On Barbara Young’s office table is a graph. A bar chart, actually: Four columns of green, purple, red and bright blue showing the progression, in England, of rates of coronary heart disease, stroke, cancer and diabetes over the past five years. The first two are flatlining or falling. Cancer, in red, is rising, but slowly. Trace a line between the blue bars from 2005 to last year and it soars off the chart.
“Diabetes,” Young says flatly, “is becoming a crisis. The crisis. It’s big, it’s scary, it’s growing and it’s very, very expensive. It’s clearly an epidemic and it could bring the health service to its knees. Something really does need to happen.”
Baroness Young is, admittedly, the chief executive of Diabetes UK, Britain’s main diabetes charity and campaigning group. It’s her job to say such things. However, the figures are behind her all the way: Diabetes is fast becoming the 21st century’s major public-health concern. The condition is now nearly four times as common as all forms of cancer combined and causes more deaths than breast and prostate cancer combined. About 2.8 million people in the UK have been diagnosed with it; an estimated 850,000 more probably have type 2 diabetes, but don’t yet know. Another 7 million are classified as at high risk of developing type 2; between 40 percent and 50 percent of them will go on to develop it. By the year 2025, more than 5 million people in Britain will have diabetes.
The implications for the National Health Service (NHS), obviously, don’t bear thinking about. Diabetes already costs the service around ￡1 million (US$1.6 million) an hour, roughly 10 percent of its entire budget. That’s not just because the condition generally has to be managed with medication or insulin, but because by the time they are diagnosed, around half the people with type 2 — by far the most common and fastest growing form — have developed a longer-term complication.
Cardiovascular disease, for example, will kill 52 percent of people with type 2 diabetes, who are also twice as likely to have a stroke in the first five years after diagnosis as the population at large. Almost one in three people with the condition will develop kidney disease and diabetes is the single biggest cause of end-stage kidney failure. You are up to 20 times more likely to go blind if you have diabetes.
“The cost of some of these complications, in terms of medical and social care, unemployment benefits, everything, is just enormous,” Young says. “People can’t work, can’t drive ... and so many personal tragedies. People with diabetes have a foot amputated 70 times a week in England, and 80 percent of those amputations wouldn’t have been necessary if it had been caught earlier and looked after properly.”
Recently, Young says, she met a former ballerina.
“No one had told her, when she was in her 20s and 30s, that maybe it wasn’t such a good idea, might be dangerous even, to keep her blood sugar level deliberately high, for energy. She just had her heel amputated,” she says.
Nor is this, of course, a national epidemic. Around the world, 285 million people now have diabetes, a figure expected to climb to 440 million within 20 years. In North America, one in five men over 50 have the condition; in India, it’s 19 percent of the population; in parts of the Middle East, 25 percent. On the tiny Pacific island of Nauru, very nearly one in three people has diabetes. This goes some way to explain why some countries are taking a tough stance on health — Denmark has imposed a “fat tax” of 16 kroner (US$2.93) per kilogram on saturated fat in a product, while France is adding just over ￡0.001 to the price of fizzy drinks (although zero-calorie “diet” versions are exempt).
So what is it? Diabetes is when there’s too much glucose in the blood. Glucose is the body’s fuel; our cells use it as their primary source of energy. However, to enter a cell, glucose needs insulin, a hormone made by the pancreas. If for some reason we don’t produce enough insulin, or the insulin we produce doesn’t work properly, glucose builds up in the blood. That’s diabetes.
There are two main types: Type 1, which accounts for around 10 percent of all diabetes, is when your body produces no insulin. Nobody quite knows what causes this, but it’s not preventable and it typically presents itself early on, often in childhood.
Type 2 is when your body can make insulin, but not enough of it, or when what it makes doesn’t work properly. For reasons not fully understood, type 2 diabetes is six times more common in people of South Asian descent and three times in people of African and African-Caribbean origin. It usually occurs from around the age of 40 (or 25 if you’re South Asian or black) and apart from genetics — you have a 75 percent chance of developing diabetes if both your parents did — the biggest preventable risk factor is weight.
This is about unhealthy diet and lack of exercise.
“It’s just so easy to eat nowadays,” Young says. “We live in what I call a glucotoxic environment. And we simply don’t get the physical exercise we used to.”
Naveed Sattar, professor of metabolic medicine at the University of Glasgow, is one of the UK’s leading diabetes researchers. He’s also very lean and alarmingly fit. Of South Asian descent, both his parents have type 2 diabetes.
“My lifetime risk,” he says, sitting in the lobby of the British Heart Foundation’s headquarters in London, “is around 95 percent. I am very careful.”
Sattar is unequivocal about the reasons for the epidemic.
“There’s genetic potential, plainly,” he says. “Family history and ethnicity. But what I tell my patients is basically this: Weight gain, excessive weight gain, will eventually lead to type 2 diabetes. This is an obesity-driven epidemic. Make no mistake.”
OVERWEIGHT
Not just obesity either; overweight can be enough. How does that excess weight lead to type 2? Scientific understanding of how this works is relatively new, Sattar says, but the thinking is roughly as follows: If we consume more calories than we burn, we store the excess as fat. Among the places we store it are the pancreas and the liver, thus interfering with the former’s capacity to produce insulin and the latter’s capacity to react to it.
Researchers at the University of Newcastle recently established that type 2 could, in some cases, be “cured,” at least temporarily, by an extreme 600-calorie-a-day diet — the effect was to reduce body weight dramatically, but also to slash fat on the liver and pancreas.
Similarly, about 73 percent of people with diabetes who have undergone bariatric surgery, and lost at least 15kg of body weight as a result, appear to be free of the condition.
“It’s looking increasingly likely that this accumulation of excess fat on the liver, and now the pancreas, is a key cause of type 2,” Sattar says.
Statistically, the risk of diabetes soars as the kilograms pile on: An increase in body mass index (BMI) — the generally accepted measure of healthy weight for height — from 21 (healthy) to 35 (obese) means you are 50 to 80 times more likely to develop type 2.
However, the correlation isn’t perfect. Some people with a supposedly healthy BMI develop the condition; others with BMIs into the 40s do not. It appears that women have to put on more weight than men to develop the condition. People of South Asian origin can develop diabetes with quite low BMIs; Sattar’s two uncles did so in their 30s, with BMIs of just 24.
“We’re thinking it’s about an individual’s ability to make and store fat safely,” he says. “Some people can store fat subcutaneously. With others, it goes straight to the liver and pancreas. That’s the classic big waist, pot belly shape; the fat isn’t distributed around the body.”
This explains why simple waist measurement — 94cm or more for men, 89cm for South Asian men, 80cm for women — is now seen as a better risk indicator for diabetes than BMI.
Once diagnosed (the symptoms, classically, include urinating more than usual, increased thirst, tiredness and blurred vision), diabetes has to be managed. For some, this can simply be about diet and exercise. Many more require a panoply of drugs that act variously to reduce sugar levels; prompt the pancreas to produce more insulin; get the insulin to work better. When drugs can’t regulate sugar levels, the final treatment line is insulin.
However, our success in managing the condition, Sattar says, is creating new problems.
“We’re getting pretty good at keeping people alive longer,” he says. “And we’re seeing more and more obese younger people going on to tablets ever earlier. That means the population living with diabetes is rising. Statistically, the number of complications could well increase.”
Young warns that that’s the last thing the NHS needs.
“This isn’t actually a money thing,” she says. “It’s not like care for the elderly. There is money in the system. But we need to switch resources: Spend money much earlier on prevention, risk assessment, early diagnosis, help with effective self-management.”
Young wants a major government healthy-lifestyle push — co-ordinated measures including a national information campaign, local support and tax incentives — that would contribute to raising the profile of diabetes as “an important and ghastly condition,” plus a proper risk-assessment program.
She’s not confident of getting the former, because this Conservative-led government doesn’t much like big, centralized, top-down initiatives. On the latter, she says, the NHS has something called a vascular health check, which people over 40 should be getting, “except most of us haven’t heard of it. We screen for cervical cancer, heart disease, high blood pressure. The stroke program’s completely revamped. But diabetes is now a much bigger problem than stroke. A vascular check would help pick it up and it’s not working.”
Diabetes UK has drawn up a 15-point list to help ensure everyone diagnosed with diabetes gets the care they need, including checks on blood sugar levels, blood pressure, cholesterol, eyes, feet and kidneys.
“We want 2.8 million people up on their hind legs, demanding they get the right care,” Young says. “That has to change. Plus there are big variations in care regionally.”
Type 2 is, additionally, a class condition: The most deprived people in the UK are two-and-a-half times more likely to have the condition than the average. Sattar reckons a big part of the future effort is going to have to be in “simple, pragmatic, sustainable” dietary advice.
“We have to get better at advising people on what they eat,” he says. “Changing someone’s eating habits is very, very hard. One of my patients from the east end of Glasgow, who’s never eaten an apple in his life ... It’s going to be hard. But that’s the way we’re going to have to go.”
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