Diabetes: the silent killer we must prevent as well as treat

The government’s latest sugar tax has sparked fierce debate about whether hiking up the price of unhealthy foods is a fair or effective way to tackle obesity. 

But one thing those at loggerheads would probably all agree on is that recent figures on obesity and diabetes are alarming. 

In the year leading into the pandemic, over one million people in the UK were admitted to hospital for obesity-related treatments, the highest number on record. The number of people living with obesity in England has almost doubled in the past 20 years to over 13 million. 

Obesity is the single greatest risk factor for developing diabetes – so it comes as no surprise that the number of people in the UK living with diabetes has doubled in the last 15 years, reaching an all-time high of over 4.9 million.

At the rate things are progressing, Diabetes UK predicts that 5.5 million people in the UK will have diabetes by 2030. 

As Mike Trenell, professor of metabolism and lifestyle medicine at Newcastle University, is keen to stress, the pandemic has exposed with devastating clarity “the extent to which those with underlying chronic illnesses – such as diabetes— are vulnerable.”

Indeed, diabetes is one of the most significant risk factors for death or severe illness from Covid-19. 

The latest figures should be a wake-up call for tackling these conditions. But in order to do so, we need to understand why rates are rising so dramatically. 

There are two types of diabetes. Type 1 diabetes is an autoimmune disease, where the body doesn’t produce enough insulin. It generally comes on in childhood and is not associated with excess body weight. 

Type 2, on the other hand, is triggered by being overweight or inactive. It occurs when the insulin being produced doesn’t work properly because of a build-up of fat in the muscle and liver – and it now accounts for 90 per cent of diabetes cases. 

But to understand the causes of type 2 diabetes, we need to place poor diet and lack of exercise in a wider context, Prof Trenell says: “To be provocative, your postcode is one of the strongest determinants of your BMI.

“Socioeconomic status plays such an important role in the development of long-term conditions. It determines the type of food you eat, the patterns of eating, whether you live in an environment where you can exercise and do more and it determines whether you have the financial flexibility to choose one type of food over another.”

Of course, the pandemic has served as a stark reminder that ill health must be placed in a wider context of social deprivation if we are to understand risk and susceptibility. According to Prof Trenell, “Covid-19 has exposed the ‘haves and the have-nots’ like never before in the UK, and that’s going to have enormous ramifications for years to come.”

The most profound thing we can to do to tackle the diabetes crisis is to “prevent poverty and decrease the gap between the haves and have-nots.” 

Here, Prof Trenell references Michael Marmot’s seminal “10 years on” report about health equity – or lack thereof – in the UK. Health inequality is on the rise, as Marmot demonstrated so saliently. From the beginning of the 20th century, England experienced continuous improvements in life expectancy. But from 2011 to 2020, the pattern changed. Life expectancy has actually started to decline in some of the most deprived regions in the country. 

Closing this health gap would benefit the nation as a whole. Indeed, type 2 diabetes represents the single largest disease cost to the NHS and taxpayer. “Ten per cent of the NHS budget every year is spent on a condition that, for many, is preventable.”

Sadly, while the pandemic may have helped to expose inequalities within the UK, it has also intensified them. “In the past 12 months, we’ve seen the gap between the poorest and the richest widen even further.

“One thing I’m sure of,” says Prof Trenell, “is that the most up-to-date stats on diabetes aren’t correct. The real figures will certainly be higher.” 

Early evidence suggests that the pandemic has led to weight gain for many people – and not just for those in poorer demographics. “We’ve stayed at home and we’ve all been way too close to the cookie jar.” Some have jibed, that “Covid-19 refers to the amount of pounds we’ve put on.”

Many of those already with a diabetes diagnosis will have seen their conditions deteriorate. Those with diabetes are in the vulnerable category and many have shielded. But staying safe from the virus also means “they haven’t gone to the doctors for their check-ups, their physical activity levels have gone down and their body weight has gone up.”

We’ve seen headlines about missed cancer screenings and cancelled surgeries, but a similar thing is happening with type 2 diabetes, Prof Trenell warns. 

“As we come out of lockdown, we have a tsunami of chronic disease coming towards us – diabetes, obesity, heart disease, liver disease.

“We will be coming back to an excess need. And now we need to equip ourselves to catch up because people will be presenting later with more complex presentations.”

This will present myriad challenges. Yet the picture isn’t entirely gloomy. 

In the past, many viewed type 2 diabetes as a chronic illness. But the narrative has shifted. If you have an early diagnosis of type 2 diabetes, then it is possible to put it into remission.

“What we’ve worked out is that if you can capture somebody before the pancreas burns out” -generally in the first five years – “then you can give the pancreas CPR; you can revive it and get it working again.”

If the pancreas has already burnt out, then you can’t put your diabetes into remission because you won’t have a pancreas to get going again. But, he adds, “changing your diet can still have a profound improvement on your diabetes and on how you feel.”

Research from Diabetes UK has consistently shown that the right support and combined lifestyle interventions – including diet, physical activity and sustained weight loss – can be effective in reducing up to half of type 2 diabetes cases – along with the accompanying risk of developing life-threatening complications.

Prof Trenell can attest to this. He has worked with “tens of thousands of people” who have successfully changed their behaviour: “It’s just that it’s easier for some than it is for others.”

Another crucial consideration is sleep. “I think good sleep is probably the most undervalued part of lifestyle. If you sleep too little or too much, the likelihood of developing type 2 diabetes increases by an order of magnitude.”

Drug development holds further promise for the future. In the past few months, we’ve seen a class of medicines called GLT-1 come through, which support weight loss. These drugs manage hunger but they also allow the body to manage its metabolism better. Incidentally, they come from lizard spit: “Who’d have thought that spit of a lizard could help you lose weight!” 

These medicines are very expensive, Prof Trenell hastens to add. “But if it means that the complications are managed, they might save the NHS money in the long run.”

One challenge is understanding which of these routes an individual is capable of going down and deciding what treatment is best for each person – in other words, when to advise a drugs route or when to focus on helping people with lifestyle changes.

There is no single answer. “The best diet is the one that you’ll do, the best exercise is the one you’ll do.” It’s about personalised care, and giving people the tools to choose.

Prof Trenell is busy turning this vision into a reality. For the last 18 months, he has been working with NHS England on a digital education programme which will soon be available to everyone in the country living with type 2 diabetes – and in many different languages. It aims to increase equity of access to support and to ensure people can get this personalised care. 

The past year has placed an enormous additional strain on our health service and perpetuated many existing social inequalities but it’s also presented us, as a nation, with a fresh opportunity to tackle diabetes.

Or, as Prof Trenell puts it: “It’s been the wake-up call we needed. It’s made us more aware of our health and wellness than ever before. So, as we start to come out of the pandemic, let’s treat this as our reset button.” 

The importance of catching diabetes early when it’s easier to tackle cannot be emphasised enough. “It’s really hard because it’s silent. It’s a long, silent scream inside your body for help.” So many people are living with it and haven’t been diagnosed – it’s “like an iceberg.”

“If you are overweight,” he says, “go onto the Diabetes UK risk calculator and it will tell you what your risk is, or speak with the doctor and undergo an assessment.”

Prof Trenell hopes that the pandemic will help to reframe how we think about public health, wellbeing and primary care. 

The NHS is a system designed for acute care. But witnessing all those most vulnerable to Covid-19 is a reminder that we must address wellbeing at an earlier stage, not just when it reaches the point of acute illness. 

In fact, Prof Trenell tells me, if we look at the history of the NHS, we can see that this was the purpose originally intended for it. 

Our health service came into existence post-Second World War following a famous report by William Beveridge, published in 1942. The Beveridge Report contained two key recommendations. The first was an infrastructure that managed acute illness. The second was an infrastructure that kept people well. 

“The government at the time said it could only afford number one, so this became the national health service. But we’ve created this acute care infrastructure without even thinking about how we keep people well.”

A focus on wellbeing encourages a medical model which places the emphasis on prevention rather than cure. And nowhere does this feel more relevant – and vital – than when it comes to tackling diabetes. 

“This is a wicked problem,” says Prof Trenell, “and there is no single magic bullet. But it’s a wicked problem we need to address.”