Preventing diabetes: a call for concerted national action

Abstract

Many words have been written about the epidemic of type 2 diabetes (T2D) in developed and developing countries, and there are few clinicians at the coal face who do not feel overwhelmed by the tsunami of diabetes cases being experienced, particularly in multi-ethnic urban areas. It is clear that preventing diabetes is certainly more cost effective than treating the condition and its attendant complications. We now have strong randomised trial evidence that intervention, either by pharmacological or lifestyle methods, in patients with pre-diabetes can reduce risk of incident diabetes. 1,2,3 The seeds of diabetes are, however, sown in childhood and nurtured by environmental factors which require concerted action to break. It is clear, therefore, that prevention of diabetes should start earlier than the phase of pre-diabetes. Increasingly concerning is the fact that the onset of T2D is occurring at an ever-younger age and is now common among children and young adults. In high-risk ethnic groups, it seems likely that T2D is set to take over from type 1 as the predominant cause of diabetes in children. 4,5 The younger the age of onset of the disease, the greater the potential for complications to occur. While obesity and sedentary physical lifestyles are the main enabling factors for T2D in youth, there is growing evidence that in-utero exposure to hyperglycaemia may increase the risk of diabetes in offspring. 6 This may suggest that vigorous control of hyperglycaemia in women with gestational diabetes may be of importance in the prevention of diabetes in their children. In the UK, the National Institute of Health and Clinical Excellence (NICE) has recently published guidelines on the prevention of diabetes. 7 They exhort local and national action to tackle obesity and physical inactivity. Local action suggested includes provision of community-based weight management programmes for people who are overweight or obese, which is sensible given the outcomes of lifestyle interventions in trials of pre-diabetes and in people with early diabetes. The guidelines appropriately state that communities at high risk of diabetes should be targeted with culturally appropriate interventions. Implementation, however, has been limited and timid at best – perhaps from an unwarranted sense of nihilism by those responsible for commissioning and a lack of financial incentives (for example from Quality Outcomes Framework payments) by those who might support or deliver these interventions. When patients are referred for intervention it is often too little and too late. The guidelines also exhort national governmental action to prevent diabetes. They suggest that the UK government works with food manufacturers to improve composition of foods and develop clear nutritional labelling information, and also with food retailers to reduce the costs of healthier foods. The UK government’s response has been muted and restricted to policies around ‘nudging’ people into healthy behaviours. Information programmes such as ‘Change 4 Life’ have been pushed as a national response to this public health crisis. 8 The effects of such policies appear to be limited and at best offer a minor short term benefit. Such programmes have also received criticism for their sponsorship by commercial companies producing sugar-sweet