277. Auditing Diabetes in Ireland

New report
A report entitled “Audit Report of the HSE Midland Diabetes Structured Care Programme” (1) has just been released in Ireland, which was conducted in counties Longford, Westmeath, Laois and Offaly. It was concluded that the Programme was delivering care to patients with diabetes in accordance with the recommended national guidelines. It was demonstrated that:
• there have been improvements in glycaemic control since previous audits;
• prescribing levels of secondary preventative medications are extremely high;
• the incidence of complications has improved considerably over time despite increased numbers of patients being enrolled onto the programme.
All of this sounds very laudable and it has to be accepted that within the context of the national policy, some progress has been achieved. However if we stand back and consider the bigger picture, it is evident that the prospects are grim. As the report itself acknowledges about 9% of people in Ireland have Type 2 Diabetes (T2D). This figure may well be an underestimate and in any case all the expectations are that the incidence of the disease will continue to increase.
Impact of diabetes
It is acknowledged that for those with T1D, life expectancy may be reduced by more than 15 years. For those who have had T1D for up to ten years, life expectancy is likely to be reduced by between five and seven years.
It is also accepted that diabetes is responsible for a deterioration in the quality of life. Complications may include:
• Retinopathy – Diabetes is one of the leading causes of blindness among adults aged 20-74 years. After 15 years of diabetes, approximately 2% of people become blind and about 10% develop severe visual impairment;
• Neuropathy – Up to 50% of people with diabetes develop nerve damage. This can lead to foot ulcers and in severe cases, limb amputation2. In fact every 30 seconds a leg is lost to diabetes somewhere in the world;
• Nephropathy – Diabetes has become the single most common cause of end stage renal disease. The WHO estimate that between 10 and 20% of people with diabetes die of kidney failure.
On top of all this the risks of cardiovascular complications are increased and so heart disease is the leading cause of death in those with T2D. Compared to those without T2D, the risks of a heart attack or stroke are increased by a factor of between two and five.
In the year 2000 it was estimated that the total annual direct cost of treating those diagnosed with T2D was €377.2 M, which increased to €580.2 M when those who were not diagnosed were taken into consideration. This was equal to 6.4% of total healthcare expenditure. Obviously this current cost would be increased significantly because of the increased incidence of the disease coupled with inflation. In the UK, diabetes accounts for at least 10% of healthcare expenditure.

The audit results

First of all, the change in treatments between 2003 and 2009 are shown in Table 1.

Table 1. Treatments for T2D in 2003 and 2009

Diet and tablets70.269.5
Diet and insulin 3.0 3.8
Diet, tablets and insulin 4.613.4

The main changes are a reduction in those given advice on diet and a substantial increase in those on diet, tablets and insulin. The nature of the tablets has not been specified but presumably are metformin and other drugs normally used to treat diabetics.
The main points arising from the audit are as follows:
• Some limited improvement in the control of blood glucose (BG) for T2D but not for T1D.
• An increase in the prevalence of retinopathy for patients with T1D and T2D since the 2003 audit. Those who were diagnosed more than five years ago have much higher rates of retinopathy.
• There have been improvements in rates of hospital admission for ketoacidosis and hypoglycaemia as well as cardiovascular complications patients compared to 2003 except for amputations which remained static for minor amputations and increased from none in 2003 to five patients in 2009.
It must be emphasised that these results show very little improvement at all in tackling the T2D. The fact remains that the patients continue to suffer and the incidence of the disease is still increased showing that it remains out of control. There is no indication that there has been any improvement inpatients with T1D.
The fundamental issue is that the policy is a complete and utter failure. In a previous blog, I have described diabetes as a “flood of sugar” (2), which is analogous to a flood in a house caused by a burst water pipe. The solution is to stop the excess water coming in by fixing the pipe. Similarly, T2D can be reversed by limiting the glucose entering the blood that can be achieved by restricting the amount of sugar and carbohydrates consumed. There is plenty of reliable evidence to confirm that this approach works very well (3). The policy on diabetes in Ireland and in many other countries is exactly the same as trying to control a house flood with buckets and mops. It does not take a genius to appreciate that this is doomed to failure.
If genuine progress is to be achieved, it is essential to face up to these harsh realities. Why does this audit report totally ignore the excellent work of Dr David Unwin and colleagues (4)? They offer patients with T2D a choice of drugs or lifestyle change, which involves a reduction in the consumption of sugar and foods with a high starch content such as bread, pasta and rice. This could be replaced by increasing consumption of green vegetables, whole-fruits, such as blueberries, strawberries, raspberries and the “healthy fats” found in olive oil, butter, eggs, nuts and full-fat plain yoghurt were advocated. There was no need to do any calorie counting.
In a group of over 60 men and women, there was an average reduction in the HbA1c from 52.4, to 42.4 mmol/mol which is regarded as “normal”. There was a marked and significant reduction in GGT activity, which indicates that non-alcoholic fatty liver disease (NAFLD) had been reversed. There was an average weight loss of 9kg.
The participants reported that they felt healthier and more energetic on the LC diet. They also appreciated that the diet did not involve any weighing of food or calorie counting.
In addition, there was a substantial reduction in the use of drugs, which has resulted in a saving of about £40,000 per annum by the practice. It is striking that the audit did not report on the amounts of drugs used. As there is no suggestion that the per capita use of drugs had decreased, in all probability there was a big increase because of the growing numbers of diabetics.
When will the authorities in Ireland and elsewhere wake up to the fact that existing national policies are a complete failure and that there are alternative strategies, which not only improve health but require much less resources?
This represents a huge opportunity for politicians yet the reality is that no-one in any nation that I know has seized the opportunity.
1. http://www.lenus.ie/hse/bitstream/10147/110893/1/AuditReportDiabetesAudit2009.pdf
2. https://vernerwheelock.com/259-diabetes-is-a-flood-of-sugar/
3. R D Feinman et al (2015) Nutrition 31 (1) pp 1-13
4. https://vernerwheelock.com/198-more-good-work-from-dr-david-unwin/

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