Steve How and Oli Hudson, of Wilmington Healthcare, assess the scale of the diabetes crisis and how coronavirus might impact on it
The spotlight is firmly fixed on COVID-19 as countries battle
to contain it, yet lurking in the shadows another devastating global pandemic – diabetes – claims more lives annually in the UK than what is currently predicted for coronavirus.
On March 28, Stephen Powis, national medical director of NHS England, said the UK would have done “very well” if there were fewer than 20,000 deaths from coronavirus infections. However, figures show that nearly 33,000 people died as a result of diabetes in England and Wales alone in 2017, and it is feared that death rates among diabetes patients might rise even higher than currently predicted because COVID-19 can pose serious risks to them.
In this article, we will explore the scale of the diabetes problem and how COVID-19 might impact on it. We will also look at the NHS’ strategy for diabetes care and how services are changing as a result of the pandemic.
The diabetes crisis
Facts and statistics cited in a report compiled by Diabetes UK show that by 2025, more than 5 million people are likely to have diabetes in the UK. Currently, 4.7 million people have the disease – which equates to one in 15 of the population. Around one million of these people are estimated to be living with undiagnosed type II diabetes, a condition that causes the level of sugar (glucose) in the blood to become too high.
The number of people diagnosed with diabetes in the UK has more than doubled in 20 years. This is largely attributed to a huge increase in type II diabetes, which now accounts for about 90% of all cases.
In type II diabetes, the body is either unable to produce enough insulin to efficiently transport glucose into the cells, or the insulin produced does not work properly. Risk factors for type II diabetes include age, having a close family relative with the disease, ethnicity and social deprivation. Being obese can contribute up to 85% of the risk of developing the condition, and it is estimated that more than half of all type II diabetes cases could be prevented or delayed.
Prevention, and even remission, are therefore at the heart of the NHS Long Term Plan strategy for diabetes. Indeed, as per the Plan, the NHS has promised to double the scale of the NHS Diabetes Prevention Programme for type II diabetes to include 200,000 people per year. Recent figures from NHS England highlight the success of this programme, with the 17,000 who attended most of its healthy living sessions losing an average of 3.4kg, over one kilogram more than originally predicted.
Around 8% of people with diabetes have type I disease. This occurs when blood sugar levels get too high because the body cannot produce any insulin, due to an attack on pancreatic cells. It is not related to diet or lifestyle, and risk factors are unknown. A smaller number of people – 2% – have rarer forms of diabetes.
Co-morbidities are common among diabetes patients. For example, according to the Diabetes UK report, people with type II diabetes are nearly two and a half times more likely to have a heart attack and twice as likely to have a stroke than people who do not have the condition. This, combined with the vast number of people affected by the disease, means that it places a huge strain on NHS resources. The NHS spends 10% of its entire budget on diabetes – with over 80% of costs the result of managing complications of the disease – and one in six people in a hospital bed has the disease.
Diabetes and COVID-19
Illnesses and infections, including COVID-19, make it particularly hard to control blood sugar levels as they naturally rise to try to tackle the problem. This means that people with diabetes are at greater risk of experiencing serious blood sugar highs and lows, as well as longer-term problems with their eyes, feet and other areas of the body.
A condition called Diabetic Ketoacidosis (DKA) is a particular risk, mainly in patients with type 1 diabetes, if the body starts to run out of insulin. It causes harmful substances called ketones to build up in the body which can be life-threatening if not spotted and dealt with quickly.
The co-morbidities associated with diabetes are also of concern with regard to coronavirus because generally it is believed that the more health conditions patients have, the higher their risk of serious complications from COVID-19.
The risks that the virus poses to diabetes patients are already evidenced by data that is emerging from some of the countries that have been affected. For example, in China, where the COVID-19 outbreak started, the first published piece of research, which involved a small number of people, showed that 19% of those who died in hospital after developing the condition also had diabetes.
The Chinese study was carried out at two hospitals in Wuhan – the epicentre of the outbreak – and involved 191 people, of whom 137 were discharged and 54 died. Further analysis showed that 48% of those people had a co-morbidity, with hypertension being the most common health complaint (30%), followed by diabetes (19%) and then coronary heart disease (8%).
According to a report on patient characteristics from Italy’s National Institute of Health, released on March 17, 99% of COVID-19 patients who have died in the country had at least one pre-existing condition. Diabetes was the second most common condition among COVID-19 patients who died: 35.5% had the illness.
UK COVID-19 strategy
A key element of the government’s strategy to tackle COVID-19 has involved social distancing to avoid contracting the virus, with shielding in place for certain sectors of the population. While some diabetes patients might be self-isolating or shielding, the majority will be following the measures which require everyone to stay at home during lockdown and go out only for very limited purposes.
Essentially, people with diabetes will remain at extreme risk until a coronavirus vaccine becomes available and although estimates vary, this is not expected to happen until the middle of next year at the earliest.
NHS strategy and diabetes
The COVID-19 pandemic has been forcing the pace of some of the transformational change envisaged in the NHS Long Term Plan, particularly with regards to providing more services remotely, rather than via traditional face-to-face methods, and adopting population health management techniques.
In the weeks leading up to the coronavirus lockdown, many GP surgeries began advising patients not to attend booked appointments at surgeries to lower the risk of infection. Instead, a GP or nurse contacted the patient to arrange a telephone triage as near to the appointment as possible and this practice has now become widespread.
Before the pandemic began, the NHS had already moved away from routine face-to-face check-ups for diabetes patients who have the disease well under control. Diabetes patients who need to keep in regular contact are expected to engage with healthcare professionals over the telephone or via digital means during the COVID-19 pandemic, unless they have a specific problem that requires a follow-up appointment.
COVID-19 presents an unprecedented challenge to the NHS and the fight against it is touching all of us in some way; yet the huge number of people who die from diabetes each year in the UK and the immense strain that this disease places on NHS resources goes unnoticed by most people.
However, diabetes is another a global pandemic and one that is likely to insidiously gather pace in the UK, given the vast number of people already known to have the disease, those believed to be at-risk of contracting it, and the potential complications that COVID-19 may pose to this sector of the population.
In short, with those that already have the condition, and the two million at high risk of developing type II disease, diabetes is a time bomb and the clock is ticking. Dietary and lifestyle changes are key to averting a crisis reining in the swell of type II diabetes cases. However, with immense pressure now being placed on the NHS by COVID-19, it remains to be seen how far it will be able to go this year in implementing its vision to prevent type II diabetes and even achieve remission for some patients.
Steve How is programme director and Oli Hudson is content director, both at Wilmington Healthcare. For information on Wilmington Healthcare, visit www.wilmingtonhealthcare.com