Type 2 diabetes a growing problem
Diabetes is a chronic, metabolic disease characterised by elevated levels of blood glucose (or blood sugar), which over time, can lead to serious damage to the heart, blood vessels, eyes, kidneys and nerves. Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little to no insulin by itself. However, the most common type is type 2 diabetes, usually seen in adults, which occurs when the body becomes resistant to insulin or doesn't produce enough of it. In the past 3 decades, the prevalence of type 2 diabetes has risen dramatically in countries of all income levels (WHO, 2021a).
In the UK, and globally, the prevalence of type 2 diabetes has risen in line with growing obesity levels (WHO, 2021a: WHO, 2021b). In the UK, diabetes mellitus (DM) affects 7.4% of the population but 15% of those with severe mental illness (Diabetes UK, 2021; Public Health England, 2018). Figure 1 illustrates the increasing numbers of people in the UK with diabetes (Diabetes UK, 2021).
Health consequences of diabetes
Diabetes can have a major effect on a person's life, their family, the health service and society as a whole. Undiagnosed or poorly managed diabetes leads to premature death (Harding et al, 2016). People who develop type 2 diabetes under the age of 40 are more likely to experience rapid deterioration in pancreatic function and have a greater incidence of adverse outcomes (Magliano et al, 2020). High blood glucose levels cause lack of energy, lack of reserves and increased risk of tissue damage. Diabetes leads to problems with vision, circulation, increases the risk of heart disease, stroke, dementia, nerve damage and sexual difficulties (National Institute of Health and Care Excellence (NICE), 2022a).
The main complications of diabetes are microvascular-such as diseases affecting the eyes, nerves and kidneys, and macrovascular, such as diseases leading to cardiovascular disease (CVD), cerebrovascular disease and lower extremity arterial disease (Vithain and Hurel, 2010).
Each week, diabetes leads to 2,000 cases of heart failure, 680 strokes, 530 myocardial infarctions and 169 amputations (Diabetes UK, 2019). This is illustrated in Figure 2.
Some individuals with diabetes can develop various eye problems-cumulatively known as diabetic eye disease. These conditions include diabetic retinopathy, diabetic macular oedema, cataracts and glaucoma (Pearce et al, 2018). Microvascular damage can also increase the risk of stroke, impaired cognition and depression (van Sloten et al, 2020). People who are overweight and have diabetes are at increased risk of severe and progressive changes in their brain structure and of dementia (Sujung Yoon et al, 2017).
Diabetes affects the heart and blood vessels and increases the adverse effects of hypertension. These changes increase the risk of cardiovascular disease and this is the leading cause of death in people with diabetes (Strain and Paldánius, 2018)
Type 2 diabetes can lead to ill health, diminished quality of life and premature death. In order to help people improve their health and well-being, the nurse needs to adopt a three-pronged strategy, to prevent the disease, induce remission, and treat it. Figure 3 illustrates this.
Detection of those at risk and prevention
Diabetes risk factors can be divided into two categories: modifiable-those we can change, and non-modifiable, those we cannot change, Figure 4 illustrates modifiable and non-modifiable risk factors.
The risk of diabetes increases with age, due to individual factors and age–related changes. Individuals can gain weight as they age and ageing is associated with a decrease in muscle mass and an increase in fat. Insulin is produced in the Islets of Langhern's and there is a decrease in functional cells as people age. This means that older people produce less insulin and they also become less sensitive to insulin (Meneilly and Elliot, 1999; Ingelfinger and Jarcho, 2017: Hermann et al, 2021).
Men are at greater risk of developing type 2 diabetes than middle aged women with higher body mass indexes (BMIs). This is thought to be because men and women carry fat in different ways. Men tend to have central obesity and higher levels of fat around the abdominal organs, that is, visceral fat. Women tend to deposit more fat around the hips and have lower levels of visceral fat (Karastergiou et. al, 2012: Kautzky-Willer et. al, 2016).
In people of South Asian, Chinese, and African-Caribbean family origin, the risk of type 2 diabetes increases at an earlier age and at a lower BMI level (NICE, 2018).
People of South Asian and Chinese origin have a lower muscle mass than Caucasian populations and are at greater risk of developing diabetes than the white European population (Jenum et al, 2019).
An estimated 13.6 million people in the UK are at an increased risk of diabetes (Diabetes UK, 2020).
In England, the NHS has set up diabetes prevention programmes. These offer intensive behavioural intervention and set goals for weight loss, diet and physical activity. The programmes aim to enable people to make simple changes to reduce the risk of developing diabetes. The programme is open to people who are not pregnant, are aged 18-79, do not currently have diabetes and have received a score of 16 or over when using the ‘know your risk tool’. Links to the assessment tool and the programme is in the resources section.
Box 1.Finnish Diabetes Risk Score (FINDRISC)
NOTE: Total risk score: <7 = low risk; 7–11 = slightly elevated risk; 12–14 =moderate risk; 15-20 = high risk; >20 = very high risk
| Risk factor | Assessment | Score |
|---|---|---|
| Age | <45 years | 0 |
| 45-54 years | 2 | |
| 55-64 years | 3 | |
| >64 years | 4 | |
| BMI | ≤25kg/m2 | 0 |
| >25-30kg/m2 | 1 | |
| >30kg/m2 | 3 | |
| Waist circumference | Men <94cm; women <80cm | 0 |
| Men 94cm to <102cm; women | 3 | |
| 80cm to <88cm | 4 | |
| Men ≥102cm; women ≥88cm | ||
| History of hypertension medication | No | 0 |
| Yes | 2 | |
| Previously measured high blood glucose | No | 0 |
| Yes | 5 | |
| Consumption of vegetables, fruits or berries | Every day | 0 |
| Less often than once a day | 1 | |
| Physical activity | ≥30 min/day | 0 |
| <30 min/day | 2 | |
| Family history of diabetes | No | 0 |
| Yes, secondary degree | 3 | |
| Yes, first degree | 5 |
NOTE: Total risk score: <7 = low risk; 7–11 = slightly elevated risk; 12–14 =moderate risk; 15-20 = high risk; >20 = very high risk
Source: Lindström and Tuomilehto (2003)
Although an individual's ethnicity can increase diabetes risk, biology is not destiny and the person at greater risk can take steps to reduce that risk.
Calculating diabetes risk
Risk assessment scores aim to identify people who have certain risk factors and to measure the level of risk an individual has of developing a certain disease or problem. The risk of developing diabetes varies according to ethnic group, weight and genetic factors. The NHS England website has an online calculator that asks seven questions to calculate diabetes risk, see resources for details. The Finnish Diabetes Risk Score (FINDRISC) was developed in Finland and works out a person's risk of developing type 2 diabetes; it is slightly more comprehensive as it checks diet and exercise (Lindström and Tuomilehto 2003). Table 1 shows the FINDRISC.
Diagnosing diabetes
NICE (2022a) guidance recommends testing for diabetes if a person shows some of its clinical features.
A HbA1c blood test is commonly used to diagnose or monitor diabetes. It measures the amount of glucose attached to the haemoglobin over a 2 to 3 month period, as this is how long the blood cells typically last for in the body (Medline plus, 2021). Fasting blood glucose (FBG) levels can be checked using capillary or venous blood.
The WHO states that diabetes is defined as HbA1c greater than 48mmol/mol or a FBG greater than 7mmol. However, these tests should be repeated to confirm the diagnosis (WHO, 2011). In 2011, the WHO stated that HbA1c can be used to diagnose type 2 diabetes due to increased convenience for the patient, reduced need for fasting, and reduced dietary preparation (NHS London, 2018).
Inducing remission
In the past, people with type 2 diabetes were encouraged to lose weight and to increase activity levels. Most people were prescribed medication. We now know that dietary interventions that lead to weight loss can enable many people with type 2 diabetes to go into remission. The Diabetes Remission Clinical Trial (DiRECT) showed that 86% of people with type 2 diabetes who had been diagnosed in the previous 6 years could achieve remission if they lost weight rapidly. A weight loss of 15kg led to 86% remission and a weight loss of 10kg led to a 46% remission (Lean et al, 2017). This ground-breaking study has led to NHS England introducing a new programme to enable the remission of type 2 diabetes. The programme will initially provide 5,000 people in 10 areas with access to a meal replacement programme “soups and shakes” for 3 months. These provide around 900 calories daily. The programme will provide ongoing support from clinicians and coaches to enable people to maintain healthy lifestyles. (NHS England, 2020: NHS England, 2021).
Treatment
A number of different classes of medication can be used to treat type 2 diabetes these are, biguanides, SGLT2 inhibitor, DPP-4 inhibitors, glitazones and sulphonylureas. Figure 5 illustrates treatment pathways.
Biguanides
Metformin, a biguanide class drug, was developed from lilacs and was used in herbal medicines for centuries (Skugor, 2018). It is normally used as a first line of treatment in type 2 diabetes. It reduces the amount of glucose released by the liver and enables cells to take in insulin by reducing insulin resistance. It also helps to reduce the risk of heart disease.
Metformin does not cause hypoglycaemia when used as a monotherapy. It can lead to weight loss (3–5% of body weight), and it has been shown to decrease plasma triglycerides concentration (10–20%).
The most common side-effects of metformin are diarrhoea, nausea, abdominal discomfort and a metallic taste in the mouth. These side effects often resolve with continued use.
It is normally given twice daily or once daily (modified release). The normal starting dose is 500 mg daily. It is gradually titrated to reduce the risk of gastro-intestinal side effects, starting at 500 mg with breakfast and increasing by 500 mg in weekly intervals, until a dose of 1000 mg with breakfast and dinner or two grams MR once daily with breakfast is ingested. The maximum dose is 2550 mg per day but most practitioners use up to 2000 mg per day (Skugor, 2018).
Metformin can cause very rare, but life-threatening lactic acidosis (<1 in 100 000). It should be used with caution in people with renal failure. The dose should be reviewed when estimated glomerular filtration rate (eGFR) falls below 45ml/min and should not be used when eGFR is 30ml/min or below (NICE, 2022a).
Sodium glucose cotransporter 2 inhibitors
There are four Sodium glucose cotransporter-2 inhibitors (SGLT2) available: dapagliflozin, canagliflozin, empagliflozin, ertugliflozin (NICE, 2022a). SGLT-2 enables the proximal renal tubules in the kidneys to reabsorb around 90% of glucose from tubular fluid. SGLT2 inhibitors block the reabsorption of glucose by the kidney, and increase the amount of urine excreted by the kidney. This reduces blood glucose levels in people with diabetes who have elevated blood glucose levels. SGLT2 inhibitors work independently of insulin and can be used in combination with insulin. They reduce major adverse cardiovascular and cerebrovascular events, such as stroke, myocardial infarction and cardiovascular death, as well as the number of hospital admissions for heart failure (Vallon, 2015: Zelniker et al, 2019)
Common side effects include candida infections, back pain, increased amount of urine passed, dizziness and a mild skin rash. Serious, life-threatening, and fatal cases of diabetic ketoacidosis (DKA) are rare in people with type 2 diabetes. Gangrene (necrotising fasciitis of the genitalia or perineum) is a rare but serious and potentially life-threatening infection, has been associated with the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors. They should not be prescribed if estimated glomerular filtration rate (a measure of renal function) is less than 60 mL/minute, as they are dependent on good renal function to act (British National Formulary (BNF), 2022).
NICE (2022a) guidelines recommend that if the person with diabetes who has been prescribed metformin has heart failure, cardiovascular disease or risks of either, an SGLT2 should be prescribed in addition to metformin. Metformin should be initiated first and the SGLT2 added when the person is stabilised on metformin.
SGLT2 inhibitors can be combined with insulin in people with type 2 diabetes. They improve HbA1c, reduce body weight and decrease the required dose of insulin without increasing the risk of hypoglycaemia (Yang et al, 2017).
DDP-4 inhibitors
DPP-4 inhibitors, known as gliptins, work by blocking the action of DPP-4, an enzyme which destroys the hormone incretin. Incretins help the body produce more insulin only when it is needed and reduce the amount of glucose being produced by the liver when it is not needed (NICE, 2022a).
The DPP-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliptin) are usually well-tolerated but hepatic, renal and cardiac function should be checked prior to prescribing. Linagliptin can be used safely in renal failure at a normal dose but dose should be reduced in the other gliptins (NICE 2022b).
They should be avoided in people with a past history of pancreatitis as they are associated with acute pancreatitis. Patients should be advised to report severe upper abdominal pain and medication should be stopped if this occurs (BNF, 2022). There is an increased risk of heart failure in all gliptins other than linagliptin (Li et al, 2016; McGuire et al, 2019; NICE, 2022b).
Glitazones
The only glitazone licensed for use in the UK is pioglitazone. It works by treating insulin resistance (Singh et al, 2022). It is contraindicated in heart failure, can cause fluid retention, increase fracture risk in post-menopausal women and increases the risk of bladder cancer (NICE, 2022d). NICE (2022a) recommend pioglitazone as a second line medication. A careful assessment of the risks and benefits of this medication should be undertaken before use.
Sulfonylureas
There are five sulfonylureas-glibenclamide, gliclazide glimepiride, glipizide and tolbutamide (NICE, 2022c). Sulfonylureas stimulates the beta-cells in the pancreas to produce more insulin and decrease clearance of insulin by the liver. They are only effective if there are functioning pancreatic beta-cells (Sola et al, 2015). Sulfonylureas can cause hypoglycaemia and should be used with caution in older people, as hypoglycaemia is damaging to the ageing brain and can contribute to ill-health and cognitive decline (Mathur et al, 2015; Thorpe et al, 2015). Sulfonylureas lead to weight gain, so long-term use is best avoided in people who are obese.
Glucagon-like Peptide 1 receptor agonists (GLP-1)
There are five GLP-1 agonists-exenatide, liraglutide, lixisenatide, dulaglutdie, semaglutide (Nice, 2022d). GLP-1 agonists work by activating GLP-1 receptors in the pancreas, which leads to an increase in insulin release, reduces glucagon release and slows gastric emptying, aid in the reduction of blood glucose and body weight (Shaefer et al, 2015). GLP-1 agonists generally do not cause hypoglycaemia alone; however, they can contribute to hypoglycaemia if used in combination with Sulfonylureas and insulin (Filippatos et al, 2014).
Diabetes-a global and national emergency
In the 20th century, there were fears that a rising global population would lead to famine. In the 21st century diabetes is affecting 537 million people. In 2021, 6.7 million people died of diabetes – that accounts for one person every 5 seconds. It is one of the top causes of premature death (International Diabetes Federation, 2021).
In the UK, 13.6 million people are at increased risk of type 2 diabetes and the number of people with a diabetes diagnosis is expected to rise to 5.5 million by 2030 (Diabetes UK, 2021).
Primary care will provide most of the treatment and care for people with type 2 diabetes.
Conclusion
Currently one in 16 adults has diabetes and it is estimated that by 2030 this number will increase to one in 10. The most important risk factor is obesity. Community nurses can help stem the tide of diabetes on a personal and a professional level.
On a personal level, staff working in healthcare do not always manage to maintain a healthy body weight. Department of Health (DOH) research indicates that 21% of the healthcare workforce, an estimated 300,000 staff were obese (DOH, 2009).
A study of English healthcare workers found that two groups of healthcare workers, nurses and unregistered healthcare workers were most likely to be obese. The study found that 25.1% of registered nurses and 31.9% of unregistered healthcare workers were obese (Kyle et al, 2017). Community nurses need to look after themselves as well as their patients.
On a professional level, nurses can screen people for diabetes risk, discuss this with the individual at risk and advise self-referral or refer the person to a diabetes prevention programme. People who have been diagnosed with diabetes can be referred to for the ‘soups and shakes programme’ in an effort to induce remission. People who require medication can be supported to manage diabetes.
Community nurses can make a real difference to the health and well-being of people who are at risk of or who have diabetes.
Key points
- The incidence of diabetes has reached epidemic proportions, globally and nationally
- There will be 5.5 million people with diabetes by 2030 if no action is taken
- The prevention and treatment of diabetes is to change radically with prevention programmes and the Soups and Shakes diets which will help induce remission
- Type 2 diabetes shortens lives and impairs health but it is preventable
- At an individual level, we can improve health and well-being.
CPD reflective questions
- Do you know your diabetes risk? If not, have it checked. If its abnormal what changes would you make to reduce your risk of developing diabetes?
- What factors have led to the increase of diabetes over the last 30 years?
- If you were in charge of the Department of Health and Social Care, what changes would you make to reduce the number of people developing diabetes?