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Public Health Module Venue Date Unit: Public Health Aspects of Diabetes WB1 © 2010
2 Course Aims This unit will: –Explore how common diabetes is; –Familiarise students with the risk factors of diabetes –Explore the efficacy interventions for the prevention and management of diabetes WB3 LTPHN/JS © 2010
3 Outline Part I: DIABETES AS A PUBLIC HEALTH PRIORITY 1.What is diabetes? 2.Classifying diabetes 3.Epidemiology - how common is diabetes? 4.Risk factors and consequences Part 2: PREVENTING AND MANAGING DIABETES 1.Primary prevention of diabetes 2.Secondary prevention 3.Screening in diabetes 4.Self care 5.Monitoring diabetes care WB3 LTPHN/JS © 2010
What is health? WB5 WHO Definition‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ Antonovosky:Salutogenic model ‘sense of coherence’ Seedhouse and Duncan:Achievement of potential Empirical Lack of health 4 LTPHN/JS © 2010
What is public health? ‘the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society’ C.E.A. Winslow, WB6 LTPHN/JS © 2010
The wider determinants of health Source: Dahlgreen and Whitehead, G and Whitehead M (1991) WB7 6 LTPHN/JS © 2010
The challenge for public health WB7 7 LTPHN/JS © 2010
Statistical description of nation’s health WB8 Census data Health Inequalities data Infant Mortality Rates 8 LTPHN/JS © 2010
9 1. What is diabetes? Diabetes results from reduced production of the hormone insulin, resistance of body tissues to the effect of insulin, or both. The result is abnormally high levels of glucose in the blood and widespread disturbances to metabolism. WB9 LTPHN/JS © 2010
10 History 30-90AD: Diabetes named by Greek Physician Aretaeus: means ‘a flowing through’ to describe its constant thirst, excessive urination and weight loss Japanese name: 'Shoukachi', the thirst disease 1600s: Professor Thomas Willis of Oxford University describes urine in diabetes mellitus as ‘wonderfully sweet’, distinguishing it from diabetes insipidus 1889: Oskar Minkowski and Joseph von Mering of University of Strasbourg remove a dog’s pancreas - it produces diabetes 1921: Banting & Best isolate insulin, successfully treats a patient, transforming diabetes to a treatable, chronic condition WB9 LTPHN/JS © 2010
The Healthy Body 3. Insulin triggers liver to take up glucose and turn into glycogen 1. Glucose, produced from carbohydrates, released into bloodstream 2. The pancreas produces insulin, also released into the bloodstream 4. Insulin enables cells to take up glucose Source: Diabetes UK, Diabetes and the Body animation (www.diabetes.org.uk/Guide-to-diabetes/Introduction-to-diabetes/What_is_diabetes/Diabetes-and-the-body/) WB14 11 LTPHN/JS © 2010
12 2. Classification The WHO recognises several types of diabetes Type 1 Type 2 Gestational diabetes Other types WB16 12 LTPHN/JS © 2010
I. Type 1 Diabetes The pancreas unable to produce insulin Accounts for ~15% of diabetes in the UK Mainly diagnosed in children/young adults Characterised by insulin deficiency Symptoms develop quickly WB16 13 LTPHN/JS © 2010
14 In type 1 diabetes, no insulin is available so cells are unable to take in glucose WB17 LTPHN/JS © 2010
15 Symptoms of type 1 diabetes Frequent and excessive urination Thirst Dehydration Tiredness Urinary or genital tract [eg thrush] infections Blurred vision Symptoms develop quickly Can progress to ketoacidotic coma WB15 LTPHN/JS © 2010
16 Type 2 diabetes Characterised by insulin resistance, though may also have deficiency [Used to be classified as Non-insulin dependent diabetes (NIDDM) but can require insulin] Similar acute symptoms to type 1 Compared with type 1, often develops gradually Some have no symptoms at diagnosis Milder forms: can be controlled by diet, and exercise Accounts for ~85% of diabetes in the UK Mainly diagnosed in older adults though increasingly seen in younger age groups too WB17 LTPHN/JS © 2010
17 II. Type 2 diabetes Fat deposits affect cells’ insulin (i) sensitivity. They are less able to take in glucose (g) WB19 LTPHN/JS © 2010
18 III. Gestational diabetes Excess blood glucose during pregnancy (both diabetes mellitus and impaired glucose regulation) Increased risk of diabetes related complications in pregnancy Health consequences for the baby include increased risk of birth complications: caesarean sections; still births and perinatal deaths very high birth weight babies birth defects obesity and diabetes in the child. For the mother: increased long term risk of type 2 diabetes (30% as opposed to 10% in the general population) higher risk of diabetes-related complications in subsequent pregnancies WB20 LTPHN/JS © 2010
19 IV. Other types Monogenic diabetes 1-2% of all diabetes, affecting 20,000-40,000 in UK Usually develops in under 25s Due to a single gene mutation Runs in families – affected person has 50% chance of passing on Currently 6 types of monogenic diabetes recognised Some types managed by diet and exercise alone Often initially misdiagnosed as type 1 or type 2 diabetes Diagnosing correctly can help inform which treatments are most appropriate give some idea of how the diabetes is likely to progress affected families understand their risk of diabetes and/or risk to their children WB22 LTPHN/JS © 2010
20 Diabetes insipidus Moderately rare condition - affects 1 in 25,000 Symptoms of excessive urination Distinct from diabetes mellitus: not related to production or sensitivity to insulin Urine not sweet related to function of vasopressin hormone in the pituitary gland WB23 LTPHN/JS © 2010
Classifying glucose regulation Normoglycaemia (low risk of diabetes/CVD) FPG: ≤ 6.0mmol/l Impaired glucose regulation (higher risk of diabetes/ CVD) FPG: >6 to <7mmol/l Diabetic (high risk of CVD) FPG: mmol/l “Healthy”“Diabetic” Diabetes Low risk Risk Glucose levels WB23 21 LTPHN/JS © 2010
22 3. Long term impact of diabetes Diabetes is an important cause of death and disability Diabetes is a leading cause of blindness, renal failure and neuropathy in the UK Life expectancy is reduced on average by 20 years in those with Type 1 diabetes and up to 10 years in Type2 diabetes WB12 LTPHN/JS © 2010
23 Retinopathy Common cause of blindness in people of working age in West Nephropathy 20% of all ESRD Erectile Dysfunction May affect up to 50% Macrovascular 2–4 x increased risk of CVD, 75% have hypertension 2–4 x increased risk of CVD, 75% have hypertension Foot Problems 15% develop foot ulcers; 5–15% need amputation Source: The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, WB12 LTPHN/JS © 2010
24 ‘Macrovascular’ complications cardiovasular diseases Biggest cause of death in diabetes: 75% of deaths in people with diabetes caused by cardiovascular disease People with diabetes have: 2x risk of death from heart disease 1.5-4x risk of stroke WB12 LTPHN/JS © 2010
25 ‘Microvascular’ complications Nerves (neuropathy): –affects up to 60-70% of people with diabetes –symptoms include tingling or burning, pain, numbness –increases the chance of foot ulcers and limb amputation –other conditions e.g. erectile dysfunction Eyes (retinopathy): –biggest cause of blindness in working aged adults in UK –long-term damage to the small blood vessels in the retina –after 15 years of diabetes, ~ 2% of people become blind, and about 10% develop severe visual impairment Kidneys: –Disease detected by protein in the urine –affects 30% of people with diabetes WB13 LTPHN/JS © 2010
Source: Yorkshire & Humber Public Health Observatory 2008 Deaths from diabetes ~ 2700 death certificates with diabetes as cause of death pa ~26,000 deaths from the diseases caused by diabetes pa So death certificates underestimate diabetes attributable deaths. Variations by area too: WB25 26 LTPHN/JS © 2010
27 Cost of diabetes Diabetes is a clinical area of high expenditure eg in one year, October 2007 to September 2008, there were 31.9 million NHS items prescribed = £581.2 million ~ 5% of total NHS spend is used for the care of people with diabetes The growth in expenditure on prescribing for diabetes is greater than any other major clinical area WB26 LTPHN/JS © 2010
28 4. Prevalence of diabetes Current prevalence Trends Models WB27 LTPHN/JS © 2010
Global impact Diabetes accounts for estimated 5.2% all world mortality 80% deaths occur in low & middle income countries Prevalence increasing fastest in these countries Source: WHO WB25 29 LTPHN/JS © 2010
Diabetes prevalence in England 2.1 million on diabetes registers BUT 25% in coronary care have undiagnosed Type 2 DM Y&H PHO modelling estimates: another 400,000+ not diagnosed The estimated prevalence of diabetes (diagnosed and undiagnosed) is 4.82% of population of England prevalence varies by area WB27 30 LTPHN/JS © 2010
Trends Diabetes expected to rise in England to 6.5% by 2025 WB28 31 LTPHN/JS © 2010
Diabetes UK Silent Assassin Campaign What do these images say to you about diabetes? WB29 32 LTPHN/JS © 2010
33 5. Risk factors Why consider risk factors? Type 1 v 2 WB30 LTPHN/JS © 2010
Type 1 Highest prevalence in northern European populations Strong familial link – genetic factors WB30 34 LTPHN/JS © 2010
Relative risks of type 2 diabetes Population factors:WB Family history; Age; Socioeconomic circumstances; Ethnicity Modifiable risk factors Obesity; Exercise; Smoking WB31 35 LTPHN/JS © 2010
Obesity BMI = weight (kg)/height (m) 2 BMI categories: In the Nurses Health Study, compared with women with a BMI or 23 or less, diabetes was nearly 40 times higher with a BMI of times higher with a BMI or UnderweightNormalOverweightObeseMorbidly obese < WB32 36 LTPHN/JS © 2010
37 Ashwell shape chart WB34 Take CareOKTake CareAction LTPHN/JS © 2010
38 Physical activity, obesity and the risk of diabetes WB33 LTPHN/JS © 2010
Age Prevalence of doctor-diagnosed diabetes, by age WB34 39 LTPHN/JS © 2010
40 Ethnicity In England, compared with the general population, rates of diabetes are: 3-4 x higher Bangladeshi, Pakistani and Indian men 5 x higher in Pakistani women 3 x higher in Bangladeshi and Black Caribbean women 2.5 in Indian women When assessing risk of diabetes, need to consider ethnicity, & also need to consider gender WB35 LTPHN/JS © 2010
Deprivation Age adjusted prevalence of known diabetes by fifths of deprivation score Mortality and morbidity are increased by socio- economic deprivation The complications of diabetes have been shown to be more prevalent in areas of high socioeconomic deprivation J Epidemiol Community Health 2000;54: WB36 41 LTPHN/JS © 2010
42 Other risk factors Smoking: small relative risk compared to obesity, but of public health importance given prevalence of smoking, particularly in poorer socioeconomic groups Physical health problems Mental health WB37 LTPHN/JS © 2010
43 Diabetes and gender Risk factors affect men and women differently Risk of death from heart disease linked to diabetes is greater in women than men: Is diabetes more harmful to women? and/or Is treatment better for men? and/or?? Gestational diabetes: numbers of diabetes cases in women of childbearing age increasing Risk factors: family history; pre-pregnancy obesity; advanced maternal age; gestational diabetes in previous pregnancy; ethnic background; large baby (≥ 4.5 kg) in a previous pregnancy; smoking WB38 LTPHN/JS © 2010
44 Part 1 summary Diabetes is a chronic condition –It can lead to CVD, kidney failure, limb amputation and blindness Type 1 and type 2 diabetes share similar symptoms but different public health implications Type 2: –85% of diabetes in UK –Obesity most important modifiable risk factor. –more common in people over 40 years, Pakistani, Bangladeshi, Indian and African Caribbean populations Women and poorer socioeconomic groups more at risk of diabetes complications and death from diabetes Problems assessing the health burden of diabetes because: –~20% with type 2 diabetes remain undiagnosed –diabetes seldom recorded as cause of death but its complications – heart disease, stroke, renal failure – are leading causes of death. WB40 LTPHN/JS © 2010
45 Exercise: ‘Westport’ PCT’s local diabetes Needs Assessment ‘Westport’ PCT needs to understand the current impact of diabetes on its population – prevalence, health consequences and effects on services - and to forecast the impact of diabetes in the future From what you’ve learnt in the module so far, how would you find out about the impact of diabetes on your local population? What sources of data could you access? What information would you collect specifically? Who would you ask? WB41 LTPHN/JS © 2010
46 Part 2: Preventing and managing diabetes 1.Primary prevention of diabetes 2.Secondary prevention 3.Screening in diabetes 4.Self care 5.Monitoring diabetes care WB42 LTPHN/JS © 2010
47 1. Primary prevention Three strategies for primary prevention- Upstream- whole population Midstream- special high risk groups e.g. children, elderly Downstream- high risk ‘individuals’ Type 2 prevention Government priority in England: “The NHS will develop, implement and monitor strategies to reduce the risk of developing type 2 diabetes in the population as a whole and to reduce the inequalities in the risk of developing type 2 diabetes.” Standard 1 of the Diabetes National Service Framework, 2003 WB43 LTPHN/JS © 2010
48 Population measures Reducing obesity Increasing physical activity Choosing health: choosing a healthy diet and choosing activity –5-a-day –5-a-week WB43 LTPHN/JS © 2010
49 Identifying high risk individuals Why? –Can target interventions to those most at risk How? –Risk assessment considering »Weight (BMI, waist circumference) »Blood pressure »Cholesterol »Blood glucose WB45 LTPHN/JS © 2010
50 NHS Health Check WB46 LTPHN/JS © 2010
Interventions for high risk individuals Lifestyle interventions significantly reduce progression rates to diabetes in prediabetic individuals Trials have shown that sustained lifestyle changes in diet and physical activity can reduce the risk of developing type 2 diabetes StudyCountry% risk reduction Diabetes Prevention Programme (Tuomilehto et al, 2001) Finland58 DAQing (Pan et al, 1997)China46 Diabetes prevention programme (Knowler et al, 2002) America58 WB47 51 LTPHN/JS © 2010
52 Programmes for high risk Medications & non-drug interventions to: –reduce blood pressure –lower cholesterol (eg statins) –manage blood glucose Community referrals for programmes on: –exercise –weight management –smoking cessation Specialist referrals for bariatric surgery? WB48 LTPHN/JS © 2010
Exercise: theory… Chief Medical officer Report 2004: ‘5 a week’ call for action At least 30 minutes exercise 5 times a week can improve health, prevent diabetes and reduce overweight WB48 53 LTPHN/JS © 2010
54 …reality? And…people with diabetes less likely to meet exercise recommendations WB49 LTPHN/JS © 2010
55 target high risk or provide for the whole population? In public health, there is often debate about whether to target high-risk individuals or offer population wide strategies to promote health and prevent disease Think of some of the pros and cons of these contrasting approaches for lifestyle interventions to adopt healthier diets and take more exercise to prevent diabetes WB50 Exercise 2: Encouraging healthy eating and regular exercise LTPHN/JS © 2010
56 3. Screening Primary prevention –To identify people at increased risk of disease Secondary prevention –To identify early stages of disease NSC found no evidence to implement national screening for diabetes in UK. Better strategy to: –optimise management of blood pressure and hyperglycaemia in people with known diabetes; and –ensure universal screening for eye disease WB53 LTPHN/JS © 2010
57 4. Self care and self management DESMOND for type 2 diabetes Diabetes Education and Self Management for Ongoing and Newly Diagnosed patients Group sessions to help new patients to –identify their own health risks –develop behaviour and health goals tailored to their own circumstances Evaluation found: –greater weight loss & smoking cessation –improvements in beliefs about illness –No change in HBA1c WB56 LTPHN/JS © 2010
58 5. Monitoring diabetes care Why? –To find out if services delivered as intended –To find out whether services reaching groups that need them How? –Local monitoring, checks, visits, feedback –National data Monitoring against targets: access Patient survey: patient experience Hospital admissions & procedures: outcomes WB59 LTPHN/JS © 2010
59 NCHOD admissions and procedures WB61 LTPHN/JS © 2010
60 Part 2 summary Type 2 diabetes is preventable Complications of diabetes can be avoidable Interventions aim to: –encourage healthy eating and regular exercise –reduce blood pressure, cholesterol and improve glucose regulation –reduce complications Programmes in England to improve diabetes care focus on identifying high risk individuals, rewarding quality services, screening for retinopathy Monitoring indicates room for improvement in access and effectiveness WB63 LTPHN/JS © 2010
61 Exercise 3: Shaping your local services ‘Westport’ PCT’s public health department has been asked to recommend how Nowhere should develop its diabetes services. How would you assess the impact of diabetes services provision locally? From what you’ve learnt in the module, how would you decide on your top priorities for diabetes in your local area? Think about: –Prevention vs treatment –Evidence based programmes vs learning through doing –National policy priorities and targets WB64 LTPHN/JS © 2010
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