Predicted increase in diabetes for next five years and resources to deal with this increase including prevention

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WRITTEN QUESTION TO THE MINISTER FOR HEALTH AND SOCIAL SERVICES BY DEPUTY R.G. LE HÉRISSIER OF ST. SAVIOUR

ANSWER TO BE TABLED ON TUESDAY 14th MAY 2013

Question

What are the predicted increases in diabetes rates for the next five years and what additional resources, if any, will be allocated by the Department to deal with these predictions particularly in relation to prevention?

Answer

There are several different types of diabetes and the three predominant varieties are all increasing, albeit at different rates.

The current best estimate of past and present diabetes prevalence in Jersey is the Central Disease Register, which includes all persons known to have been diagnosed with diabetes, and still be living in Jersey. This register has been held by the Jersey Diabetes Centre since 1991.

Of the three main categories of Diabetes – Type 1, Type 2 and Gestational - Type 2 is showing the most significant increase in prevalence trends, with around 300new cases diagnosed each year. [1]

The only useful way of preventing diabetes is to prevent obesity. Although levels of childhood obesity among five years olds are showing small signs of flattening out, the numbers are still of real concern, while obesity in adults continues to increase rapidly.

In an ageing society, where the strains on health and community social services are, inevitably, going to increase, obesity and diabetes will continue to present enormous challenges for the H&SSD.

Clearly, it is not a problem that can be managed or addressed by the Health department alone, but one that demands an overall States of Jersey strategy. Securing cross departmental support is a pre-requisite for any meaningful joined up action, and is essential if Jersey is to have any hope of tackling the growing problems presented by the increasing prevalence of obesity and diabetes

While this does not yet exist, there are a range of current initiatives which are likely to have an effect, in time, on reducing the number of people becoming overweight or obese and these could actively underpin an overall States of Jersey strategy to tackle the problems. [2]

The prevalence of Diabetes and the challenges facing prevention is summarised below, followed by a more detailed background on trends and initiatives being developed to target obesity.

Executive Summary:

Three key types of Diabetes – Type 1, Type 2 and Gestational. All three are increasing, with Type 2 showing the most significant rise in prevalence

There are currently 3233 people living in Jersey, who have been identified on the register as having Type 2 Diabetes. This compares to 670 cases 20 years ago.

It is estimated another 400 have been diagnosed but not yet added to the register, and around 1500 additional people living with the condition, but not yet diagnosed

Cases of Type 1 Diabetes and Gestational Diabetes are both also increasing, though on a comparatively slower scale

It is estimated that a total of 5500 in Jersey are currently living with some form of diabetes with an expected increase of around 2000-3000 over the next five years

Preventing obesity is the only useful way to tackle the increasing prevalence of diabetes, and any treatment is unlikely to succeed without strategies to reverse obesity promoting' social trends

An overall States of Jersey strategy, with cross departmental support and joint initiatives, is essential if Jersey is to tackle the increasing prevalence of obesity and diabetes. This does not currently exist.

Despite the lack of an overarching States of Jersey Strategy, a number of initiatives are in place, including:

• Public Health Department currently developing an outline business case for a food and nutrition strategy
• Breastfeeding initiative
• Early years food guidance/training: Covers basic food hygiene requirements as well as best practice in providing healthier foods suitable for the nutritional requirements of under 5's
• Jersey school food standard: Secondary school canteens monitored in offering healthier foods and drinks with an emphasis on reduced fats and saturated fats, sugar and salt as well as increasing fruits and vegetables
• Healthy Schools: Schools work to achieve best practice standard across four areas, in particular food and physical activity
• Eco-Active schools: Develops programmes and facilities that encourages, supports and promotes the benefits of walking and cycling to school
• Strategic Travel plan: Includes improvements in cycle routes and pedestrian friendly infrastructure, as well as walking and cycling awareness raising events
• Provision of Health Education materials: SoJ web basic fact sheet information with links to UK best practice sites
• Public Consultation on Sport: joint initiative, being led by the Education Department, working closely with H&SS and involving other Departments

HSSD has made a commitment to further investment in existing diabetes services within the next 12 months, as well as allocating additional investment in the development of community diabetes services through White Paper funding

Prevalence and Trends: A Breakdown

Type 2 Diabetes is the most prevalent type of the disease in Jersey and other Western societies.

The prevalence of Type 2 Diabetes in Jersey has been rising, according to an exponential trend, doubling approximately every six years for the past two decades. There are currently 3233 people living in Jersey, who have been identified on the register as having Type 2 Diabetes, compared to 670 cases 20 years ago.

To these must be added a further estimated 400 people who, according to past patterns of delayed registration, have been already diagnosed with Type 2 Diabetes but are yet to be added to the register. It is estimated that a further 1500 people in Jersey have developed Type 2 Diabetes but are yet to have the condition diagnosed, giving a current estimated total of around 5100 people with Type 2 Diabetes.

Based on recent trends, this number can be expected to rise to c7000-8000 people with Type 2 Diabetes in the next five years, of whom approximately 4750 will be diagnosed and on the disease register.

New cases of Type 2 Diabetes in Jersey are currently being diagnosed and registered at a rate of around 300 cases per year. If past trends continue, this rate is expected to rise to approximately 525 newly-diagnosed and registered cases per year, five years from now, but a true incidence of c750-800 new cases developing per year. A significant proportion of people with Type 2 Diabetes, perhaps 15-20%, die from a complication of the condition without their diabetes ever being diagnosed. This is usually as a result of a vascular complication, such as a heart attack or stroke, and generally because, unless proactively sought out, the delay from development to diagnosis of Type 2 Diabetes is up to 10 years.

Type 1 Diabetes is the second most prevalent type of diabetes.

The prevalence of Type 1 Diabetes in Jersey has been rising more slowly and, according to a linear rather than an exponential trend over the past two decades, there are currently 425 people with Type 1 Diabetes in Jersey, compared to 251 cases 20 years ago.

It is unlikely there are any significant numbers of undiagnosed or unregistered cases of Type 1 Diabetes. Prevalence of Type 1 Diabetes in Jersey, according to past trends, is increasing by just under nine cases per year, meaning there will be an estimated 470 cases in five years time.

Gestational diabetes, which is diabetes arising for the first time in pregnancy, is the third most common type of diabetes diagnosed in Jersey. It is estimated, using the most up-to-date diagnostic criteria, that around 16% of pregnancies are complicated by Gestational Diabetes.

The majority of these cases are presently undiagnosed, in part because less stringent diagnostic criteria are used and, in part, as current detection protocols do not detect many cases. Undiagnosed or untreated Gestational Diabetes is the cause of a range of pregnancy-related complications, including some which are life-threatening to both mother and baby.

The rate of diagnosis of Gestational Diabetes in Jersey has increased from 10 cases per year to more than 50 cases per year over the past decade. Many units in the UK do not attempt to detect or treat the majority of cases of Gestational Diabetes because they lack the resources to do so. The total number of people with a form of diabetes in Jersey is estimated at 5500, with an expected increase of 2000-3000 over the next five years.

Prevention

Preventing obesity is the only useful way to tackle the increasing prevalence of diabetes. The obesogenic environment we have been living in for several decades is generating the upward trends in obesity across Western civilisation and, in turn, the rise in Type 2 diabetes.

A report by the International Obesity Taskforce blames social trends for the increase in childhood obesity, such as an increase in being driven to school, increased sedentary recreation, computer- based games and TV, as well as greater quantities and easily available energy-dense foods etc.

The report concludes that treatment is unlikely to succeed without strategies to reverse these obesity promoting' social trends.

An overall States of Jersey strategy with cross departmental support and joint initiatives, is essential if Jersey is to tackle the increasing prevalence of obesity and diabetes. In line with this, a number of initiatives are currently in place to tackle the problems of obesity.[3]

Investment

H&SSD has not escaped the impact of the financial pressures facing the public sector in recent years, and the department has struggled to meet the levels of investment in services needed to keep up with the unprecedented increase in diabetes prevalence trends over the past decade.

Some of the shortfall has been made up with the help of the local diabetes charity. HSSD has, however, made a commitment to put further investment into existing services within the next 12 months, as well as allocating additional investment to support the development of community diabetes services through White Paper funding.

ADDENDUM: OBESITY & DIABETES TRENDS

Obesity in Adults

• Increasing trend
• Currently over 17,000 (18%) likely to be obese
• 14,000 at high risk of cardiovascular disease
• Obesity in other European countries range from 10 to 30% of the population

Obesity  has  been  estimated  using  local  surveys  since  1999.   This  is  likely  to  be  an underestimation of the actual prevalence of obesity in the population, as respondents to self reporting surveys tend to under report their weight and over report their height.

Although the proportion of the population who are obese is not as high as some other European countries, where obesity ranges from 10 to 30% of the population, there is an increasing trend in obesity in both men and women in Jersey (Figure 1).

A greater proportion of the population are now overweight or obese, compared to 1999 figures. In 2010  18%  of  adults  were  obese  (over  17,000  individuals)  and  an  additional  38%  were overweight. Obesity is slightly higher in men than women (19% of men; 17% of women). It tends to be more prevalent among men aged 16-54 and more evenly spread in women (Figure 2). Waist size is a good indicator of individuals who are at increased risk of cardiovascular disease. Self  reported  surveys  have  indicated  that  over  14,000  individuals  (15-16%  of  the  adult population) report they have an increasing waist size, with both men and women, aged 55 and over, the most likely to be carrying excess weight around their middles.

Figure 1: Obesity trend in adults

Figure 2: Obesity by age and gender

Male Female

16%

r14%

ove12%

d

an10%

se

e

ob 8%

eof 6% 13% 14%12%

ntag 4% 9% 11% 9% 9% 10% rce 6% 6%

e 2%

P

0%

16-34 35-44 45-54 55-64 65+

Age group

Obesity in Children

• Increasing trend appears to be flattening
• 10% of our 5 year olds are obese
• Prevalence of obesity in 5 year olds of 9.4% in England

Data on obesity in five year olds has been collected at school health checks and analysed since 1997. The first data on obesity 10 year olds will be available later this year, following the completion of the first year of measurement in 2011/12

The increasing trend in obesity in younger children (to 2003/04) now appears to be flattening out (Figure 3) but it is still too early to be certain that this represents a long-term change in the trend. This reflects similar findings in the Health Survey for England 2010.

In 2010, 10% of five year olds were obese and an additional 15% were overweight, suggesting that one in four reception class children are likely to be overweight or obese. This is similar to the prevalence of obesity in five year olds in England, which is recorded at 9.4%.

Figure 3: Reception age BMI

NORMAL OVERWEIGHT OBESE

100% allrecetionchildren 40%

90% 80% 70%

p 60% 50%

f 30% geo 20%

nta 10% rce 0% e

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

P

Year: three year rolling average

Diabetes

• 4,000 individuals with diabetes
• Increasing trend
• UK average of 4.2% of the population with diabetes.

The diabetes service in Jersey has around 4,000 individuals on its data base. This amounts to around 4% of the population of Jersey. Of these around 3,000 individuals have Type 2 diabetes and around 450 have Type 1 diabetes. This is in line with the UK average of 4.2% of the population with diabetes.

As a consequence of increases in levels of obesity the diabetes service report increasing numbers attending with diabetic problems (Figure 4)

Figure 4: Diabetes patients in Jersey 1990-2012

Number of patients with Diabetes alive and in Jersey 1990-2012, projected to 2014

7000 7000

Newly Diagnosed This Year

(Projected)

6000 Total Number of Cases 6000

(Projected)

5000 5000 4000 4000 3000 3000 2000 2000 1000 1000 0 0

Year

Progressing a Strategic Approach

While there is currently no overall States of Jersey strategy on obesity, a number of long-term initiatives are in place, aimed at reducing the number of people becoming overweight or obese (See Table 1).

Table 1: Existing activity which would be included in an Obesity Strategy