Type 2 diabetes, a preventable disease caused mainly by obesity and poor diet, has become the 21st century’s first pandemic
From cholera to TB, humanity has known many fearsome epidemics and pandemics. And while medicine and hygiene have been hugely effective in fighting disease, one of the best weapons has always been education. From practising safe sex to avoiding contaminated water, improving public health often demands nothing more than a simple message.
The first modern pandemic of the 21st century is no different, and the message is already well-known. Yet around the world no government, scientist, doctor or public advocate has been able to stem the rise in numbers. Type 2 diabetes now affects more than 220 million people worldwide, according to the World Health Organisation (WHO); in 2004 an estimated 3.4 million people with type 2 died from consequences of high blood sugar, and the WHO projects that diabetes deaths will double between 2005 and 2030.
The charity Diabetes UK says that there are 2.8 million people diagnosed with diabetes in Britain and an estimated 850,000 people who have the condition but don’t know it. ‘If trends continue, 60 per cent of men and 50 per cent of women will be obese by 2050, and the majority will either have type 2 diabetes or be at high risk,’ Professor Sir George Alberti, the chairman of Diabetes UK, says. ‘This frightening escalation will result in an estimated cost of £50 billion to the NHS.’
Type 1 diabetes is a condition in which the immune system attacks cells in the pancreas that produce insulin, the hormone that regulates blood sugar. It occurs in childhood, is unpredictable and irreversible (cases make up no more than 10 per cent of overall sufferers). Type 2, on the other hand, ought to be completely preventable. It is caused principally by obesity and poor diet, with internal organs taking a battering from large quantities of sugar and fat, preventing the pancreas from producing enough insulin, or the body using it effectively. Those with the condition may become infertile, lose limbs, their sight, even their lives because of it.
‘This is not a mild or benign condition,’ Professor Nick Finer, a consultant in endocrinology and bariatric medicine at University College London, says. ‘You never get a “touch” of diabetes, as some patients seem to describe it. Yes, you can control it – with scrupulous care of your blood pressure, cholesterol levels and insulin. But within 10 years of diagnosis, most people will end up self-injecting insulin daily. And the disease will probably be inflicting damage on the minor blood vessels in their eyes and kidneys, and in the large vessels around the heart and in the legs.’
Though clearly linked with obesity, another concern for doctors is that most people underestimate how easy it is to slip into the danger zone of weight where diabetes becomes much more likely. ‘You don’t have to be obese to be at risk,’ Simon O’Neill, the director of care, information and advocacy at Diabetes UK, and a qualified nurse, says. ‘Much depends on where you store your fat. Women whose waists measure more than 31½ inches, and men whose waists are greater than 37 inches [35 inches for men of south-east Asian descent] are in the at-risk category. As we age, we all find it harder to control our weight, so that means we all become more at risk of diabetes simply with the passing of time. Already we are spending 10 per cent of the health budget on five per cent of the population simply trying to control and manage the problem, and soon one in five hospital beds will contain a diabetes patient. And we are not alone. India and China are both seeing huge rises in numbers. The brakes are simply not going on.’
What really concerns doctors is that growing levels of obesity in children have led to cases of type 2 being diagnosed among the under-18s. ‘Twenty years ago it was unheard of,’ O’Neill says. ‘Now, obesity-led onset of diabetes is a completely new paediatric disease. There are parts of the world where 10 per cent of children have type 2. If you have diabetes at 50, and you control it well, even with some damage to blood vessels, you may shorten your life a little, or be more incapacitated at 70 than you might have been, but what happens to someone diagnosed at 20? The consequences for them will be huge. They will spend their lives on medication, at increased risk of stroke and heart disease, never knowing a normal life.’ He gives a warning: ‘We are at risk of seeing the first generation of humans who will have shorter lives than their parents.’
Charlie Bruce, 24, from north London, works in a guitar shop and hopes to become a professional musician. Bruce became insulin-resistant at the age of 10, when he weighed 10 stone. ‘I honestly don’t think I ate a lot,’ he says, ‘but I just didn’t move around much.’ Doctors prescribed metformin to control his insulin production – an oral antidiabetic drug which helps the body manage its blood sugar, keeping levels as stable and similar to a non-diabetic as possible. Metformin is rapidly becoming one of the most widely prescribed drugs in the world – in the US alone, there were 42 million prescriptions in 2009 for generic versions of the compound (in Britain, prescriptions rose from 7.6 million in 2004/5 to 13.2 million in 2009/10).
By the time he was 12, Bruce had gained a further two stone. His mother, Suzy, took him to more doctors and nutritionists, but no one, she says, knew how to help. Eventually he was referred to Great Ormond Street Hospital and, at 16, was diagnosed with type 2.
Bruce admits he was not a perfect patient, and that the diagnosis made little impression on him. He would skip his medication as it gave him terrible stomach upsets (a common side effect). He dieted on and off, with little enthusiasm, losing weight and then regaining it. ‘My teenage years were not a happy time,’ he says. ‘I never felt good about myself. So I stopped going out.’
Suzy, 53, who two years ago weighed 19 stone, could relate to those feelings. ‘I’ve been plump all my life, and I’ve dieted all my life,’ she says. ‘With a Spanish mother and a Jamaican father, both of whom developed diabetes in later life, my genes were always pushing me that way.’
Her weight soared during her two pregnancies (Charlie has an elder brother, Jason, 33) – ‘even my earlobes were fat’ – and she says she was always alert to her sons’ weight. ‘I can’t tell you how much I worried about them, and tried to ensure our diet was healthy. I was constantly aware of being judged on my mothering skills. I even fell out with a neighbour who went on and on about Charlie’s weight.’
At 18 Bruce gained a place at the Academy of Contemporary Music in Guildford, Surrey, and spent four years living away from home. ‘I was beside myself with worry by this time,’ Suzy recalls. ‘I couldn’t even attempt to control what he was eating or remind him to take his medication.’ At 22, Bruce weighed 25 stone.
Roger Lewis, 61, a former drama teacher and actor, wishes he had taken the risks of type 2 diabetes more seriously when he was a young man. In 2006 type 2 cost Lewis his lower right leg; he now manages with a prosthesis, ‘a real bionic thing, with a flexible foot,’ he says. ‘I’ve never been a drinker, but I’ve always loved my food,’ says Lewis, who lives in Watford with his wife, Irina, 42. ‘I was a gourmand, and ended up weighing nearly 19 stone. Late nights rehearsing or performing meant I didn’t have a lot of time for exercise. And I was a smoker, too; a 40-a-day man from the age of 14.’
Smoking is a common factor in developing type 2; it raises blood glucose levels, probably due to the nicotine and other ingredients in cigarettes causing insulin resistance. Type 2 sufferers who smoke risk developing neuropathy (nerve damage), nephropathy (kidney damage) and retinopathy (eye damage); smoking also decreases the amount of oxygen reaching the tissues of the body, which can lead to a heart attack or stroke. And it can make blood cells stick together, which attracts cholesterol and causes fats to stick to the artery walls, making it difficult for blood to circulate. The end result is damaged and constricted blood vessels (known as atherosclerosis), or the formation of a clot which can break away to travel round the body, leading to a heart attack, stroke, peripheral vascular disease and worsening of foot and leg ulcers.
Lewis was diagnosed with type 2 just over 30 years ago, during investigations for an irregular heartbeat. ‘I was in hospital having tests, and was aware that I felt thirsty all the time. My father brought me in a bag of clementines, and I scoffed the lot in 10 minutes – I craved the sweetness of the juice.’ Nurses noticed Lewis’s thirst. It is a classic symptom of type 2, caused when the body responds to the need to excrete toxic amounts of sugar circulating in the blood, which would normally be managed via insulin and burnt off or stored; instead the kidneys flush it out – leading to intense thirst, and constant trips to the lavatory.
Sufferers of type 2 don’t automatically need to begin injecting insulin, which is naturally produced whenever we eat, with the stomach sending a message to the brain that food is present, and the brain sending a message along the spinal cord (the neurotransmitter superhighway) to the pancreas to warn that insulin is needed to deal with the sugar that will be produced when food is digested, and be transported by the blood. Insulin acts as a key, unlocking the cells, so if there is not enough insulin, or it is not working properly, the cells are only partially unlocked (or not at all) and glucose builds up in the blood.
If you eat constantly (the modern passion for grazing), or consume a lot of high-sugar foods (such as sweetened drinks, cakes and sweets), or super-calorific food such as pizzas and chips, your pancreas is bombarded with demands for insulin. Eventually the pancreas stops responding and either floods the body with insulin that no longer works properly or packs up altogether.
Lewis was prescribed metformin, and the daily tablet was no big deal. ‘To be honest,’ he admits, ‘I saw the pills as taking care of the inconvenience of diabetes. I still felt I was invincible. I carried on smoking and scoffing biscuits.’
In 2004, while on holiday in Rome, Lewis found he was having trouble walking; his feet were sore and uncomfortable. ‘Back home, I went to see my doctor and said I suspected I had gout. But I was told I had “ischemic foot” – the blood was not getting through, specifically to my right foot. I was taken to hospital as an emergency case and underwent an angioplasty, where a needle is placed into the groin and a deflated balloon passed through into the blood vessels, before being expanded to try and open them up again.
‘I was furred up like an old kettle from the effects of too much blood sugar still circulating in the blood, despite the tablets. I had developed gangrene in my foot. I had to lose it or die.’ He admits that the message finally hit home. ‘I was lying on the bed, tearful and depressed, but it was a no-brainer.’
Early in 2006 Lewis was admitted to Watford General to have his lower right leg removed. ‘I woke up screaming in pain,”My ankle, my ankle.” The registrar said, “What are you fussing about; we’ve taken that off.” I had phantom limb pain, common to amputees.’
Losing a limb is traumatic – Lewis admits he wept a lot in the weeks that followed. ‘You feel you’re alone; you’re the only one.’ But when he began rehabilitation at Stanmore Royal National Orthopaedic Hospital, he was inspired by other amputees to get moving properly. ‘I saw one lady running so easily on the treadmill – it turns out she had lost both legs in the 7/7 bombings.’ Now, although he doesn’t have the stamina to teach or act, his passion for life has returned; although when he looks back to how he refused to take the condition seriously, he thinks, ‘What a prat I was.’
Previn Diwakar, a consultant interventional radiologist at East Kent Vascular Centre, Kent and Canterbury Hospital, sees many patients like Roger Lewis. He believes that if the public were more aware of the complications, they would be less complacent. He treats diabetics with furred-up arteries, and trying to prevent them losing a limb takes up a large part of his caseload. He uses angioplasties to try to de-fur arteries, and inserts stents to keep them open when he can.
The public’s lack of concern is something he finds enormously frustrating, but it is the national political attitude that angers him most. He finds the lack of medical protocol for care very worrying. ‘There are Nice [National Institute for Health and Clinical Excellence] guidelines, but that is all they are – guidelines, not rules. There is no minimum standard of care for patients with diabetes, so how it is managed will depend hugely on how seriously your region takes it. Until now this has meant local Primary Care Trusts, but with the proposal for GP commissioning [GPs taking control of budgets from local PCTs] the chance of a postcode lottery governing patients’ futures has increased significantly. For example, there is much more emphasis on the management of stroke than there is for diabetes.’
Mr Diwakar also worries about the lack of continuity of care between GPs and specialist clinics. ‘If a diabetic patient has an ulcer, they should be referred urgently to me. Ulcers that don’t heal are a sign that the condition is not being controlled properly as the bacteria in the wound are feeding off an uncontrolled high-sugar blood supply. That also means the vessels are likely to be thickening up. If we don’t act fast, this is a classic case where a patient could lose a limb.
‘But if I do see them soon enough, I can reverse some of the damage, perhaps prevent an amputation. Yet, lack of communication or continuity of care means I often see patients whose ulcers are two years old – their outlook is much bleaker.’ He is aware that there is a socio-economic connection. ‘The map of amputations performed clearly shows up that the worst areas are in the most deprived regions: the North-east and North-west.’
Britain lags behind its European neighbours, too. A report in the journal Diabetic Medicine about amputation rates across Europe suggested a lack of early referral rates in Britain meant that doctors such as Mr Diwakar were not seeing type 2 patients until their condition had become severe.
‘There has been a lack of investment in diabetes care and in vascular medicine, and this is the result,’ he says. ‘Short-termism means that often I will be refused the chance to insert stents into patients’ arteries where I feel they would benefit; instead, these patients are left until they need amputations, and then they become a much bigger burden on society through disability payments and social benefits. We need to spend more money ensuring diabetic patients get lifestyle advice so they can control the disease themselves. I want to do my best for patients, but my hands are tied.’
Simon O’Neill at Diabetes UK is frustrated, too. ‘We know that when we get out and do local roadshows explaining the connection between obesity and the onset of diabetes, and the risk of not taking the problem seriously, we can have an impact. We use a simple series of questions and refer people on to their GPs. But we’d like to see screening programmes everywhere.’
Sometimes more radical measures are called for. Bariatric surgery – fitting obese patients with gastric bands (which restrict the size of the stomach pouch) or performing gastric bypasses (re-routing the stomach to limit calorie absorption) – has been found to improve type 2 diabetes significantly. The often huge weight loss triggered by the operation allows the body’s insulin levels to stabilise and the diabetes goes into remission.
‘People who are clinically obese should try to lose weight through diet and lifestyle changes in the first instance,’ Sir George Alberti of Diabetes UK says. ‘However, bariatric surgery should be used as an alternative treatment to help people lose weight if all other attempts have been unsuccessful and their diabetes remains poorly controlled. Bariatric surgery is not a cure for type 2 diabetes, although it can result in a lengthy remission.’
Pratik Sufi, a consultant general and bariatric surgeon at Spire Bushey Hospital and the Whittington Hospital NHS trust, explains, ‘Endocrinologists used to treat diabetes with medication and were reluctant to recommend surgery, but that view is changing. It is recognised that type 2 diabetes can even be avoided if the weight problem is tackled early on. Unfortunately not all paediatricians agree. So although it is safe to operate on teenagers – girls from 13, boys from 15, when 80 per cent of their growth is completed – young patients may be told to work on their diet and exercise for years before they are handed over to us.
‘And of course, the NHS has to balance its books, which is often the argument used for not recommending surgery. Yet bariatric surgery makes good financial sense: the patient gets the health and social benefits immediately; the state benefits in the long term as the patient needs fewer long-term medications or the costs with associated health problems, plus there are concomitant incoming taxes and fewer outgoing welfare benefits.’
But, he admits, many people are unsympathetic to bariatric surgery. ‘They see it as an easy option, a shortcut to weight loss. Nothing could be further from the truth.’ It is still a major surgical procedure, with all the risks that entails. Afterwards, there are only minor restrictions. ‘You have to take daily multivitamins, because the surgically altered body finds vitamins harder to absorb, and you have to maintain portion control and eat healthily.’
Charlie Bruce was lucky. His GP was sympathetic to the idea of bariatric surgery. After consultation with Pratik Sufi, his operation took place last July. To prevent the onset of type 2, his mother, Suzy, had the same operation a few months later. Although Bruce, now living with his mother once again, found it ‘nerve-racking’, it has been a huge success. He recovered well and has already lost more than eight stone. ‘I’m out every day now,’ he says. ‘I play football every Thursday with friends, and just completed a 15-mile walk across London for charity. My life has changed completely. I used to be plagued with heartburn, but that’s gone.’
Best of all, his diabetes is in remission. He can legitimately forget about metformin, although Suzy – who now weighs 13 stone – still has to nag him to take his vitamins. ‘I’ve got tons more energy,’ he says. ‘I live in the now, not the past.’amputee, blood sugar, diabetes, Diabetes UK, irregular heartbeat, pandemic, phantom limb pain, prosthesis