Diabetes mellitus(DM) is a “growing epidemic” of the twenty first century (Wild et al. 2004) which is a medical and social problem in economically developed and, recently too, in developing countries. Professor Stig Pramming, director of the Oxford Health Alliance, in a report published by the Economist Intelligence Unit stated: “This epidemic is responsible for many more deaths than HIV/AIDS, tuberculosis and malaria combined. The tragedy is that this crisis is largely avoidable.” (The silent epidemic 2007 p. 4)
In 2000 prevalence of diabetes worldwide was 171 million people, and the World Health Organization (WHO) (2001) predicted that the number will double to 366 million by the year 2030. The International Diabetes Federation (IDF) also made estimates in 2006 on diabetes cases worldwide (IDF 2006) in which similar trends with WHO were shown. The most recent research was conducted by Shaw et al. (2009) who estimated the number of people worldwide with diabetes for the years 2010 and 2030. These estimates suggested that there will be 285 million adults having the condition and an increase up to 439 million adults by 2030 (a 69 per cent increase in numbers of people with diabetes in developing countries and a 20 per cent increase in developed countries). However, WHO (2011) estimated that there are 346 million people diagnosed with diabetes at the moment with the largest number of people diagnosed with diabetes is in the United States (US) (18,8 million people are diagnosed and 7 million people are not diagnosed) (National Diabetes Statistics 2011).
A look into Europe shows that there are approximately 32 million people with diabetes of which 90 per cent have type 2 diabetes mellitus (Beale et al. 2006). To look at the issue in the United Kingdom (UK): Diabetes UK (2010) estimated that there were 2.6 million people in the United Kingdom (UK) who had been diagnosed with diabetes in 2009, and the number is expected to increase to more than 4 million people by 2025. To be more precise, the recent numbers of diabetes cases in the UK are: 2,455,937 in England; 223,494 in Scotland; 160,533 in Wales; and 72,693 in Northern Ireland (The Health and Social Care Information Centre 2011). In addition, approximately 750,000 people had diabetes but were not aware of it (Diabetes UK 2006). It is noteworthy to add that DM is a potentially life-threatening and costly disease which can affect nearly everyone, regardless of ethnicity, sex, and age (Ritchie et al. 2003). It is strongly related to political (Robert and Mihai 2004) and economic change as well as to lifestyle of the population as well (King et al. 1991).
The aims of this paper is to look more in depth into type 2 diabetes mellitus (T2DM) in youth and interventions to prevent T2DM which has become an emerging epidemic in the UK. Diabetes mellitus is a non-communicable disease which can be described as a group of metabolic disorders of various etiologies characterized by chronic hyperglycaemia (high levels of glucose in blood) with disturbances of carbohydrate, fat and protein metabolism results from defects in insulin secretion, insulin action, or both (WHO 1999). If diabetes (chronic hyperglycaemia) is not controlled by a patient it leads to long-term macrovascular (arteries, heart) and microvascular (eyes, kidneys, lower limbs) complications with dysfunction and failure of various organs, leading to blindness, renal failure, neuropathy (foot ulcers), and atherosclerosis (Diabetes UK 2011). There are various categories of diabetes.
They differ in terms of etiology, onset period, and pathophysiology. The most prevalent is type 1 diabetes mellitus (T1DM), formerly known as insulin-dependent diabetes or juvenile-onset diabetes mellitus which is known as an autoimmune disease without any successful prevention methods (Parent et al. 2009). However, type 2 diabetes mellitus, formerly known as insulin-independent diabetes or adult-onset diabetes, is a preventable metabolic disorder characterized by reduced ability of the muscle and liver cells to respond to insulin, insulin deficiency, and increased hepatic glucose output (Ritchie et al. 2003). Although T1DM is a disease which affects more children than T2DM, in this essay the priority is given to type 2 diabetes among children and adolescents. The reason for looking at the issue of T2DM in youth is that there is no precise methods of preventing T1DM or interventions to delay T1DM (Buckle and Caple 2011; Gale et al. 2004; Skyler et al. 2005).
Over the past decade, there has been a catastrophic increase in cases of type 2 diabetes in children and adolescents globally. T2DM formerly occurred only in adults almost exclusively (Ritchie et al. 2003). A study conducted by Zimmet et al. (2001) had found a clear evidence that a rapid increase in T2DM among children and adults is parallel to high rates of obesity, overly rich nutrition, physical inactivity, and malnutrition (in the first thousand days of life) (The Growing Danger of Non-Communicable Diseases 2011 ). In particular, this makes diabetes mellitus capable of being addressed through assorted public health interventions. The first children to develop type 2 diabetes were found in Oji-Cree people (a First Nation population in the Canadian provinces of Ontario and Manitoba) in the paediatric age group in the 1980s (Mendelson et al. 2011). There was a study conducted by Ehtisham et al. (2001) which estimated the prevalence of diabetes among children in the UK.
This study was the first study of pediatric type 2 diabetes to provide comparisons with other types of diabetes, national minimum prevalence estimates, and case definitions. As the number of children diagnosed with T2DM increases each year, the concomitant health care costs and the impact on the health of the populations could be devastating because of the results of its impact on personal and national health. Early-onset of the condition ends up with premature morbidity and mortality which are associated with the complications of T2DM (Zimmet et al. 2001). Therewith, this disease is associated with a colossal physical and emotional burden for individuals with T2DM and their families (Johnson et al. 2006). Epidemiological evidence suggests that the prevalence of the disease will continue to have an upward trend unless effective prevention and control programmes are implemented. (REFERENCES) It is believed that the governments have a duty to do all it reasonably can to reduce risk factors on population’s behalf, such as making sure that foods are safe (World Health Report 2002).
Although T2DM historically has been considered an adult-onset disease, a considerable amount of literature has been published on its dramatically increasing incidence in younger populations over the past decade (Laffel and Wood 2010). It has been demonstrated that the condition is usually diagnosed during puberty (between the ages of 12 and 16 years) when they are incidentally being tested for glucosuria or hyperglycaemia (Burchett et al. 2009; Morales Pozzo 2010; Orr 2008). The aetiology of T2DM is multifactorial, including such risk factors as genetic predisposition, environmental factors, obesity, sedentary lifestyle, high-risk ethnicity (e.g. UK-based African-Caribbean- or Asian-origin populations), and family history of the disease. Thus, the treatment of the condition should not be glucocentric (focused on glucose, particularly to the exclusion of other factors); it should be targeted to improving hypertension, dyslipidaemia, glycaemia, weight control and the prevention of complications.
Moreover, strategies for primary and secondary prevention of the condition should be targeted to families, schools, food industries, and governmental agencies (Libman and Arslanian 2007). It is noteworthy to say that these risk factors are modifiable (Swartz et al. 2011) and they provide incentive and optimism to develop and implement copious education and extensive management strategies to assist most advantageous treatment of diabetes while at the same time focusing on delaying the onset of diabetes through prevention in younger population of the UK to avoid enormous costs of treatment and management of diabetes. T2DM is one of the most costly diseases in the world. The increasing prevalence in children and adolescents will result in higher rates of prevalence in subsequent generations due to risk factors such as family history of the disease. According to the projections of Bagust et al. (2002) type 2 diabetes mellitus was not considered as an “epidemic” in the UK in 2002.
However, Wilmot et al. (2010) pointed out that it has become an emerging UK epidemic since 2008 as the previous studies had several limitations. The main limitation of the study conducted by Bagust et al. was that they gathered data on those up to the age of 16, while the recent study was looking at those up to 18 years of age. Thus, the rapid increase in diabetes prevalence across the UK gives diabetes the status of an epidemic. Notably, the model in one of the studies conducted by Jonsson (2002) showed that the total cost of diabetes in the UK was of just over 7 billion US dollars or around 3,300 US dollars per capita. It is approximately 10 per cent of National Health Service (NHS) budget goes on diabetes and its complications (£9 billion per year or £1 million per hour) (Diabetes UK 2009). This discrepancy is seen due to using International Dollars (ID) in Jonsson’s research. These costs could be more tremendous if the youth will not be aware of the disease (Ritchie et al. 2003). The most striking feature of T2DM is that many people with this disease are not aware of that they have it due to vaguely developing symptoms of the illness. In some cases the symptoms are absent or non-specific.
This leads to severe and irreversible complications before children and adolescents are aware of the condition. Approximately, 50 per cent of children and adolescents with type 2 diabetes have no symptoms (Callahan and Mansfield 2000). Moreover, 80 to 100 per cent of children are typically overweight or obese (WHO 2005). This is one of the major risk factors that may be modified by intervention programmes for prevention of type 2 diabetes mellitus (Ritchie et al. 2003). Since this epidemic was rapidly increasing in prevalence each year in the US and was related to obesity, there had been many considerations about the exact relationship between these two conditions. Astrup and Finer (2000) were the first who proposed the term “diabesity” for obese children with diabetes.
For the purposes of analysis two models were used in this study: “traditional model” represented that obesity was one of the prerequisites, while the “new model” showed that obesity is the major factor in development of T2DM. There are many further examples expressing the same opinion, such as Whitmore’s (2010) literature review where she stated that weight control is a cornerstone in the management of T2DM as just 5 per cent weight loss can improve insulin sensitivity. Prevention of type 2 diabetes is an international public health concern to reduce the morbidity and mortality rates. The IDF (Zimmet et al. 2007) highlighted the need for an urgent action globally. Those who are at high risk of diabetes, and especially those who get diabetes, need to be identified and engage in an intervention programme that involves the health system, the community and the patient. (the who book bout social…).
Many trials had success demonstrating that weight control resulting from healthier diets and physical activity can diminish the incidence of type 2 diabetes mellitus. For example, the Finnish Diabetes Prevention Study (FDPS), in a follow-up trial, has noted the importance of weight reduction and physical exercise in high-risk groups. Briefly, in this trial the intervention participants of 522 people were given individualized counselling to attain the lifestyle goals as well as advice to increase their physical activity. During the first year of the trial they had seven counselling sessions and every three months thereafter. Final results indicated that there was a 43 per cent reduction in relative risk of T2DM. Notably, there was a 36 per cent reduction after the discontinuation of the trial (was found out during the post-intervention follow-up trial) due to participants’ experience in maintaining a healthy diet and weight (Lindstorm et al. 2006).
Similar results were shown in the US Diabetes Prevention Program (DPP), with 58 per cent reduction in the onset of type 2 diabetes mellitus (US National Diabetes Information Clearinghouse 2008). Although researches have focused on behavioural factors as the cause of T2DM, behaviours are influenced by historical, political, and social forces that shape local contexts (Kannan et al. 2005). However, lifestyle interventions need to be considered, as the prevention programmes should be equally effective among diverse cultural and regional populations. Therefore, more researches are needed to be conducted to look at how prevention actions may translate to wider population in different settings (i.e. paediatric populations) (Diabetes UK 2009).
There is strong evidence base for the prevention of T2DM, however, there is unsubstantial evidence on how to intervene to decrease socioeconomic inequalities in T2DM’s incidence, outcomes and consequences. The prevalence and incidence of T2DM is strongly related to socioeconomic status within a country. If in high-income countries it is inversely related to socioeconomic position: with the highest numbers of cases among those of lowest socioeconomic position; it is different in low- and middle-income countries: higher prevalence is apparent in people of high socioeconomic position. Though there is evidence that the impact of diabetes is higher in communities with low socioeconomic status (Equity Social Determinants and Public Health Programmes 2010).
Prevention strategies depend on the implementation of affordable and effective interventions which will encourage behavioural change (increasing physical activity levels, controlling low-fibre and calorie-dense diets). In the UK, both population-wide and individual-based interventions and prevention strategies may be feasible and cost-effective. However, there are several uncertainties which require further research and economic modelling that should be resolved. The guidance must take ethics and effectiveness into account as when promoting behaviour change; also health inequalities have to be intensified. The most recent Diabetes UK (2009) policy report has focused on prevention of prediabetes and diabetes. The aims of this policy report were to improve insulin resistance, pancreatic-cell function and reduce other cardiovascular risk factors (hypertension and dyslipidaemia).
In a document published by the World Bank and WHO (Disease control priorities in developing countries) there is a division of interventions into three levels according to cost-effectiveness and feasibility of effective and affordable diabetes care. The UK is considered to attempt almost all of the interventions (Equity Social Determinants and Public Health Programmes 2010). There are some population groups that are particularly in higher risk of type 2 diabetes than others. These higher rates can be found among ethnic minorities and indigenous people within some countries and there are no clear known reasons for this.
Higher levels of obesity and overweight and sometimes other risk factors such as smoking and alcohol abuse or excess can be contributed by poorer socioeconomic positions among those of marginalized groups. There is also a genetic susceptibility which can also play a role: the “thrifty genotype hypothesis” which was postulated by James Neel in 1962. He suggested that “exposure to periods of famine during human evolutionary history resulted in selection pressures in favour of a thrifty genotype that led to highly efficient fat storage during periods of abundance” (Zeggini et al. 2009 p.1847). It means that poor nutrition in childhood can leave them vulnerable to type 2 diabetes if they grow up in the environment of excess (this can occur in rapidly developing society)
Current UK policy directions already have evidence-base guidance on the prevention of overweight and obesity and the promotion of healthy lifestyle (SIGN (2003) and NICE (2009)). Relevant policy and consultation documents have been published in 2009 in English and Scottish Departments of Health. However, their programmes were focused on different populations. For example, Scottish consultation documents such as ‘Well North’ and ‘Keep Well’ have targeted rural communities and deprived communities respectively. Another example from English Department of Health is a programme called ‘Change4life’ which has targeted both middle-aged and 40-74-yearolds in the population. It is worth noting that there is not enough evidence for the impact of population-level interventions on preventing diabetes in UK populations.
Slight changes in behaviour seen in prevention trials, however, suggest that interventions to achieve similar goals in the general population could be feasible (Simmons et al. 2006). A look into individual-level interventions shows that there is clear evidence to prevent diabetes from international trials (such as those mentioned before: FDPS and DPP); and their long-term results are promising. The challenge is that there should be translation of trial findings into “real-world” prevention programmes. Another challenge which has to be considered is a minimisation of costs and improved sustainability when scaling up trail interventions. There is a concern about the effectiveness of interventions in youth since behavioural change is difficult to sustain without supportive cultural, social and physical environments.