Prof Kamlesh Khunti discusses the importance of Diabetes risk assessment tools and the need for creating awareness about Diabetes with Sunila Kelkar.
Prof Kamlesh Khunti is the Head of Department and Professor of Primary Care Diabetes & Vascular Medicine at University of Leicester. His interests include undertaking research into the early identification and interventions in people with diabetes and at increased risk of diabetes. He is a principal investigator on several major studies including DESMOND Diabetes Study. Professor Khunti is currently an advisor to Diabetes UK, RCGP, the Department of Health’s National Screening Committee on Vascular Risk, Chair of the Department of Health-RCGP Committee on Classification of Diabetes, Chair of the NICE Guidelines on Prevention of Diabetes, Clinical Advisor for the Diabetes NICE-led QOF Panel and member of the Primary Care Diabetes Society. He was awarded the RCGP’s John Fry Award for Research for 2001, the Mary McKinnon Lecture at the 2006 Diabetes UK Annual Professional Conference and the Paul Cromme Award by Primary Care Diabetes Europe in 2010.
Is it really essential to educate ourselves about Diabetes? The answer is a resounding YES!
98% of the time a person with Diabetes has to manage it on their own. Only 2% of the time, they have any contact with a health care professional. So for that 98% who self-manage their Diabetes, it is essential that they know how to deal with their Diabetes as in terms of what to expect and what to do, how to avoid complications, take medications, caring for their feet, eyes and such.
Prevention is better than cure
It is essential to identify people at risk and ensure that they have a tight control of their glycaemia and blood pressure. This helps them in the long term as it decreases their risk of heart disease, kidney disease, and eye problems.
In terms of screening there lacks strong evidence but past research in the field of addiction shows that if at risk people are identified early then it lowers the probability of cardio-vascular problems later in life Timely intervention improves the chances of lowering risk factors. This field needs further research to validate these findings.
Need for intensive lifestyle intervention
In people with Diabetes, studies have shown that early detection leads to improvements in overall health. A Chinese intensive lifestyle intervention program studied people with a high risk of Diabetes. It showed that it was possible to prevent micro-vascular complications and also cardio vascular complications.
An increasing number of teenagers are being diagnosed with Type 2 Diabetes. This trend is seen especially in obese South Asians teenagers. They also have marked heart problems at a younger age. Young people who are obese and have Type 2 Diabetes are seen to have cardio-myletis. Creating awareness in this age group, educating and changing their lifestyle practices is usually faced with teenage rebellion. Specific programs need to be in place to handle such scenarios.
Diabetes risk assessment tools
The first risk assessment tool developed was used widely in many countries. We tested it on our population and it didn’t work well due to differences in the British population and those who were previously tested. So we developed our own, tested it out and validated it. We developed a new score based on the same questions using factors such as age, sex, family history of Diabetes, amount of exercise they do, whether they have hypertension, food intake etc.
Patients fill out the form themselves. The tool provides them a risk assessment and informs them whether they need to be tested for Diabetes. This works well for Caucasian as well as the South Asian population. The tool is widely used and Diabetes UK use the tool on their website where it has been accessed by over 3,00,000 people.
In the UK, the National Health Service (NHS) offers health checks programs for which I was one of the advisors. People between the ages of 40 and 75 years were screened for Diabetes, high risk of Diabetes, kidney disease, hypertension and the possibility of risk of cardio vascular diseases. A lot of people were found to have high risk factors for these diseases. These people are then signed up for different therapies. This also leads to cost effectiveness in the long run if you identify people at high risk put them onto intensive lifestyle modification.
One of the risk assessment and prevention programs that I had chaired were requested to try and give guidance to South Asians as well. The findings were surprising. Lifestyle intervention for high risk South Asians between 25 and 39 years led to cost benefits not just cost effectiveness. The onset of Diabetes in South Asians is faster than the Caucasian population. Therefore there are more benefits in trying to prevent Diabetes and other diseases.
DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed ) is a six hour education program for newly diagnosed Diabetes over 1 full day or 2 half days. It is a family of group self management education modules, toolkits and care pathways for people with, or at risk of, Type 2 Diabetes. It has shown that it does lead to decreased depression, increased physical activity and better cardio vascular risk factor.
- It is TV driven lifestyle program which involves group based education where most of the time the participants do the talking rather than educators.
- DESMOND provides training to healthcare professionals and Diabetes educators to convey the DESMOND modules and toolkits to people.
- DESMOND offers a platform for people to meet and share life experiences.
- DESMOND empowers the patient to make their own decisions.
This program is now being used in 50 percent of UK Diabetes related setting.
Ethnicity and Diabetes
People of Indian descent are more susceptible to heart disease and type 2 Diabetes. Evidence shows that people of South Asian origin have a higher risk compared to the indigenous population of wherever they have migrated. Studies from Africa, Fiji, UK, Canada and America have replicated these findings. So in people of Indian descent, onset of both Diabetes and cardio vascular disease is five to eight years earlier. It was also seen that people of Indian descent who had heart disease died five to eight years earlier as well.
No one knows why Indians are predisposed to Diabetes. Researching this genetic predisposition is still in its infancy. Waist circumference has been associated with a higher risk for Diabetes and cardio vascular disease in South Asians. Abdominal obesity is associated with a high risk of Diabetes and cardio vascular disease in South Asians.
One reason could possibly be that people of Indian descent have developed the tendency to store fat to over the years which can be used in times of famine. Instances of famine are few now so most people are at a disadvantage. There is also the possibility of people having a lower metabolism rate. Too much stored fat with too little exercise and intake of rich food are the leading causes of abdominal obesity. Some evidence hints that South Asians may have to exercise twice as much as Caucasians to experience the same health benefits.
Two studies conducted targeting Indian population who have migrated to UK echo these findings.
- One study studied people from Punjab who had moved to UK and their relatives. They were found to have increased insulin resistance and higher waist circumference.
- Another study was by Joshi and Patel studied people in Nausari, Gujarat. Their relatives in the UK had increased insulin resistance and higher glucose levels.
Genetics and the sudden transition from a rural to an urban setting (environmental change) increased their risk of early onset of Diabetes and other diseases.
In an Indian context
Simple means could go a long way in tackling diabetes-
- Local interventions by local leaders on diet and healthy life could not only lower for the costs involved but also benefit a greater number of people.
- Enrolling people with Diabetes as educators (called peer support programs) to deliver education and create awareness has two-fold advantages. This could benefit them as well as encourage others to learn from their experience.
- Web based interventions; including social media which is an emerging field could prove helpful in an Indian context.
- Involving pharmacists and faith centres to help create awareness could help spread the message faster.
- Posters, movies, videos can be used to improve communication about diabetes and it’s problems, and connect to people in a more effective manner.
The need for early diagnosis and intervention cannot be stressed enough as the fact remains that 70% of people with Diabetes die of heart disease and we know we can prevent that.