Diabetes has got us in a quandary. Numbers of diabetics have more than doubled over the past two decades, with an estimated 3.5 million people currently diagnosed in the UK. Ten per cent of the entire NHS budget is spent treating it – there’s been an explosion of new, expensive pharmaceutical products capable of lowering blood sugar. And the medical profession is slowly waking up to the realisation that we are a large part of the problem.
Diabetes comes in two types. Type 1 typically presents in childhood, when an aberrant immune system destroys the pancreas’s ability to make insulin. Type 1 diabetics need insulin therapy for life, and they’re a tiny minority of all diabetic patients. For the purposes of this column, forget about them.
Type 2 diabetes is very different. It usually presents in mid- to late life, mostly as a consequence of obesity. In the early stages, the pancreas continues to make insulin, but the excess fat tissue in the body blunts its effect – so-called insulin resistance. Sugar levels rise, driving the pancreas to produce ever more insulin in a vain attempt to keep them under control. At this stage, type 2 diabetes is potentially reversible: if patients can lose weight then their insulin resistance reduces and demands on the pancreas decrease. Without weight loss, though, there comes a point when the escalating demand for insulin causes the pancreas to burn out, and insulin production begins to fail. At this stage, type 2 diabetes can no longer be reversed.
Diabetes causes serious complications: blindness, kidney failure and heart disease, to name but three. Traditionally, doctors have doled out pills and injections to help prevent its sequelae. We perform regular blood tests to monitor things, and are forever adding new treatments to tighten sugar control.
We may mention lifestyle factors such as weight, diet and exercise, but our every action conveys to patients that this is not what we’re really interested in. Patients learn that they “have” a disease called diabetes, and become passive recipients of ongoing medical care. They even become eligible for free prescriptions, such is the importance we attach to drug therapy. But many of our treatments (and our flawed dietary advice) actually cause further weight gain. Once someone gets sucked on to the medical merry-go-round, there’s virtually no way off.
The burgeoning rates of diabetes reflect the current epidemic of obesity. We’re surrounded by cheap, delicious, energy-dense foodstuffs. For too many people, “exercise” equates to the walk from the car to the supermarket door. It’s gradually dawning on the medical profession that we have to stop treating type 2 diabetes as a disease; we can’t keep turning millions of people into long-term patients.
The alternative is a cultural shift to viewing type 2 diabetes as a lifestyle issue. Around the country, the NHS is beginning to offer newly diagnosed type 2 diabetics referral on prescription for exercise, weight loss, dietary advice and cooking skills. This approach needs to be far bolder. Currently these “lifestyle prescriptions” last for up to 12 weeks, after which patients are left to get on with it. Offering free prescriptions for, say, a maximum of six months, but unlimited free access to gyms and weight-loss classes, would start to send the right signal.
As a profession, we also have to overcome an ingrained cynicism. We can all think of patients who prefer to “have” a disease and rely on medication to manage it, but we tar too many people with the same brush. Pioneering doctors are reporting high success rates from initial conversations that starkly set out the options: multiple drugs for life, or a chance to turn things round with simple lifestyle measures. Not everyone is willing or able to change. But if we offer everyone support to take a different path, we’ll be pleasantly surprised. Both patients and the NHS budget stand to gain.
This article appears in the 26 Jul 2017 issue of the New Statesman, Summer double issue