Why has diabetes increased? The answer may be economics rather than lifestyle

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Over the last couple of days we've seen reports that the numbers of diagnoses for diabetes in the UK has risen by 60% over the last decade.

The number of people living with diabetes has soared by nearly 60% in the past decade, Diabetes UK warns.

The charity said more than 3.3 million people have some form of the condition, up from 2.1 million in 2005.

There's no disputing the accuracy of these figures or indeed the impact of the increase on the NHS (although claims it will 'bankrupt' the service are stretching the point a little). And we obviously need to know what it is that's causing the increase so as to try and prevent or mitigate those causes.

The most common 'cause' fingered in the reports is "lifestyle":

Martin McShane, national medical director for long term conditions at NHS England, said: “These figures are a stark warning and reveal the increasing cost of diabetes to the NHS. Evidence is piling up that added sugar and excess calories are causing avoidable increases in obesity and diabetes.

“We’ve said it before and we’ll say it again, it’s time to get serious about lifestyle change. Prevention is better than treatment for individual health as well as the health of the NHS.”

And let's be clear here about lifestyle. There's a well established link between morbid obesity and type-2 diabetes (which makes up 90% of the increase):

The relationship between obesity and diabetes is of such interdependence that the term 'diabesity' has been coined. The passage from obesity to diabetes is made by a progressive defect in insulin secretion coupled with a progressive rise in insulin resistance. Both insulin resistance and defective insulin secretion appear very prematurely in obese patients, and both worsen similarly towards diabetes.

So if there has been a significant increase in obesity, we would expect a comparable increase in type-2 diabetes. The problem is that this dramatic increase in diabetes has come during a period when the UK's rates of obesity were pretty stable (perhaps rising slightly):

If obesity is the main cause of new diabetes cases, this graph suggests that the increase should have been significantly less than 60%. So we have to look for another cause - perhaps it's something specific in the diet - sugar is the usual culprit here (mostly because diabetes is all about blood sugars and stuff like that so it stands to reason, doesn't it). Listening to a radio report on the story, I heard the interviewer ask something like "but it's not every kind of sugar is it, there are good sugars like the ones in fruit" - receiving a response all about 'five-a-day' rather than an accurate answer explaining how there's a link between fructose and type-2 diabetes (fructose being the dominant sugar in fruit).

It's worth therefore looking at whether sugar makes up more or less of our calories than it did a decade age - if there has been a substantial increase in sugar as an element in our diet and especially fructose then we might be able to point at that as a reason for the huge increase:

So here are some facts about the consumption of "non-milk extrinsic sugars" (this is all the added sugar as well as honey) in the UK. The figures come from the National Nutrition and Diet Survey (NNDS) conducted by the Government to provide a nationally representative snapshot of the nutritional intake and status of the UK population.

In 2000/01 NMES consumption in daily grammes was:

Male: 79
Female: 51

In 2008-20011 the average is:

Male: 70
Female: 50.1

So our sugar consumption has fallen. And this includes ALL forms of added sugar - the scary hidden stuff in processed food and the spoonful of lovely honey you stir into your hot toddy. Other than for women over 65 every category of consumption has fallen - with the biggest fall being among children.

We still eat a lot of sugar but there's no indication that it can be blamed directly for the increase in diabetes and especially type-2 diabetes. Despite all the shouting about diet and obesity, all the damnation of 'lifestyle', we're not really any closer to understanding why the last decade has seen such a big increase in diabetes. There is, however, one other thing that changed in 2004:

The new GP contract has been quoted as the most radical change to health care since the advent of the NHS in 1948. A major component of the contract is the Quality and Outcomes Framework (QOF). This offers a scoring system for achievement of health-care targets which is linked to financial rewards.

Put more simply - from 2004 family doctors were given a direct financial incentive to diagnose conditions that were within health-care targets and this included diabetes. Prior to 2004 few GPs ran routine diabetes tests - afterwards, with a direct financial incentive, loads more cases were identified. Don't get me wrong here, I'm not suggesting the incentive was a bad thing (it did mean lots more people got their diabetes treated who didn't before) but that it was perhaps the main reason why we saw a steady increase in diagnoses for diabetes.

Finally there's the matter of demographics - or to put it another way, how we're living longer:

You can see (perhaps) the impact of the rapid increase in obesity during the 1990s but look at the prevelance in the over-65s. Combine an incentive for GPs with an ageing population more likely to be visiting those GPs and we can see the source of our 60% rise. And this means that, rather than shouting about lifestyle, we should be celebrating just how well we've done in identifying diabetics - the task is to get that diabetes managed so as to avoid the expensive clinical interventions that are the big drivers of cost.

But then shouting about fat people and blaming sugar is much easier isn't it!

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On the ideology of public health

Building London's sewers - real public health work

I know I rant and rave about them, complaining about their outlook, attitudes and policies. I've called them health fascists, nannying fussbuckets and the Church of Public Health. And I don't regret a word if it.

However, being a kindly sort, I thought I'd have a bash at understanding what we mean by 'public health'. Not just for the entertainment but rather to set out why the approach and strategy - how millions in public funding is spent - might be improved.

We recognise that public health begins with us recognising that there are environmental factors that affect the health of populations. The classic example is John Snow and the Broad Street Pump but there are many other examples where interventions in the environment improved health - clean water, sewage systems, the clean air acts and the whole system of driver training and road safety. We should also note that, while the medical profession was involved in identifying the problem, its solution was largely in the hands of different professions, not least the often criticised environmental health officer.

Within public health budgets these interventions are still important - responding to epidemics and disease outbreaks, vaccination and inoculation and pollution control. But the profession made a significant shift away from public health being about environmental intervention to improve people's lives. Instead of clean air, clean water and inoculation against disease, we got this as a definition:

The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society.

This comes from the Faculty of Public Health and represents a significant change from the idea of public health being about interventions where either an all-population or environmental justification exists.  We've gone from using science and statistics to understand how cholera can be prevented to using price intervention to try and alter the behaviour of alcoholic. And the starting point for this shift was smoking - or rather the long campaign against smoking.

I won't revisit the history of anti-smoking - if you want to know more read Chris Snowdon's 'A History of Anti-smoking' - but the decision to target smoking allowed public health people to link environment and personal choice. And, at the beginning of the campaign, smoking was more-or-less an all population problem - most people smoked. In this campaign (and it was, up to five or six years ago, very successful) the crucial moment wasn't Professor Doll linking smoking to lung cancer but the acceptance that passive smoking was a health problem. There may be some question over this belief but there can be no doubt that eliminating passive smoking provided the substantiation for other public health interventions in lifestyle choices.

Running in parallel with this idea of societal harm from the cumulative impact of lifestyle choices (typically drinking, smoking and overeating) was another idea - the passive consumer. Popular books such as Naomi Klein's 'No Logo' presented us as victims of marketing, led by the nose into excessive consumption, at the mercy of manipulative corporations. This idea's inception goes back to what TV viewers should see as the 'Golden Age' of advertising when discredited theories such as 'subliminal advertising' were proposed. However, it was another age of excess - from the mid-1980s for about ten years - that spawned the idea of consumption as sinful and the consumer as victim.

By portraying the individual as a hapless addict, some public health thinkers were able to justify extending public health interventions into those individuals' personal choices. Both because those choices affected wider society (such as by costing publicly-funded health services more) and because the individuals weren't making real choices but were merely responding to an 'intoxogenic' or 'obesogenic' environment.

To complete the picture (again Chris Snowdon has the definitive review here) we need to add an older tradition - moral disapproval. We know that the temperance movement has considerable influence within public health and this more considered moralising is compounded by the more hypocritical sensationalism in popular media.

These three factors - environment as a factor in personal choice, the passive consumer and a sense of moral offence - combine to create the platform on which today's public health policies are constructed and support for them from politicians and media is obtained. And it presupposes the significance of government in health:

...recognises the key role of the state, linked to a concern for the underlying socio-economic and wider determinants of health, as well as disease

So, when Bradford Council considers its new role as a public health authority, it brings its broader ideology into the discussion.  Onto the prevailing ideology of state-directed opposition to certain choice behaviours is latched the idea of 'health inequality'. At present nothing has changed, public health remains unchanged in Bradford. But, at some point, the imperative of inequality will mean that the idea of public health addressing environmental (and all-population) issues is further blurred as resource is targeted to those places suffering 'health inequality'.

My concern with all this mission creep is that the ideal of public health becomes lost. It seems evident that anti-smoking campaigns have stalled as campaigners focus their efforts on denormalisation rather than on the reduction of harm. And, with the apparent success (in political not health terms, I might add) of these approaches, other areas adopt the denormalisation palette rather than approaches aimed at reducing harm or preventing harm from occurring in the first place.

Also this focus on choice and lifestyle overlooks some important public health issues - reducing excess winter death in the elderly population, improving air quality in cities, extending vaccination programmes - in favour of media-friendly campaigns around smoking, drinking or fast food. We enlist other parts of the local authority into these campaigns - trading standards, planning, licensing - pulling them away from their own public safety and regulatory responsibilities.

My polemic - the stuff about nannying fussbucketry and health fascism - is a reaction to all this. And it reflects a real desire to get public health back to its roots - concerned with the real environment in which people live, with preventing the spread of disease and ill-health and with promoting well-being. None of these require the condemnation of lifestyle choices let alone their denormalisation.

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It should read: "The NHS must treat working-class lifestyles not killer diseases"

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Four in every five deaths in London today are due to unhealthy lifestyles, including factors such as smoking, alcohol, bad diets and a lack of exercise.

This simply isn’t true. Or rather we can’t demonstrate that this is true. Here’s the ONS on causes of death:

Around half a million people, representing less than one per cent of the total population, died in England and Wales in 2009. The vast majority of deaths occurred at older ages, with almost eight out of ten men and nearly nine out of ten women dying at age 65 or above.

It’s worth noting here that the annual number of deaths is as low as the number of deaths in the 1950s when there were significantly fewer people. So there are (per 1000 population) fewer people dying than ever before and the average age of death is higher than ever before. The chances are that it’s old age that’s killing people rather than a libertine lifestyle:

For those aged 80 years and above coronary heart disease and stroke were the leading causes of death for both men and women. For men, influenza and pneumonia appear amongst the top three leading causes of death; these illnesses also appeared as a leading cause of death for males in the youngest age-group, one to four years. For women, dementia was prominent among the leading causes of death in this oldest age group and it is notable that the total number of deaths for women aged 80 years and above exceeded the combined total of all deaths amongst females at younger ages.

So why is it that health ‘leadership’ is so keen to take on the evil choices we make rather than continue the work of getting better at managing heart conditions, better at treating cancer and better at responding to injury? Why finger lifestyle rather than the truth – that our longevity is placing an ever greater strain on health and care services?

Dr Andy Mitchell, Medical Director for NHS England is right when he says:

“London’s hospitals are at breaking point and the demand for health care will outstrip the funding available in just seven years unless we fundamentally change the way services are delivered."

But absolutely wrong when he tries to blame this problem on “...conditions that stem from what we are doing to ourselves.” 

This simply isn’t true – unless he means eating better, living healthier and surviving for longer.

The medical mafia has decided that it must correct our lifestyles. Not because a correction is needed but because that mafia has decided it disapproves of our lifestyles. Or, to be more specific, the lifestyles of people in lower socio-economic classes – you know the sort who drink beer, eat supermarket microwave burgers and drink fizzy-pop. For this health mafia the working classes really are a drain on society.

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Getting heavier? It's not the calories it's the sitting around....

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As I listened to some professor of public health this morning, I was grateful that the radio is firmly attached to the car. Had it been loose, it would have been out the window - as ever we got fictitious 'deaths saved' that would come from a tax on sugar, a ban on trans fats and the compulsory reduction of salt (to dangerously low levels). And, as we've come to expect, the BBC interviewer simply allowed these lies to be told.

However, there was a little redemption in the news - unreported next to the latest collection of ban this or tax that campaigns from the public health mafia. It said this:

The full study is to be published later this summer, but details disclosed on Monday show that the average adult has cut calorie intake by around 600 a day. 

Yes that's true - we're eating less, indeed considerably less than we were in the 1980s. The problem is that we're getting fatter. Now we don't know the full details of the study but the suggestion is that the extra weight is a consequence of a more sedentary lifestyle, an older population and (I'm guessing) an increase in average height.

These findigns remind us that the mounting - and poorly evidenced - attack on sugar, fat and salt is misplaced. Our extra weight is much more to do with sitting a desks, on sofas and in car seats all day than it is to do with scoffing too much nosh.

Which probably explains why the BBC didn't give it a big splash.

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NHS response to criticism - blame the patient

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Yesterday "The Doctors" were out in force. All over the airwaves, in every newspaper. Telling us that the reason we don't live as long as the Spanish is because of our terrible lifestyle decisions:

But the problem is only in part to do with hospital care – much of it is about the way we live. Our diet, our drinking and continuing smoking habits all play a part, according to one of the report's authors, Prof John Newton, chief knowledge officer of Public Health England, which assumes its responsibilities on 1 April.

The problem is that this really doesn't stack up when we look at the figures. The evils thing - the targets of nannying fussbucket disapproval - are smoking, drinking and being too fat.

First smoking. According to the OECD, the UK sits pretty close to the average (indeed slightly below the average) at 21.5% of the population smoking. The two top countries for happy and healthy life - Spain and Italy - have smoking rates of 26.2% and 23.2%. Clearly it's not the smoking.

So it's the drinking then? Well here - again - the UK is below the European average with a per capita comsumption of 10.2 litres of alcohol per capita. And those long-lived Southern Europeans? The Italians are Europe's soberest folk at just 6.9 literes per head. But the Spanish - they love the stuff and stick back 11.4 litre. Not sure it's the booze then.

Maybe is the obesity - all those Latin folk are slender and snake-hipped after all, aren't they? Well for Spain:

Adult obesity rates in Spain are higher than the OECD average, and child rates are amongst the highest in the OECD.

And Italy:

Obesity rates are low in Italy, relative to most OECD countries, but are very high among children. 1 in 3 children is overweight, one of the highest rates in the OECD.

Doesn't look like the fatness.

Just for completeness, it isn't taking illegal drugs either:

National rates range from 0.8% to 11% with the lowest rate recorded in Malta, followed by Bulgaria, Greece and Sweden. Italy has the highest rate, followed by Spain, the Czech Republic, and France. 

It really is a problem for our fussbuckets, isn't it? This I mean:

The performance of the UK in terms of premature mortality is persistently and significantly below the mean of EU15+ and requires additional concerted action.

You see the problem really isn't our lifestyles - or not so much as "The Doctors" would have us believe. The problem lies elsewhere. Perhaps we should point the finger at the scandal of Mid Staffs, the weakness of our primary care system and a health service that is over-centralised and producer-controlled?

But that wouldn't suit the producers - that would mean them stepping up and accepting responsibility for the failings of our health system. It would mean turning their cosy little world upside down and putting patients - you and me, the users of the system - in change. It would mean looking at how our neighbours run their health systems. As BoM points out:

What this study really highlights is that when it comes to health, we have a lot to learn from our neighbours. None of them have a nationalised health system, yet most of them enjoy longer healthier lives than us. Instead of pretending our healthcare system is the envy of the world, we should have the humility to look and learn.

 In the meantime we can anticipate another episode of doctors, "health professionals" and supine politicians who daren't challenge these nannying fussbuckets telling us that it's all our fault.

Faced with criticism, the NHS always blames the patient.
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On the cult of public health...

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The transfer of public health from the clutches of central government and the NHS presents a real opportunity. An opportunity to appraise what it is we mean by ‘public health’ and how those considerable sums - £31 million in Bradford’s case – should be spent. Sadly, this won't happen.

Some while ago public health was captured by an aggressive, new puritan cult intent on using government funding to change the way people choose to live. This attack on the lifestyles of ordinary people is founded on a few principles:

• Denormalisation – the idea that those making certain choices should be ostracised since this will force them (assuming they want to be ‘part of society’) to change their wicked ways. This strategy is most advanced in the case of smoking (and anything that even looks like smoking) but the template of denormalisation is now applied to drinking and to eating certain sinful foods
• Government health spending is for the good not the evil – sinful people who smoke, drink and eat burgers, who might be a little short of breath or a couple of stone overweight represent a burden on health services meaning that the righteous do not receive the care they need. We should stop people smoking, drinking and eating burgers – not for their own good but for the ‘good’ of the NHS
• The poor can’t help it – far from the choice to smoke, drink and scoff Gregg’s sausage rolls being just that, a choice, it is in fact the fault of the makers of these products – “Big Tobacco”, “Big Food” and “Big Drink”. The poor are like helpless sheep thoughtlessly trotting into oblivion, responding to the sirens voice of advertising and the manipulation of faceless, besuited men
• Medicalisation – smoking, drinking, eating the wrong stuff – even sex – can be treated with medicines. And the pharmaceuticals industry has spent a great deal of time – and money – creating new illnesses and new conditions that require drugs. Thus conditions such as “female impotence” arrive following pharma funding and their capture of researchers and clinicians. This medicalisation underscores denormalisation by making lifestyles an illness rather than a choice.

And the application of these principles has now spawned a vast industry:

‘The NCD Alliance, a global advocacy organization representing a network of more than 2,000 civil society organizations led a major lobbying campaign, and mobilized its network to ensure this target was secured.’

These aren’t noble volunteers we’re speaking of here but committed campaigners paid by these ‘civil society organisations’ to lobby government and international organisations such as the World Health Organisation. And much of that funding comes from either the very governments being lobbied or from those who benefit from the medicalising of normal conditions.

Public health long since stopped being about great programmes such as building sewers, immunisation and clean air. Instead it has become a bitter little profession dedicated to finding fault with the choices that ordinary people make, with punishing them for enjoying a few simple little pleasures and with hectoring us about our lifestyles. None of this is really about our health. Rather it is about sin - about disapproving of what we do, of believing that the focus of our lives should be the search for eternity. Not in the afterlife but here on Earth.

And the believers in the public health creed say that this is done by a purposeful life dedicated to well-being - to the rejection of hedonism and its replacement with the comfort blanket of a false contentment. But worse these believers whip up hatred and disapproval of anyone who rejects their search for eternity, who believes that we only get a short time living and that our first duty is to have as much fun as we can in that short time.

This dreary and depressing cult is enough to drive you to drink!

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Today's nannying fussbucket is another Tory MP: Dr Phillip Lee

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Welcome to the world of judgemental government, to nudging with a baseball bat. Welcome to Phillip Lee MP (he's a GP too so this comes as less of a a surprise) and the punishing of people for their lifestyle choices:

Tory MP and GP Phillip Lee made a striking call this morning for patients suffering from lifestyle-related diseases such as type 2 diabetes to pay for their prescriptions as part of a larger shake-up of the NHS. He was speaking as part of a series of presentations from members of the Free Enterprise Group ahead of next week’s Autumn Statement on their proposals for spending cuts which would allow George Osborne to meet his target of having debt as a proportion of GDP falling by 2015/16.

But Dr Lee's proposal isn't for everyone with a lifestyle problem - he's not suggesting that horse riders pay for having their broken legs plastered or Sunday morning footballers for patching up their sprained ankles. No these punishments fall only on "Officially Disapproved Lifestyle Choices". And the good Doctor gives us a clue:

‘If you want to have doughnuts for breakfast, lunch and dinner, fine, but there’s a cost.’

Choose the things we disapprove of and you won't get free treatment on the NHS. That's the message from Dr Lee MP.  So Dr Lee wants a world like that proposed - and rubbished by one of his colleagues - by Katie Hopkins, the well-known former apprentice contestant.

Former Apprentice contestant Katie Hopkins argues that people who eat, drink and smoke more than is good for them should pay more towards the NHS health care they need, as she sets out her calls for additional payments for some health services.

Please Dr Lee MP, just will you shut up with your fussbucketry, with your judging of folk for lifestyle choices and leave us alone. And if you want people to pay for healthcare, say you want them to pay rather than picking on the few who choices you don't like.

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More from the New Puritans at Benenden...

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We've met Benenden Healthcare Society before when they spread a few myths about drinking and misrepresented some research. And they're back!

More than one-third of British adults believe that a person's healthcare treatment should be affected by whether their lifestyle is healthy or unhealthy, according to latest research.

A poll by healthcare provider Benenden Healthcare Society found that 29% of people believed that those who lead healthier lives should receive priority treatment over those with less healthy lifestyles.

I'm guessing therefore that two-thirds of the population - between six and seven out of ten - don't think those who lead healthier lives should get priority on the NHS. Indeed, the researchers at Benenden tell us that even with the ultimate pariah - the smoker - most people (61%) don't think that they should be 'deprioritised' in receiving NHS treatment.

There is some hope - but not if folk like those at Beneden get their way!

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