2. MAINTAINING HEALTH AND WELLBEING
Improving the health of people with diabetes in Scotland and reducing health inequalities
2.1 Primary prevention of type 2 diabetes
Where we want to be:
We want to reduce the rate of increase of prevalence of type 2 diabetes in Scotland.
Why we want to be there:
We want to improve the health of people in Scotland and reduce the burden of ill health caused by diabetes.
We know that being overweight seriously increases an individual's chance of developing type 2 diabetes. The Scottish Diabetes Survey found that over 80% of people with the condition are overweight or obese. Scotland, in line with much of the rest of the world, is experiencing an obesity epidemic, with one of the highest rates of any Organisation for Economic Cooperation and Development ( OECD) country.
It is clear that population-level interventions to stabilise and then reverse obesity trends are probably the single biggest factor in reducing the incidence of type 2 diabetes. This challenge has been taken up by the Scottish Government and the Convention of Scottish Local Authorities ( COSLA) through the development and delivery of an Obesity Route Map ( http://www.scotland.gov.uk/Publications/2010/02/17140721/0), published in March 2010. The Route Map recognises that obesity cannot be viewed simply as a health issue, and cannot be solved by reliance on individual behaviour change. Tackling obesity successfully will require change across the whole of society; this will involve collaboration and investment across Government and across sectors to make deep, sustainable changes to our living environment in order to shift it from one that promotes weight gain to one that supports healthy choices and healthy weight for all.
There is very good evidence that diet and physical activity changes can reduce the risk of cardiovascular disease and diabetes.
A population strategy for the prevention of cardiovascular disease and for type 2 diabetes should focus on diet and increased physical activity so that the risk factors are reduced in the whole population in all age groups.
The Scottish Government Health Directorates are aware of the health impact of all policies which influence diet and activity. An approach combining the medical model (screening, detection and treatment of individual people with lifestyle intervention) and the public health model (changing the behaviour and risks of the population by public health measures such as promoting healthy eating and physical activity, and hence weight control) is required. This includes reducing the progression to diabetes of people with impaired glucose tolerance. 1 The Scottish Government has already identified a national indicator to 'reduce the rate of increase in the proportion of children with their body mass index outwith a healthy range by 2018'. A further indicator is being developed to cover the whole population, in addition to identifying a series of milestones that must be met if we are to reverse obesity trends.
Action we will take:
NHSBoards should take account of the Obesity Strategy Route Map in their work with Community Health Partnerships ( CHPs) and NHS Boards' planning partners.
Responsibility: Scottish Government Health Directorates, NHS Boards.
Quality Healthcare Dimensions: effective and equitable.
2.2 Screening for type 2 diabetes
Where we want to be:
We want to detect and diagnose diabetes earlier in order to prevent, so far as possible, complications.
Why we want to be there:
Research shows that there is a long, asymptomatic phase in which the condition can, however, be detected. Up to 50% of people diagnosed with type 2 diabetes present with complications at diagnosis. Impaired glucose tolerance ( IGT) and non-diabetic hyperglycaemia ( NDH) are associated with increased risk of premature cardiovascular disease. Early treatment may reduce progression to diabetes.
It is estimated that over 20,000 people 2 with diabetes remain undiagnosed in Scotland. Further action is needed to ensure that people with diabetes are identified earlier.
In Scotland, screening for diabetes and non-diabetic hyperglycaemia ( NDH) should be integrated into NHS Board population-based vascular screening plans. An implementation plan for vascular risk assessment in Scotland is needed and the diabetes screening element should be included in that plan. The screening strategy should include risk factor assessment and blood tests.
SCOTTISH PUBLIC HEALTH NETWORK REPORT ON TYPE 2 DIABETES
The Scottish Public Health Network's draft report has advised that HbA 1c be used as the preferred screening test for diabetes. This approach has been cleared by the National Screening Committee as being consistent with the vascular screening programme across the rest of the UK and with international work. The best alternative is fasting glucose. Random blood glucose is not recommended for screening for diabetes and SIGN Guideline 97 on risk estimation and prevention of cardiovascular disease should be updated accordingly. Random glucose measurement remains a satisfactory way of confirming a clinical diagnosis in a symptomatic patient.
The report has also recommended that in asymptomatic individuals an HbA 1c = 48mmol/mol (6.5%) should be repeated. A repeat level of = 48mmol/mol confirms type 2 diabetes mellitus. Those with an elevated HbA 1c = 39mmol/mol (5.7%) but not meeting diagnostic criteria for diabetes should be classified as having non-diabetic hyperglycaemia ( NDH) and should be offered intensive lifestyle intervention. In those with initial HbA 1c < 39mmol/mol screening with an HbA 1c should be repeated every five years as part of cardiovascular screening.
These recommendations are under review (August 2010).
Methods of raising public awareness of screening programmes and the benefits of screening need to be explored. As the basis of that work, the Health Directorates should look at lessons arising from existing programmes such as the 'Keep Well' and 'Well North' programmes, which relate to cardiovascular disease risk, including diabetes, using the ASSIGN risk calculator as recommended by SIGN Guideline 97. Screening for type 2 diabetes also needs to link to the 'Life Begins' health checks, which aim to allow everyone when reaching 40 to undertake a general assessment of their health.
Action we will take:
The Scottish Public Health Network recommendations on screening will be considered through further discussions with:
- Scottish Government Health Department Directorates;
- NHSBoards; and
- Key stakeholders such as the clinical biochemistry community.
Responsibility: SGHD, Directors of Public Health.
Quality Health Care Dimensions: effective and efficient.