women. It is four times more prevalent in Bangladeshi and Indian people as a whole.
Generally speaking, diabetes prevalence is often six times higher for people of South Asian origin and three times higher for those of African origin. It is unsure why this is the case, however, a number of risk factors could be the reason, for example, factors of socio-economic and lifestyle are noted to lead to unhealthy dietary patterns. Genetics is another potential factor.
Many patients with type 2 diabetes have an insidious onset of hyperglycaemia with few or no classical symptoms. Some patients are unaware of the disease even with presentations of classical symptoms since they begin very gradually over a prolonged period of time. Patients often present diabetes when the complications of sustained hyperglycaemia have already developed e.g. cardiovascular or renal disease.
What is prediabetes?
Alongside confirmed diagnosed type 2 diabetes, prediabetes is also a real concern for the NHS. Prediabetes, also commonly referred to as borderline diabetes, is a metabolic condition. It is a growing global problem that is closely tied to obesity. It is characterised by the presence of blood glucose levels that are higher than normal but not yet high enough to be classed as diabetes. It is often described as the “grey area” between normal blood sugar and diabetic levels. In the UK, around 7 million people are estimated to have prediabetes and thus have a high risk of developing type 2 diabetes if it goes undetected.
The increasing number of new cases of prediabetes presents a concern for the NHS as it carries large-scale implications regarding the cost of the future of healthcare. Between 2003 and 2011, the prevalence of prediabetes in England alone more than tripled, with 35.3% of the adult population, or 1 in every 3 people having prediabetes. If intervention is not made early on, there is a high likelihood that these people will go on to develop Type 2 diabetes.
Cost to the NHS
The treatment and management of diabetes is extremely important for our National Health Service. Currently, the number of people diagnosed with diabetes in the UK is estimated to be 3.5 million, rising from 1.4 million in 1996 and it is predicted that up to 549,000 people in the UK have diabetes that is yet to be diagnosed. This means that, including the number of undiagnosed people, there is estimated to be over 4 million people living with diabetes in the UK at present. This represents 6% of the UK population or 1 in every 16 people having diabetes (diagnosed and undiagnosed). It is currently estimated that around 10% of the NHS yearly budget is contributed to the treatment of diabetes. This equates to nine billion a year or rather, £173 million a week and it is expected to rise quite significantly. It is growing at a particularly high rate and is now one of the world’s most common long-term health conditions. Prevalence in the UK is estimated to rise to 5 million by 2025.
Complications of Diabetes
Uncontrolled or undetected diabetes can lead to a number of short and long-term health complications.
Short-term complications include:
- hypoglycaemia; where the blood sugar level drops significantly often due to overmedication in situations of decreased carbohydrate and glucose consumption. This causes the release of counter-regulatory hormones adrenaline, noradrenaline and glucagon which subsequently create autonomic symptoms such as sweating, trembling, tachycardia, palpitations and pallor. Other glycopaenic symptoms include a loss of concentration, faintness, drowsiness, visual disturbances and confusion.
- Diabetic ketoacidosis (DKA): a serious and potentially life-threatening situation where severe hyperglycaemia results in non-esterified fatty acids being released into circulation and taken up by the liver which produces acetyl coenzyme A which is rapidly metabolised leading to higher amounts of ketone bodies, acetoacetate and hydroxybutyrate being released into circulation. Osmotic diuresis increases leading to a lower serum volume causing dizziness and weakness due to postural hypotension. This weakness is exacerbated by the loss of potassium ions caused by urinary excretion and vomiting due to stimulation of the vomiting centre by the presence of ketones. In severe cases, this can cause coma. The presence of ketones increases the acidity of the blood which stimulates an increase in respiratory response to in an attempt to correct the acidosis. The patient’s breath may have a fruity odour of acetone.
- Hyperosmolar hyperglycaemic state (HHS): Hyperglycaemia over a period of time leads to dehydration which if severe results in hyperosmolarity. This can increase the viscosity of the blood and increase the risk of thromboembolism.
Long-term complications include:
- Macrovascular complications: This includes cardiovascular disease and peripheral vascular disease. It arises from damage to large blood vessels which lead to atherosclerosis of the vessels which may eventually lead to partial or complete occlusion. In microvascular complications do to with the heart, CVD accounts for 80% of death in type 2 diabetics. In PVD, blood vessels in the legs may become affected which results in intermittent claudication and cramping of the muscles. Many of the associated foot problems which occur in diabetics are as a result of damage to the blood vessels due to prolonged hyperglycaemia.
- Microvascular complications: These include retinopathy, nephropathy and neuropathy.Retinopathy is symptomless until the disease is far advanced. It occurs as result of damage to the tiny blood vessels in the eye as a result of long-term hyperglycaemia. It is therefore extremely important that diagnosed diabetics have regular eye checks to detect any early signs of retinopathy.The presence of nephropathy is indicated by the detection of small amounts of albumin in the urine i.e. microalbuminuria. If there are high amounts of albumin detected, this is termed proteinuria and is indicative of severe renal damage. Tight control of glycaemic levels and blood pressure reduces the risk of developing nephropathy.Peripheral neuropathy is the progressive loss of peripheral nerve fibres resulting in nerve dysfunction. It occurs due to prolonged hyperglycaemia damaging the small blood vessels, which prevents essential nutrients reaching the nerves causing them damage. It can lead to a wide range of sensory, autonomic and motor symptoms. These include the sympathetic and parasympathetic nervous system.
The potential for short term and long term complications is why managing diabetes is very important and why there is much emphasis on preventing someone developing type 2 diabetes from the prediabetic stage. NHS England, Diabetes UK and Public Health England have put together a lifestyle service called the Diabetes Prevention Programme (DPP). It is a product of the NHS Five Year Forward View commitment to getting serious about prevention.
The NHS DPP is underpinned by a strong evidence base. A recent systematic review and meta-analysis published by Public Health England in August 2015 examined the effectiveness of diabetes prevention programmes. The review concluded that behavioural interventions conducted in ‘real world’ settings are effective in reducing weight and reducing the incidence of diabetes. Overall the incidence of diabetes was reduced by 26% over a period of 12–18 months post-intervention.
The learning from this evidence review, alongside an Expert Reference Group and existing NICE guidelines, has been used to inform the structure and content of the NHS DPP intervention. The programme commenced with a phased national rollout in spring 2016 with the capacity for up to 20,000 people to access a behavioural intervention programme. This will roll out to the whole country by 2020 with an expected 100,000 referrals available each year after. NHS England has commissioned these behavioural interventions nationally. Local Clinical Commissioning Groups and local authorities are responsible for supporting identification and referral of people with Non-Diabetic Hyperglycaemia i.e. those who have been identified as Prediabetic. The programme supports these individuals over a period of at least 9 months to increase their physical activity, achieve a healthy weight and improve their nutrition – the key steps in reducing the risk of type 2 diabetes.
Imaan Pharmacy – Werneth
As a healthcare practitioner, I have a special interest in type 2 diabetes. I am currently working towards specialising in type 2 diabetes as an independent non-medical pharmacist prescriber. My pharmacy branch in Oldham is also currently working in partnership with the service lead for diabetes at Oldham Public Health and with the clinical lead GP for diabetes at the Oldham Clinical Commissioning Group (CCG) to identify members of the public at risk of developing type 2 diabetes. In order for us to deliver this service, Oldham Public Health has provided the pharmacy with the loan of three Alere Affinion point of care testing machines and the consumable testing kits. We have used these impressive machines to conduct HbA1c and cholesterol tests for those in the community who score highly on a diabetes risk assessment.
We have already conducted many sessions in community centres, faith institutes and public libraries, and we will continue to do so. The intention is two-fold;
- To identify those at risk of developing type 2 diabetes on the basis that they have a HbA1C reading of 42-47mmol/mol or 6-6.4% and are therefore 2) To increase interaction with at-risk communities in order to educate them on bespoke lifestyle interventions that they can implement to reduce their individual risks of developing type 2 diabetes.
The initiative we have set up has been a great success so far. We have detected a number of individuals who are high-risk of developing type 2 diabetes from being prediabetic and have referred them to the national diabetes prevention programme (DPP). We have also detected a significantly high number of individuals who may not yet be at the clinical level of prediabetes, but their lifestyle and HbA1c scores indicate that they are on a trajectory to prediabetes and diabetes.
The next phase is to start offering this service to high-risk patients visiting the pharmacy itself. Our parent group, Imaan Healthcare, have designed marketing material to advertise this service, and all staff have been trained to engage with the service. We hope that it enables us to make beneficial lifestyle interventions that will not only save the NHS money in the long term but also help our patients considerably with their healthcare.
This article was written by Ghulam Esposito Hadar, Manager at Imaan Pharmacy Werneth, Follow him here:
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Walker, Roger & Whittlesea, Cate (2012). Clinical Pharmacy and Therapeutics. Edinburgh: Churchill Livingstone Elsevier.