Diabetes in the UK Case - Report Example

Is there a case to undertake population screening for diabetes in the UK? Introduction Diabetes has been known since at least 1552 B.C.E. (Canadian Diabetes Association, 2011), although modern insulin therapy, as required for Type 1 Diabetes, did not begin until 1922. With present calls for urgent financial cuts in the National Health Service it could perhaps be argued that there is no money for a new or more extensive screening service, whether for diabetes or any other condition. However this is a very short term view point, as untreated diabetes leads to so many preventable complications which result not only in long term problems such as heart disease, loss of sight or damage to eyesight, kidney damage or perhaps neurological problems. Any of these could lead eventually to the need for extreme measures such as amputation as described by the Diabetes and Hormone Center for the Pacific (undated). These problems not only cause untold suffering, but of course are expensive in that long term care is required for sufferers of the many complications that can ensue, any or all of which might well have been prevented. Diabetes UK has for some years been asking for the establishment of an active screening programme which would identify those with Type 2 diabetes at an early stage, in order to ensure that the person involved receives the most appropriate future care.( June 2006) In 2010 the group estimated the number of undiagnosed cases within the United Kingdom to be 1 million or more. Type 1 Diabetes Type I Diabetes usually presents in young people, often in a quite abrupt way, with weight loss and attacks of hyperglycemia, possibly after a viral illness. The body stops producing insulin. The condition is relatively uncommon, covering only 10% of those with diabetes, and does not have a long latent stage, according to Norman (1997), so would not fit into a national screening programme. If the condition were suspected then testing would be done in the same ways that it is done for Type 2 diabetes in order to confirm a diagnosis. Type 2 Diabetes Type 2 Diabetes in its early stages is relatively symptomless, with a gradual decrease in the body’s ability to control blood sugar levels. Problems build up slowly. However, if spotted early enough the condition can be controlled and the most serious side effects prevented or moderated. It therefore makes sense to have a nationwide screening programme in place. However Engalou et al (2000) point out that screening a whole population is uneconomic due to low levels of diabetes in the general population. They suggest that screening sections of the population known to be prone to the condition, such as those with a close family history of the disease, would be an effective use of resources. In the general population this would mean aiming screening at obese older people, especially those with a close family history of diabetes , and including those with a BMI of 25-30kg/m2 and over. Diabetes UK ( 2006, page 4) give details of waist measurements in various racial types which require further investigation, as well as naming a number of associated conditions such as peripheral vascular disease. As Simmons and Voyle pointed out in 2003 particular racial groups world wide may be particularly vulnerable. The American Agency for Healthcare Research and Quality in 2001 found that diabetes was more prevalent in black people at 10.8%, whereas in the white population it was at the lower level of 6.2%. Asians in the UK have a high risk of developing the condition with the percentage running at 20% in those over 40. (Greenhalgh, 1997 ). In 2009 de Hert stated ( page 3) that diabetes is three times more prevalent in those with severe schizophrenia than in the general European population. Such people should therefore be screened for the condition, even if apparently symptomless. . In the United Kingdom Diabetes UK report (June 2006) that only 60% of the UK has definite programmes in place to identify diabetes at an early stage. Effective Screening According to a WHO paper (2003), cited by Diabetes UK, Type 2 diabetes has a very long latent period in its development during which time it can be easily detected. In 2002, the Department of Health in the U.K. realised the need for a more systematic system of screening for Type 2 diabetes. For this reason a review of research was commissioned. This had the task of testing implications for a primary care programme aimed at those at greatest risk. Any screening programme developed had to fit into the criteria described by Wilson and Junger (1969) i.e. Type 2 diabetes is a major disease whose progress is well comprehended. It has an easily recognisable early stage i.e. loss of control of blood glucose levels. There are readily available tests for the condition which can be used even at a non symptomatic stage. The test can be repeated at intervals and is acceptable to patients. The risks of any testing are far less than if it were not done. It can be easily shown that screening is cost effective and, although treatment will be needed, this will cost less than if the condition is allowed to progress without intervention. Diabetes UK suggests that those cases discovered will require education and advice as to their lifestyle including diet and activity. They will also need retesting at 3 yearly intervals. The WHO ( 2003, page 8) mentions risk assessment questionnaires. Together with these 4 methods of testing are described by Diabetes UK (2006). These are given in order of accuracy. 1) The blood sugar level, also referred to as the plasma glucose level, is expressed as millimoles per litre (mmol/l). A post glucose load blood glucose assay which measures this accurately is the most technically complicated method used. The patient consumes 75grams of glucose, usually in liquid. After two hours the blood glucose level is tested. If properly supervised this is the most accurate method, but may not always be feasible. Anyone found to have a level of 11.1 mmol/l definitely has diabetes. Any people with levels between 7.8 and 11.1 may be in a pre-diabetic state and will require retesting after an interval. These levels also apply on the other tests. 2. Fasting blood glucose. This test is less reliable as it can miss any one with a condition whereby they only exhibit hyperglycemia after a definite glucose load, so is less likely to pick up all cases. . 3. In many circumstances testing for random blood sugar levels may be the most practical method to use, as such testing requires no preparation. High levels give an accurate diagnosis, but lower levels are less are accurate, and will indicate the need for further testing. 4. Post prandial/post glucose glycosuria. This test is very easy to carry out, requiring only a fresh specimen of urine and a commercially produced dipstick which changes colour in the presence of glucosuria.. This would be a good method to use opportunistically, and when large numbers are involved. It could of course then be followed up by one of the other methods if this were considered to be necessary. Blood Sugar Levels Another way of measuring blood sugar levels is to calculate the amount of glucose per deciliter Blood Sugar Levels in an Adult Male ( Right Health Community 2007) Adult male Low level Highest level Normal level 70mg dl 100 mg dl Early diabetes type 2 101 mg dl 126 mg dl Established diabetes type 2 126 mg dl Any level above 126 mg. per dl Measuring waist circumference and BMI is also a way of predicting risk in type 2 diabetes. Those who carry their weight and body fat in a central position are known to be at more than average risk of developing both diabetes and heart disease (Cut the Waist 2009). These patients would then be tested in one of the ways described above. If such testing is to be effective it will of course require follow up and testing for any hidden complications such as retinal problems and neurological changes which they may not be aware of. Patients need to know more about their condition and any changes that they need to make in diet or exercise levels etc. The means of offering active management and the necessary education and support need to be in place or there is little point in screening, whether in at risk groups or more generally. . World Health Organization In 1968, on behalf of the World Health Organization , Wilson and Junger produced their paper ‘ Principles and Practice for Screening Disease’ They define ( Preface) the reason for screening as ‘to discover those among the apparently well who are in fact suffering from disease,.’. The authors spend some considerable time on screening for diabetes mellitus - pages 78 – 86. On page 86 they include a chart adapted from United States of America, Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics which shows how the condition is most prevalent in older women and that by ages 75-79 some 41.5 % of the population are affected to some degree. While the authors agree that people in this group should be screened, they also point out how hard it might be to actual achieve participation from them, as their knowledge of the condition may be very vague. A survey by the College of General Practitioners back in 1962 found that many of those diagnosed after screening, had in fact got obvious symptoms which they had had for some time. Would a more recent survey produce different findings? Having decided who should be screened the next question is how to reach them. Although diabetes is age related to a large extent, this is not the only criteria, so just choosing those of a certain age might include far too many people. There therefore needs to be more limited criteria such as those over a certain age with certain physical criteria and those with family connections to the condition. Some will be found to have an impaired fasting glycaemia ( IFG) or impaired glucose tolerance (IGT), pre-diabetic states which can lead on to diabetes. The other problem is that accurate diabetes screening needs time and planning and cannot be fully opportunistic. Conclusion It is obviously not just a simple question of should there or should there not be screening for diabetes. There are many other questions to be answered such as :- Who should be screened? Is there sufficient funding and trained staff for such testing? How can such people be reached? How should screening be done i.e. what method should be chosen? Is there provision to cope with extra patients discovered by screening? What will happen to these patients if they are not discovered in the early stages of their condition? Only when answers to such questions are resolved will it be feasible to carry out screening – but it will be effective economically and medically if it prevents long term side effects, so any perceived difficulties need to be resolved. Rather than concentrating on particular aspects of the condition at the early stage, holistic treatment will be the most effective. Also, as an important part of any screening programme, the public, as well as health care staff, need to be informed about symptoms and risks associated with type 2 diabetes. This will then mean that those most at risk are more likely to participate and so justify any expenditure of time and money. Diabetes UK in 2010 estimated that by 2030 there will be 5.5 million known sufferers from Type 2 diabetes in the United Kingdom. With adequate screening many of these will develop fewer complications, or less severe ones than they might have done. Whilst screening of at risk groups has begun, mainly through the programmes of the NHS Health Checks, ( undated) it is obvious, because of the numbers involved, that there still needs to be a greater effort needed to provide a country wide and successful screening programme for type 2 diabetes. Bibliography CANADIAN DIABETES ASSOCIATION, 2011, The history of Diabetes, (online) available from http://www.diabetes.ca/diabetes-and-you/what/history/ [Accessed 8th June 2011] COLLEGE OF GENERAL PRACTITIONERS, 1962, A Diabetes Survey, British Medical Journal 1. 1497 CUT THE WAIST, 2009, The Importance of Waist Circumference, (online) available from http://www.cutthewaist.com/importance.html [Accessed 7th June 2011] De HERT, M., DEKKER,J.,WOOD,D., KAHL, K., HOLT,D.and MŐLLER, H., January 2009, Cardiovascular disease and diabetes in people with severe mental illness. Position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC),(online) available from http://www.easd.org/easdwebfiles/statements/EPA.pdf [Accessed 7th June 2011] DEPARTMENT OF HEALTH,.2001, National Service Framework for Diabetes - England. Standards) and Delivery Strategy [2002]. DIABETES AND HORMONE CENTER FOR THE PACIFIC, (Undated) Preventing Complications from Diabetes, available from http://www.endocrinologist.com/Complications.html [Accessed 7th June 2011] DIABETES UK, June 2006, Position Statement, http://www.diabetes.org.uk/Documents/Professionals/Earlyid_TYPE2_PS.doc [Accessed 7th June 2011] DIABETES UK, 2009, One million people in UK unaware they have Type 2 diabetes., (online) available from http://www.diabetes.org.uk/About_us/News_Landing_Page/One-million-people-in-UK-unaware-they-have-Type-2-diabetes/ [Accessed 7th June 2011] ENGELGAU,M, NARAYAN,V. and HERMAN, W.,2000, Screening for Type 2 Diabetes: Questions 6: Are the costs of case finding and treatment reasonable and balanced in relationship to health expenditures as a whole, and are facilities and resources available to treat newly detected cases? Medscape Today, 2000, (online) available from http://www.medscape.com/viewarticle/406002_8 [Accessed 6th June 2011] FOROUHI et al, 2001, Diabetes prevalence in England, – estimates from an epidemiological model. Diabetic Medicine 2005, 23, 189-197 [Reference states 667,000 for England alone, if this figure is extrapolated pro rata for the rest of the UK, then the undiagnosed will be closer to 750,000] cited by Diabetes UK 2006 GREENHALGH, P.1997, Diabetes in British South Asians: nature, nurture and culture. Diabetic Medicine. 14: 10-18. NHS HEALTH CHECKS, undated, Type 2 diabetes, available from http://www.nhs.uk/Planners/NHSHealthCheck/Pages/Diabetes.aspx [Accessed 8th June 2011] RIGHT HEALTH COMMUNITY, 2007, Glucose level charts, (online) available from http://www.righthealth.com/topic/Blood_Glucose_Chart/overview/uc_kosmixarticles?fdid=uniquecontent1_693fe2e2c463fc066213bbc69ba279a0 [Accessed 8th June 2011] SIMMONS, D., and VOYLE,J., 2003, Reaching hard-to-reach, high-risk populations: piloting a health promotion and diabetes disease prevention programme on an urban marae in New Zealand, ( online) available from http://heapro.oxfordjournals.org/content/18/1/41.full [Accessed 6th June 2011] THE AMERICAN AGENCY FOR HEALTHCARE RESEARCH AND QUALITY, 2001, Diabetes Disparities Among Racial and Ethnic Minorities, ( online) available from http://www.ahrq.gov/research/diabdisp.htm [Accessed 7th June 2011] UNITED STATES OF AMERICA, DEPARTMENT OF HEALTH EDUCATION AND WELFARE, PUBLIC HEALTH SERVICE, NATIONAL CENTER FOR HEALTH STATISTICS, 1960-1962: diabetes prevalence and results of a glucose tolerance test, by age and sex, Washington, D. C. (Public Health Service Publication, No. 1000, Series 11, No. 2), quoted by WILSON, J. and JUNGER, G, 1968, Principles and Practice for Screening Disease, World Health Organization, page 86, available from http://whqlibdoc.who.int/php/WHO_PHP_34.pdf [Accessed 6th June 2011] WILSON, J. and JUNGER, G, 1968, Principles and Practice for Screening Disease, World Health Organization, (online) available from http://whqlibdoc.who.int/php/WHO_PHP_34.pdf [Accessed 6th June 2011] WORLD HEALTH ORGANISATION, 2003, Screening for Type 2 Diabetes. Available from http://www.who.int/diabetes/publications/en/screening_mnc03.pdf [Accessed 8th June 2011] Read More