Editor’s viewpoint: UK diabetes care in 2003: a view from outer space

‘After one look at this planet any visitor from outer space would say “I want to see the manager”’ (William Burroughs)

Just occasionally it is interesting to apply the Martian test – what would an alien with no background knowledge, no history and most importantly no preconceived ideas make of a specific topic or problem? For example, what would our visitor from outer space make of the following?

No one disagrees that over recent years there has been a marked increase in the number of people with type 2 diabetes. However, the question is how great has the increase been? In some populations at least, the prevalence of type 2 diabetes may have risen mainly because people are being diagnosed and treated earlier, or are living longer. Talking up the numbers may have advantages for certain individuals or groups (Gale, 2003).

A recent article in The Times stated ‘Diabetes to eat 25% of NHS budget’, and clearly linked the risk of developing diabetes to the dramatic rise in the number of people with obesity (Leake, 2003). Depressingly, a follow-up of the Framingham Heart Study has reported large decreases in life expectancy related to obesity; a 40-year-old obese female non-smoker can expect to lose more than 7 years of life, and a man 5.8 years. The numbers increase to 13.3 and 13.7 years respectively if they also smoke (Peeters et al, 2003). The rise in obesity continues unabated in children, as does the debate about who or what is to blame. A recent report commissioned by the Food Standards Agency (2003) examined the influence of food advertising on children’s eating behaviours and concluded:

• There is a lot of food advertising to children.
• The advertised diet is less healthy than the recommended one.
• Children enjoy and engage with food promotion.
• Food promotion is having an effect, particularly on children’s preferences, purchase behaviour and consumption.
• This effect is independent of other factors and operates at both a brand and category level.

It is generally accepted that the development of obesity represents a victory of energy intake over energy expenditure in the vast majority of cases. There are rumblings that the food industry will have to face the possibility of discussions with legal representatives of affected individuals about compensation for causing passive overeating. Meanwhile, the sale of school playing fields for development shows no signs of abating (Kelso, 2002).

The recent transfer of power to PCTs has led to murmurs of discontent about asset stripping of secondary care (ABCD, 2003). Locally, it seems that the amount of red-tape has increased and the ability to look beyond the next financial year has decreased as the influence of the PCT takes hold. There will be financial rewards for primary care physicians associated with lowering HbA_1c values in type 2 diabetes. This is likely to mean earlier and greater use of insulin. At present the use of insulin without tackling obesity is associated with more weight gain. As mentioned above, if the weight gain is substantial, there is a risk of a shortened life span.

I guess that our outer space visitor may observe that diabetes care in the UK is in a confused state with a lack of coherent direction. Hopefully this is temporary but unlike Mr Blair, our Martian does have the luxury of a reverse gear on the spaceship.