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Preventive action can enhance patient care

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VOL: 98, ISSUE: 23, PAGE NO: 38

Anita Khulpateea, RGN, DipDiabetes, Specialist Practitioner in General Practice, is clinical team leader, diabetes care, Leicester General Hospital

Diabetes is a complex condition with global public health consequences. Worldwide prevalence is at least 100 million cases and this is predicted to double over the next 10-15 years. It has been estimated that diabetes accounts for 5-8% of the NHS budget (Health Service Guidelines, 1997; William, 1996), and that 80% of this cost is for treating complications (William, 1996).

Diabetes is a complex condition with global public health consequences. Worldwide prevalence is at least 100 million cases and this is predicted to double over the next 10-15 years. It has been estimated that diabetes accounts for 5-8% of the NHS budget (Health Service Guidelines, 1997; William, 1996), and that 80% of this cost is for treating complications (William, 1996).

Currie et al (1997) estimated that the NHS spent an average of £2,101 a year on each patient with diabetes, compared with £308 on each one without the condition. The same study suggested that the overall cost of hospital care for people with diabetes would increase to 15% of the NHS budget by 2011.

A large number of people with type 2 (non-insulin dependent) diabetes have developed complications by the time they are diagnosed, so there have been calls for a national screening programme to identify undiagnosed cases. Early detection is desirable, but neither the value of systematic screening nor the method have been agreed. However, the National Screening Committee (2001) has argued that screening for undiagnosed diabetes is probably not appropriate and that the focus should be on prevention.

It is believed that changes in lifestyles have led to the increase in the incidence of type 2 diabetes. Although the condition usually affects adults, it is being diagnosed in teenagers and even in children under 10 years old.

The complications of this type of diabetes can be present without any classic symptoms and about half of all patients present with complications at diagnosis, suggesting that onset probably occurred at least five years before diagnosis (American Diabetes Association, 2000). In many cases, late diagnosis is likely to be the result of lack of awareness of the symptoms.

Screening trials
Many studies have compared different screening methods, but there is no consensus on who to invite for screening and none have shown that screening and intervention result in health gain.

In 1998, patients of Caucasian and Asian origin from two general practices in Leicester were screened for diabetes (Davies et al, 1999). They were asked to self-test for glycosuria one hour after a meal. Instructions and response cards were sent in the appropriate language. The response rate was 34.4% among Asian subjects compared with 54% in the Caucasian group. The authors concluded that it was not an effective method of screening for diabetes.

However, the yield of patients with diabetes in the 35-64 age group compared well with much more expensive and labour-intensive approaches, so there could be a case for screening this population in the primary care setting. Health economists have argued that while mass screening is too expensive, it may be effective in subgroups with a high prevalence of undiagnosed diabetes who are also at risk of cardiovascular complications (Wareham and Griffin, 2001).

Risk factors
The National Service Framework for Diabetes (Department of Health, 2001) requires the NHS to ensure that people with diabetes are identified as early on in their illness as possible. It also promises that the NHS will develop, implement and monitor strategies to reduce the risk of developing type 2 diabetes in the population as a whole, and inequalities in the risk of developing it.

Emerging evidence suggests that it may be cost-effective to offer screening to groups that are at increased risk of developing diabetes. The National Screening Committee has been asked to clarify policy in this area and to advise the Department of Health. It is due to report back in 2005.

Two recent studies showed that changes in lifestyle could reduce the incidence in people who are at risk of type 2 diabetes (Eriksson et al, 1999; Knowler et al, 2002). Subjects in both studies were screened and found to have impaired glucose tolerance.

Practice nurses have an important role to play in opportunistic screening. Many already provide diabetes care and have regular contact with patients who could benefit from screening. These include the following main risk factors for diabetes:

- Obesity;

- A family history of diabetes;

- Aged over 60;

- Certain ethnic groups, such as Asians with a family background on the Indian subcontinent;

- Pregnancy;

- A history of gestational diabetes;

- Cardiovascular and peripheral disease.

Opportunities to offer screening to patients who are at risk include:

- During normal surgery hours;

- In health promotional clinics;

- New patient registration;

- Routine medical checks, such as those for the over-70s or for health insurance;

- During home visits to those who are housebound.

Screening should also be offered to people attending the surgery with symptoms related to diabetes, such as:

- Thirst;

- Polyuria;

- Continence problems in older people;

- Unexplained weight loss, whether sudden or gradual;

- Persistent fatigue;

- Mood changes;

- Recurrent infections, such as skin abscesses, boils or thrush;

- Changes in vision;

- Symptoms of neuropathy, such as pins and needles in the feet and legs.

The uptake of screening could also be increased by raising patients' awareness of the signs and symptoms. This can be achieved by displaying posters in surgeries. These should be translated into languages that are common among the practice's population and should encourage people to self-refer for a diabetes check.

Although there is no justification for mass screening for diabetes in the UK, there is growing support for screening and intensive management in subgroups in whom there is a high prevalence of diabetes and cardiovascular risk. Type 2 diabetes should not be regarded as a mild condition but as a serious health problem that can result in complications and premature death.

Primary care trusts will bear most of the burden of care for managing diabetes and screening those at risk. It is therefore vital that community health care professionals receive regular education on the risk factors for diabetes, how to help people to change their lifestyles to reduce these risks, and the effective treatment and management of the condition.

Those who are diagnosed with diabetes can then be taught how to manage it, while those who are at risk of developing it can be encouraged to make changes in their lifestyle to minimise the risk, such as taking regular exercise and eating a healthy diet.

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