The prevalence of type 2 diabetes among older people aged 65 and above in Medway
1. Introduction
Diabetes is a metabolic condition that arises when inadequate amounts of insulin is produced to control blood glucose levels or when the produced insulin does not work effectively. The aim of this paper is to give an overview of the prevalence of type 2 diabetes in people over 65yrs of age in Medway, UK. The paper will additionally focus on the prevalence of the disease in ethnic communities. Using available data and evidence from public health resources, the paper will first give an overview of the region before analysing diabetes as a public health issue by studying health inequalities and determinants of health. The paper will also discuss the local public health policies and services available, particularly in a workplace setting, before suggesting interventions and improvements.
For the purpose of this report, type 2 diabetes and diabetes will be used interchangeably.
2. Medway
Medway is a conurbation in the South East with an estimated population of 2,74,000. The overall health status of the people in Medway is varied with significant percentage of the population (up to 50%) living in the most deprived neighbourhoods when compared with the England average. Inequalities in life expectancies in the area appear to be related to the levels of deprivation in the region with 6.3yrs lower for men and 4.3yrs for women. Main causes of death in the region are smoking related deaths and cancer and their prevalence is significantly worse than England average. However, diabetes is one of the leading causes of disease and poor health in the area (Public Health England (PHE), 2016).
3. Workplace setting
Present workplace setting is a community health services centre in Medway which provides full range of health services that covers assisted-living services to out-of-hour emergency care. One of the key areas of service, offered by the centre, is for type 2 diabetes through education, clinic appointments, telephone advice for patients and family members. The centre also provides assistance with maintaining personal hygiene, diet, regular appointments and maintaining accurate records for patients. It offers an exclusive education programme on type 2 diabetes which is delivered by a team of educators and administrators on a referral basis. The programme not only caters to educate the community on diagnosis and awareness but also assists patients who already have diabetes. A short programme lasting for couple of weeks, it aims to educate residents and patients about latest treatments, managing diabetes and learning more about any problems they may have. Furthermore, assistance for patients who have reached their maximum oral diabetes medication or those who are starting other types of medication is also offered by providing clinic appointments at various nearby locations upon receiving referrals.
4. Diabetes is a serious public health issue.
World Health Organisation (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Diabetes is a progressive disease that is caused by a multitude of social and physical factors such as obesity that it requires lifestyle management at every stage. While most patients will require oral drugs or insulin, a holistic approach involving diet control, exercise and mental health is required to tackle the disease including those that have not been detected (Diabetes UK).
According to PHE, 3.8 million people in England have diabetes out of which 90% carry type 2. Factors such as age, ethnicity, play a role in the prevalence of the disease. For example, while 9% of people aged between 45-54 have diabetes, nearly 24% of adults aged above 75yrs have diabetes. The higher the age, bigger its implications giving rise to cardiovascular diseases (PHE 2014). Unfortunately, these figures do not include those who have not been diagnosed. Owing to the nature of the disease being progressive, care, intervention and support systems are required at different stages.
The cost of treatment, interventions and complications for a diabetic patient was estimated to be around £8.8billion between 2010 – 2011 while the indirect costs (such as loss of productivity due to illness) was £13 billion (PHE 2014). The rising prevalence of diabetes in England especially amongst some minority ethnic groups and high-risk population such as people over 65yrs of age, means increasing costs to society and decreasing quality of life and health status. The ageing population in Medway is expected to increase by 29% (65yrs) and 34% (85yrs) by 2020. This means there will be an increase in chronic illness, heart diseases, increase in healthcare and social care costs. (NHS and Medway Council, 2012)
5. Social determinants of health related to Type 2 diabetes
According to the World Health Organisation, “The social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems”.
To understand the relevant social determinants of health with respect to type 2 diabetes, one needs to understand the disease in its entirety. Type 2 diabetes is caused by a complex interplay of factors such as age, lifestyle, environment and ethnicity. For example, research shows that obesity has a close association with type 2 diabetes. Weight status amongst adults with type 2 diabetes in 2009-2010 showed a worrying trend of 47.6% of adults over and above 55years who were obese. Furthermore, an estimated 4.6 million people or 9.5% of the adult population, in the UK, by 2030 is expected to have diabetes owing to age and changing ethnic structure (PHE 2014). And in Medway, the percentage of people on GP registers with recorded diabetes 2104/2015 is worse than England average at 6.9% when compared to 6.4% (PHE England, 2016).
Socio-economic statuses such as age, ethnicity, gender, employment, access to green spaces, debts etc., help identify heath inequalities (NHS and Medway Council, 2012):
Age: In 2010, annual public health report, NHS Medway reported that 47% of the total population to be over 40years of age with 13.6% over the age of 65 (Barnett, 2010). This percentage is expected to increase in the future drawing more attention to age-associated risk of getting diabetes.
Lifestyle factors: Unhealthy diet, lack of exercise, environments along with other economic, psychological and cultural factors, smoking and sedentary lifestyles are also contributory factors. In Medway, percentage of physically active adults in 2015 is 53.3% and significantly not different from England average of 57%. Similarly, excess weight in adults from 2012 – 2014 is 66.8 and is not significantly different from England average of 64.6 (PHE, 2016).
Obese people are found to be 7 times at a greater risk of being affected by diabetes than healthy individuals. This is because obesity is in turn closely linked to body mass index (BMI) (PHE 2014). Physical and social environmental influences also play a strong role in determining healthy diet, physical activities, and other culturally influencing factors. Marmot indicators for creating and developing healthy and sustainable places and communities through utilisation of outdoor space for exercise/health reasons show that Medway has performed significantly worse than England average. Only 8.1% of utilisation has been carried out in Medway when compared to 17.1% in England (PHE, 2015). Furthermore, the Medway health summary 2016 shows that a high percentage of the population (up to 50%) reside in areas of most deprivation. Inequalities in life expectancies gap for men and women at 6.3yrs and 4.3yrs prevail.
Ethnicity: Reports show that minority ethnic groups have a high risk of doctor-diagnosed diabetes compared to the general population. Type 2 diabetes affects people of South Asian, African-Caribbean, Chinese or black African descent at least 10years ahead of white Europeans. These differences are believed to be due to genetic predispositions, susceptibility and environmental. The National Institute for Health and Care Excellence (NICE) further states that being older than 40yrs or 25yrs for some black and minority ethnic groups is an important risk factor for developing type 2 diabetes (PHE 2014).
6. Public health policies and interventions
Considering the nature of diabetes and how intervention strategies and healthcare services need to be made available across the social gradient, three key public policies (Mermot Review, 2010) are relevant. Diabetes requires actions on both ill health prevention and healthy living promotion across the full social gradient.
1. By making available adequate resources and coming up with innovative strategies for behavioural interventions that focuses on the entire community is required. Access to advice, guidance, information sessions should be made across the social gradient both for early diagnosis as well as treatment.
2. Implement evidence-based programmes of ill-health preventive interventions that are effective across the gradient. This may result in reducing deaths due to cardiovascular diseases in the focus group and reducing the risk of death due to diabetes.
3. Improving programmes to address the causes of obesity across the social gradient which will reduce the levels of obesity and diseases associated with obesity and reduce the risk of diabetes.
A number of public health initiatives for tackling the burgeoning problem of diabetes has been implemented nationwide. Some examples include the NHS Diabetes Prevention Programme that is made available to high risk population. Through referrals, the programme offers dietary assistance, weight loss and physical activity programmes. Other healthcare programmes aim to support adults by giving health advice for those with previously undiagnosed condition. Another campaign called One You focuses on modern day lifestyles and how to avoid diseases in the future by providing tools and advice to help take behavioural actions for healthy living.
7. Area of intervention
Type 2 diabetes in adults is a lifestyle disease that arises from a collection of factors that influence a person’s lifestyle. Knowledge, attitude, habits, stress levels and motivation influence health behaviour. Owing to the progressive nature of the disease with an onset age of above 40yrs, the trans-theoretical model or stages of change model (Glanz and Bishop, 2010), might be effective when designing intervention strategies.
The model theorises that not all people will be ready to attempt change immediately they instead undergo stages of change to achieve a positive behavioural change. Studying the stage of change is believed to be useful in predicting a variety of behaviours such as eating habits. It is believed that the stages of change model can be useful for designing intervention strategies for a particular focus group such as patients above 65yrs of age as discussed below. (Glanz and Bishop, 2010)
The Medway community health clinic provides a range of services for diabetic patients through education and resources, health services such as clinical appointments, diet assistance etc. However, there are a number of areas for improvement under health improvement and health services.
1. The data used to study about the prevalence of diabetes in the aged population i.e., above 65yrs is limited. While there are broad estimates available on adult diabetes in general, more data for this particular population group in the community would be helpful in identifying and designing interventional strategies.
2. Create programmes that involve physical education by forming walking groups, volunteering activities and others that involve physical movement. Groups formed on the basis of ethnicity could also be created to encourage people to walk and participate in physical activities.
3. Dietary programmes that would consider ethnic inputs can be emphasized. Particularly for individuals belonging to the minority ethnic groups such as African-Caribbean and south Asian origins (Diabetes UK, 2014b) who are at a higher risk of acquiring the disease. Furthermore, these programmes could include low calorie diets (Taylor 2014) or other type of diets that would help patients lose fat around the pancreatic region. Such diet programmes should however be regularly monitored and followed-up so as to provide customised service. (Campbell et al., 2010).
Conclusion
Type 2 diabetes is a progressive lifestyle disorder which reduces the quality of life significantly if not diagnosed early, managed effectively and treated properly. In focus groups of adults aged more than 65yrs, with high prevalence rates and high risk, effective intervention strategies at the local community level is needed.
The health inequalities in Medway highlight the need for focus on the most deprived areas of the population to enable access to information, care services and take necessary steps to improve the health status. The increasing prevalence of diabetes in Medway along with the growing ethnic population in the region and estimated increase in the aged population in the future, local governments and community centres should join hands to closely monitor and collect data.
Considering the nature of the disease which can be controlled by making lifestyke adjustments, the workplace setting needs to adopt intervention strategies that include physical education, regular care services along with dietary assistance for the focus group. This is particularly significant for ethnic minority population in the area who are at higher risk of getting diabetes.
Reference list
• Public Health England (2014). Adult obesity and type 2 diabetes. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_obesity_and_type_2_diabetes_.pdf
• Strategic review of health inequalities (2010). Fair society, healthy lives. The Marmot review executive summary. http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review
• Association of public health observations (2010). Framework of indicators to assess performance improvement in delivering review recommendations http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review
• Karen Glanz and Donald B. Bishop (2010). The role of behavioural science theory in development and implementation of health intervention. Annual Review of Public Health 31:399 – 418
• Public Health England and UCL Institute of Health Equity (2015). Healthy life expectancy and life expectancy around 2011 census Medway. http://admin.instituteofhealthequity.org/Content/FileManager/Indicators2015/HealthyLivesPDFs/healthy-life-expectancy-and-life-expectancy-around-the-2011-census-medway.pdf
• Medway Clinical Commissioning Group, NHS Commissioning Board and Medway Council (2012). Joint Health and Well-Being Strategy for Medway 2012 – 2017 http://www.medway.gov.uk/pdf/Joint-Health-and-Well-being-Strategy-for-Medway-2012-2017.pdf
• Fiona Campbell. The social determinants of health and the role of local government. Improvement and Development Agency http://www.local.gov.uk/c/document_library/get_file?uuid=eb92e4f1-78ad-4099-9dcf-64b534ea5f5c&groupId=10180
• Public Health England (2016). 3.8 million people in England now have diabetes. Gov.UK https://www.gov.uk/government/news/38-million-people-in-england-now-have-diabetes
• Public Health England (2016). Medway Health Profile 2016. http://fingertips.phe.org.uk/search/type%202%20diabetes#page/1/gid/1/pat/6/par/E12000008/ati/102/are/E06000035/iid/90275/age/164/sex/4
• Barnett A. (2010). 2009/2010 https://democracy.medway.gov.uk/mgConvert2PDF.aspx?ID=5591&nobdr=2
• Diabetes UK. What is type 2 diabetes. Available at
https://www.diabetes.org.uk/