Type 2 diabetes how to prevent it? East of England Diabetes Mellitus Transformation and Sustainability Network 28 th March 2018

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1 Type 2 diabetes how to prevent it? East of England Diabetes Mellitus Transformation and Sustainability Network 28 th March 2018 Dr Charles Bodmer Consultant Clinical Lead Dr Sonica Goel GP Clinical Lead Adele Holcombe Diabetes Practitioner & GM

2 Size of the problem How are we doing NDPP does it work How can we do better What are (some of) the barriers Can we learn from other programmes

3 There are currently 3.4 million people with Type 2 diabetes in England with around 200,000 new diagnoses every year. There are currently five million people in England at high risk of developing Type 2 diabetes. If these trends persist, one in three people will be obese by 2034 and one in 10 will develop Type 2 diabetes. Percent of population with prediabetes (HbA1c 39-48mmol/mol, %) by year BMJ Open 2014;4:e

4 Can we afford the future burden of type 2 diabetes The figures from NHS Digital reveal that over the past year there was an almost 5% increase in diabetes prescriptions - which is more than double the 2% increase in total prescriptions. Diabetes drugs now make up 11% of total primary care net ingredient costs and almost 5% of prescriptions. Type 2 diabetes treatment accounts for just under nine per cent of the annual NHS budget. This is around 8.8 billion a year.

5 GP Referrals in the NDPP Referral rate per 100, NORTH WEST ESSEX NORTH EAST ESSEX CASTLEPOINT & ROCHFORD MID ESSEX THURROCK CAMBS & PETERBOROUGH Referral rate per 100,000

6 Number of direct referrals NE Essex Mid-Essex West Essex

7 Cambridgeshire and Peterborough DPP Total patients n (%) 413,000 % of patients who lost weight % with reduced HbA1c With Diabetes (5.8%) Referred 4891 Completed Initial Assessment Joined programme At 3 months 80 At 6 months At 9 months 73 63

8 What is holding back GPs from referring into the programme? Is there confusion about the diagnostic criteria of Pre-Diabetes? Increase in GP workload: do we have time for disease prevention? Implications of the diagnosis on patients life

9 Referral Pathway Opportunistic Detection NHS Health Check Inform GP if external NHS Health Check HbA1c 42-47mmol/mol OR FPG mmol/l within 12 months Existing cases of NDH on GP register Search GP records for NDH codes and / or blood eligibility criteria Diagnose NDH Read code Non-diabetic hyperglycaemia and Add to NDH register Refer to NHS DPP with blood result Provider invites patient and liaises with patient about the programme If blood results on referral more than 3 months old, provider will arrange repeat testing DPP programme Healthier You 9+ months, 13+ sessions Weight loss, increased activity, improved diet Discharge to GP with completion data or last data captured (if dropped out)

10 Number of tests Number of tests How did we manage Pre-diabetes in practice? 16 Hba1c 40 FPG Normal Follow up Normal 4 15 Follow up Hba1c Level 109 eligible patients 68 patients were diagnosed using Hba1c 48 patients were diagnosed using their FPG levels FPG Level

11 Diagnostic criteria of Pre-diabetes Diabetes UK WHO American Association Of Diabetes FPG (mmol/l) hr PG (mmol/l) HbA1c (mmol/mol)

12 Are there any parallels from Smoking Cessation ONS 2015: Adult smoking habits in the UK

13 GDM in NEE Gestational Diabetes Women monitoring with Previous diagnosis of GDM Screening as per NICE Guideline at weeks 3 month PN HbA1c Annual HbA1c Practice GDM/Pre-diabetes Registers Previous GDM referred at pregnancy confirmation High future risk for mum and children,?include with DPP

14 Long Term implications of GDM Fat mum-fat babies- fat kids-type 2 diabetes GDM mums get type 2 DM: 40% at 4 years 64% at 20 years: 85% with BMI > 30 GDM offspring type 2 DM in 40% Diet & lifestyle reduces risks by 40-60% mum and child Breast feeding reduces risk by: 40% in offspring 50% in mum Epigenetics: an epigenetic trait is a stably inherited phenotype resulting from changes in a chromosome without alterations in the DNA sequence Aka fat mums have fat kids who also get diabetes

15 Cumulative incidence of diabetes (%) US Diabetes Prevention Program implications for healthy life style post GDM Patients randomly assigned between 1996 and Metformin risk reduction 31% vs placebo Lifestyle risk reduction 58% vs placebo Placebo (n=1082) Metformin (n=1073) Lifestyle (n=1079) 20 The incidence of diabetes differed significantly among the 3 groups (P<0.001 for each comparison) subjects with IGT followed over 4 yrs and received: placebo or metformin 850 mg BD or Years in study lifestyle-modification programme of a healthy, low-calorie, low-fat diet and physical activity of moderate intensity for 150 mins/week with the goal of achieving and maintaining a weight reduction of 7% initial body weight BD: bi-daily; GDM: gestational diabetes mellitus; IGT: impaired glucose tolerance The Diabetes Prevention Program Research Group. N Engl J Med 2002; 346: March 2017 UKDBT Eli Lilly and Company 15

16 Conclusions NDH Diabetes prevention works But it would be an exponentially greater intervention than the NHS has ever undertaken to make it succeed to engage all those at risk Can we learn from the National Smoking Cessation programme As a population issue it mirrors GDM, as expected