One in 20 people in Ireland suffers from diabetes. In those those aged 50 and over, the figure rises to almost one in 10. Ninety per cent of these people have Type II diabetes, the form most associated with being overweight or obese. Another unknown number of people have pre-diabetes, a condition in which blood sugars are elevated but not enough for the individual to experience the classic symptoms of diabetes.
The number of people with diabetes is expected to rise further, possibly affecting 6 per cent of the population by 2020.
So, with all our knowledge of the lifestyle factors that cause most cases of diabetes, why are we not stopping this chronic disease in its tracks?
The biggest difficulty, according to the experts, is that diabetes remains symptomless for years and only by testing individuals – particularly those who are overweight – can we begin to assess the risk of diabetes and bring blood glucose levels under control at an early stage.
"Anyone in a pre-diabetes state – that is found to have impaired fasting glucose or impaired glucose tolerance – is at a 50 per cent risk of developing Type II diabetes," says Dr Diarmuid Smith, consultant endocrinologist at Beaumont Hospital.
Lifestyle interventions, such as weight-loss and physical exercise programmes, are widely known to be the best way to prevent those with pre-diabetes becoming diabetic. A study in China found that people can reduce their risk of getting type II diabetes by 31 per cent with dietary changes alone and by 46 per cent with exercise programme. An American study found that lifestyle programmes reduced the risk of getting diabetes by 58 per cent.
Regaining weight
The problem is that people find it difficult to continue these programmes over time. “Studies have found that after 12-18 months, people start to regain the weight. People need a lot of support from nutritionists, exercise coaches and counsellors to sustain their programmes,” says Smith.
The recently published Irish College of General Practitioners clinical guidelines on the care of patients with diabetes is cautiously optimistic about how integrated care in GP practices and hospitals of people with diabetes could reduce the complications such as kidney problems, vascular problems in the legs and feet, retinopathy and heart problems.
"Our aim is to find out – there still isn't a national register for patients with diabetes – the exact numbers of those with diabetes, reduce the prevalence and reduce the symptoms and complications of those who have diabetes," says Velma Harkins, a GP in Banagher, Co Offaly, who wrote the ICGP guidelines.
Harkins has been running a community-based diabetes care programme over 18 years that has seen more than 4,000 patients. She is a firm supporter of treatment of chronic conditions such as diabetes in primary care with back-up support from hospitals for complications.
“Type II diabetes can be detected before the onset of symptoms and clinical signs by identifying those at risk and doing diagnostic testing,” says Harkins. “The early identification of patients and initiation of treatment can reduce the numbers who develop complications.”
For this integrated care model to work properly, more resources such as dieticians, podiatrists and diabetes clinical nurse specialists, will be needed in the community, she says.
The role of community-based diabetes clinical nurse specialists is to offer public screening for diabetes at such events as the National Ploughing Championships. The ICGP guidelines recommend that all adults who are overweight should be tested for diabetes.
The guidelines also state that some medications have also been shown to reduce the risk of diabetes in people with pre-diabetes.
Educational programmes on the management of diabetes are also central to better treatment of diabetes in the community. For example, individuals can self-refer to the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (Desmond) programme run by the HSE. Dr Aisling O'Leary, a lecturer in pharmacy at the RCSI, says that education of patients and the general public of the symptoms and treatment of diabetes is crucial. "Patient self-management and self-care is very important," she said.
“People need to understand and take their medication correctly and monitor their blood glucose. They need to eat healthily, drink moderately, be physically active, manage their stress and not smoke.”
National guidelines
The new ICGP national guidelines clearly set out a model of care in which those with uncomplicated Type II diabetes are seen three times a year in primary care, with any complications referred to hospital specialists. Two primary care visits and one annual hospital visit is recommended for those with complications.
“It is now recognised that joint care of patients with diabetes is best. The care of patients with diabetes has previously been in hospitals but this integrated care model needs to be rolled out to reach all patients with diabetes – both those on medical cards and private patients,” says Dr Harkins.
The care of people with diabetes accounts for 10 per cent of the healthcare spending in Ireland, estimated to be about €1 billion. About 60 per cent of this spending is on treatment of the complications of diabetes.
The big question is: if the savings gained from early treatment of people with diabetes were transferred into extensive screening programmes for diabetes, could we start to reduce the numbers of those suffering from diabetes in the future?
