For those running an already overstretched NHS, there are two statistics about Type 2 diabetes that cause alarm. The first is about patient numbers. The second is about the resources they claim.
On the number of patients, says Professor Jonathan Valabhji, National Clinical Director for Obesity and Diabetes at NHS England, “we’ve seen a doubling of the number of people with diabetes every 15 years or so”. Today that means more than 3 million have been diagnosed with Type 2 which, unlike the insulin deficiency disease known as Type 1, is generally acquired later in life. In England there are 200,000 new cases a year.
In other words, between 7-8 per cent of the population have Type 2 diabetes. Yet, according to Valabhji, “if you look at all of the hospital beds across England, today, around one in six of which will be occupied by a person with diabetes”. The best estimate is that 10 per cent, or £14billion, of the entire NHS budget is spent on diabetes. Such is the current growth in cases and the cost of treating them that by the middle of the next decade it is projected NHS spending on Type 2 diabetes will be 150 per cent of that currently spent on treating all cancers.
Not that every patient in hospital with diabetes is being treated for diabetes. The condition makes sufferers prey to a host of other conditions: they have higher risk of heart attacks, stroke, and the most common cancers. Complications lead to amputations - more than 190 each week according to the charity, Diabetes UK. Covid too. “One in three Covid deaths were in people with diabetes,” says Valabhji, who notes that Type 2 typically reduces lifespan by five or six years.
Nor, depressingly, is Type 2 any longer reserved for the aged. “It used to be seen as a disease of middle and old age,” says Nikki Joule, at Diabetes UK, whose analysis shows that the number of children receiving treatment in paediatric diabetes units has increased by more than 50 per cent in the last five years alone. “I've been practising for 32 years now,” says Valabhji. “I was once looking after the grandfather, who was diagnosed at 65. Then I started looking after his daughter, who was diagnosed at the age of 45. Now I’m treating his granddaughter, who is diagnosed at the age of 28. And if you ask me what concerns me the most about the future it is this phenomenon of ever earlier age of onset.” As Type 2 ripples through the population, the result is that 5.5m people are forecast to be living with the condition by the end of this decade.
The cause is as obvious as it is inescapable: obesity. Some 85 per cent of Type 2 cases are linked to obesity, and ever more of us are overweight. Indeed, recent analysis by Cancer Research UK suggest the obese will outnumber those of a healthy weight within five years. Rates of obesity have more than doubled in less than 30 years, propelling the UK to the top of Europe’s obesity charts. Today, two thirds of us are either obese or overweight.
And fat - at least for some people - is a big problem. “People misunderstand what happens when you gain weight,” says Dr Giles Yeo, a neuroscientist who studies how the body controls weight. “You don’t make more fat cells. The existing ones balloon. The problem occurs when those cells become full.” Then, he says, the fat spills over, into parts of the body not equipped to deal with it: the muscles, the liver, the pancreas. “It is poison by fat and you tilt into Type 2 diabetes.”
Diabetes, then, is not strictly a disease of obesity, but of the ability to store fat. Which explains why East Asians, who generally are less able to do so, disproportionately suffer. Polynesians tend to be the opposite, being more able to pile on the pounds safely.
Nonetheless, the link with obesity remains overwhelming and, as a consequence, diabetes is a disease with a stigma. Among policy makers, says Joule, “it’s linked with the idea that people have brought it on themselves. It’s not seen as serious or worthy as cancer. There’s a blame culture.”
Because of this, perhaps the most significant problem for the NHS is working out how to defuse the diabetes time bomb, that to a great extent it is not a medical problem at all. Obesity is fundamentally linked with poverty. The food industry has made highly-processed products ever cheaper - supplying bountiful calories to a species programmed by long experience of famine to hoard them. Banging on only about “personal responsibility” is pointless, says Valabhji. “We’ve relied on that angle for the last few decades as a sole strategy. It's not adequate.” Other factors play a far bigger role. “We have to fix poverty, to fix the food environment,” says Yeo. “If we do that, we solve diabetes without spending a pound in the NHS.”
But the chances of such fundamental reform are slim, and so the NHS must brace to pick up ever larger pieces. The principal way it does so is with a diabetes prevention programme known as Healthier You, launched in 2016. Since then a million people have been referred to the nine-month course of face-to-face or digital sessions which help with weight management, exercise, and better eating. Average weight loss is 3.3kg. Valabhji is upbeat about its success, and the scale of what the NHS claims is the world’s largest such effort. But such success only underlines the scale of the problem: despite its size and effectiveness it is estimated to have cut new cases by only 7 per cent.
There are other tactics though. Many specialists talk about diabetes in similar terms to cancer, referring not to “cure” but “remission”. And as with cancer the most radical treatment has hitherto been surgery, in this case remodelling the stomach to make it smaller. Now however, radical diets have been shown to “mimic surgery”. “Typically it’s a liquid diet for 12 weeks, 8-900 calories a day [instead of the recommended norm of 2,000 or so],” says Joule. “It’s very severe and not for everyone. But some people respond really well.”
Studies show that almost half who take part go into diabetes Type 2 after a year, and 70 per cent of those remain in remission after two years. The method is now being rolled out in an NHS pilot scheme, while researchers in Oxford aim to draw up four other such diets to broaden its appeal. “Remission is critical because, while a huge amount of the NHS budget is spent on diabetes, crucially 80 per cent of that is spent on complications which to a large extent are preventable,” says Joule. Expensive hospital stays can be delayed or put off forever, the idea goes, by nuts and diet shakes.
Cutting down on costly treatment can also be done through effective monitoring. But the burden of that falls mostly on GPs, whom many patients find hard to see. “GPs have become effective at monitoring,” says Valabhji, keeping tabs on “kidney function, cholesterol, eyesight and the feet” where complications can first appear. Diabetes UK would love to see such GP monitoring lead to a widespread “prevention not treatment” attitude. But structural NHS issues hamper the switch. “There have been lots and lots of attempts to move from treatment to prevention, but we’ve yet to see it work,” says Joule. “We’re still not spending anything like the amount on primary [GP] care, as they are in other parts of Europe. Hospitals are so powerful they drag the money [to them].”
If old problems like NHS structure and funding prove intractable, however, there are some exciting new possibilities, particularly around treatment. Perhaps the most dazzling of a new generation of drugs is Wegovy, which Yeo describes as a “weaponised gut hormone” that tells the brain someone is full. Taken as a weekly injection, he says, trials have shown it leads to users losing 15 per cent of body weight over two years. “It will be a silver bullet for some people,” he says. In February, it was approved for the most obese patients. The problem is, it’s expensive - with a list price of £1,125 per month. Still, even such titanic sums can end up representing good value when set against long-term care for diabetes and its complications. “Every year, there’s a panic about how much we’re spending on medication for diabetes,” says Joule. “My response is we should be spending more.” A stitch in time and all that.
Technology, too, has a role to play, primarily in wearables. The NHS says around 125,000 - or half - of patients living with Type 1 diabetes now use glucose monitors [often worn embedded under the skin] so they can instantly see the impact of certain foods and avoid those that make blood sugar spike. In coming years, such monitors are likely to be rolled out to Type 2 patients too.
Then there are “digital” treatments. One of the sad ironies of obesity is that everyone agrees those suffering need support to manage it. And yet, because of the stigma attached to their bodies, the obese do not always participate in face-to-face support groups. Hence a happy accident of the pandemic: when such support groups were switched from in-person to online, participation actually increased - especially among the youngest and heaviest.
Such interventions, as well as improved treatments, are having an effect. The rise in patient numbers “is beginning to plateau,” says Valabhji. And given the obsession with prevention and intervening early, genetic testing is likely to make an impact. “At the moment it’s difficult to tell whether you have safe or non-safe fat storage,” says Yeo. What he calls “a genetic signature” will hopefully soon make that plain, allowing a Type-2 prevention plan to be put in place early in life, long before the first symptom ever arises.
Doing so, however, would still require a revolution in an NHS which, according to Joule, “doesn't tend to think in those longer term ways”. “Typically,” she says, “they’re always looking for in-year savings and prevention just doesn't work like that. You don’t get the money back immediately.”
Asked if the NHS is treating diabetes with the urgency it requires, she answers: “I don't think they are.” Previous NHS chief executive Sir Simon Stevens, she says, drove such prevention programmes through. Since his departure in 2021, “the impetus has been lost”.
Even Valabjhi acknowledges how tricky diabetes is for the health service. “The NHS does stuff to individuals. We try to delay or prevent diabetes. We have packages of care. But there’s only so much in our gift.” He mentions all those things beyond it - an individual’s life outside the hospital. “Exercise, environment. The temptation that crosses our paths in what we might eat on our way to the office.”
Yet those two mounting numbers - of patients and resources they claim - mean that doing nothing is not an option. “Because so many people will get it,” says Yeo, “if you solve it, or even a part of it, the amount of cash you free up is immense.” But if there is no solution? “The implications for the NHS are dire. We need to take it seriously and fix it.”
Type 1 diabetes (in contrast to type 2) is an autoimmune condition which is not caused by poor diet or an unhealthy lifestyle. Information and support about this condition can be found at jdrf.org.uk/