NHS diabetes prevention programme expanded but what about pharmacists!

NHS National Diabetes Prevention Programme expanded in Lancashire and South Cumbria 

Type 2 diabetes remains as one of the major serious diseases, resulting in many long term medical issues such as blindness and amputation. Type 2 diabetes causes extreme suffering to its victims and is an ever increasing burden on the NHS, even though it is largely a preventable disease. The most effective prevention and treatment of this "lifestyle disease" is weight loss. Pharmacy is in an ideal position to deliver significant weight losses, resulting in the reduction of type 2 diabetes prevalence and severity, all with no expense to the NHS. Pharmacy is undervalued.

Using QOF figures with estimates from the Diabetes Prevalence Model 2016 (Public Health England) and 2012 APHO Diabetes Prevalence Model, there are an estimated 4.5 million people with diabetes in the UK. This includes 1 million people not aware they have type 2 diabetes and are yet to be diagnosed.

Five million people in England are at high risk of developing Type 2 diabetes. More than 90% of people with type 2 diabetes are obese. Forecasts predict that there will be a large increase in the prevalence of diabetes with one in three people likely to be obese by 2034. Since one in ten people are likely to develop type 2 diabetes in this time period, the NHS must find a better preventative method than currently employed.

The current programme is designed to aid people take control of their health by giving them the tools, information and support needed to make significant lifestyle changes. Ultimately the work done through the NHS Diabetes Prevention Programme aims to reduce the risk of diabetes and the burden of diabetes on the NHS.

This Lancashire Telegraph article looks into the expansion of the national NHS Diabetes Programme

Lancashire Telegraph Article - National Diabetes Programme

In this news article Russ McClean, 56, Chair for patients across East Lancashire said:

"As a diabetic, I am really pleased that the commissioners have decided to roll out the programme and give people the tools to look after themselves." 

"We all know the NHS is falling down, it will take prevention to save money when it comes to diabetes."

The Telegraph's health expert Dr Tom Smith said:

"If something doesn't change, diabetes is going to be the biggest health issue for our country in the future, not alzheimers, not cancer, Type 2 diabetes".

Lipotrim welcomes any move to address the rising levels of type 2 diabetes in the population but feel there is an important opportunity being missed by both the NHS and type 2 diabetic patients.

Firstly what is Type 2  diabetes?

Type 2 diabetes is one of a group of metabolic diseases in which the person suffers from prolonged high blood glucose levels (blood sugar). The  most common cause of high blood sugar is due to insulin resistance where the body's cells do not respond properly to insulin. To compensate for the reduced effectiveness, excess insulin is carried in the blood. Ultimately the system is overwhelmed by prolonged elevated sugars with serious long term health consequences.

The primary risk factor for type 2 diabetes appears to be related to carrying excess weight. Having a family history of diabetes may also increase the person's diabetic risk.

What is the NHS Diabetes Prevention Programme missing?

The NHS Diabetes Programme, although commendable in its attempt to reign in the levels of type 2 diabetes, misses the two key issues surrounding diabetes that it is aiming to solve:

1    Decreasing the risk of diabetes

Significant weight loss for a majority of existing type 2 diabetics will usually send the diabetes into remission (it is important to note that current medication cannot cure diabetes). For those patients at high risk of developing type 2 diabetes, namely those overweight but not yet obese, a reversal of their excess weight to a more healthy level (ideally BMI <25) will greatly reduce the likelihood of developing type 2 diabetes. In some ethnic populations, notably those from South Asia, the increased risk from weight starts at an even lower BMI.

So the NHS programme should work? 

Yes and no. The issue surrounding losing significant weight is time. The patients that are most likely to require such lifestyle interventions will often need to lose a greater  amount of weight and at a faster rate than is traditionally lost on lifestyle intervention programmes. A patient losing weight through lifestyle intervention will be lucky to sustain  weight losses of 1lb a week.

Many diets fail to produce significant weight loss because it takes too long, and daily life events can often negatively intervene. When there is an element of food addiction the problem is magnified. If the patient cannot exercise, the problem is enhanced.

The diabetes prevention programme entails the patient being actively recruited by the NHS healthcare provider. If the patient accepts their place on the programme they will be attending monthly sessions for around 12 weeks each lasting in the region of 1 to 2 hours:

7.1   Individuals with a Body Mass Index (BMI) > 25 are eligible for Tier 2 WMS.iiTier 2 WMS are commissioned by local authorities, they tend to be deliveredin person through group sessions in the community, should be multicomponentlifestyle services (including physical activity, behaviour changeand nutrition elements) and typically last for 12 weeks. 

Data used to construct the programme, taken from randomised trials in countries such as USA and Japan, has claimed a 30% to 60% reduction in type 2 diabetes. Real world studies however have suggested this type of programme might reduce type 2 diabetes incidence by 26%, with a measly 1.57% reduction of weight at 12 to 18 months compared with "usual care".

A patient with a starting BMI of 35 would finish with a BMI of 34.5 with this predicted reduction in weight, way short of even reaching a non-obese BMI at <30. A 26% reduction in type 2 diabetes is an unlikely result.

2    Decreasing the burden on the NHS by diabetes

The cost to the NHS in delivering the diabetes prevention programme is not insignificant, especially since the desired uptake number is 100,000 interventions in the first year alone. The expected costs are:

• £2.70 to invite and recruit each patient
• £270 per patient on average per year to deliver the interventions
• initial implementation payments per area of between £30,000 and £60,000

The NHS is therefore going to be spending a vast amount of money and resources to simply educate and motivate people to be healthier.

Is Bariatric surgery the face behind the programme?

The diabetes prevention programme Tier 3 and Tier 4 involves the recommendation and use of bariatric surgery. Weight loss surgery is a serious proposition for both the patient and NHS because bariatric surgery;

• is not always a single operation for the patient. Follow-up operations may be required and results are not guaranteed. In a study of 209 type 2 diabetics who underwent surgery, only 34.4% had complete diabetic remission. The conclusion of the study was that "Focusing on improved glycaemic control rather than remission may better reflect the benefit of this type of surgery". 
• can cost around £10,000 per operation. Does the NHS have this money going spare to not achieve high remission rates?
• requires surgeons, and plenty of them, if the lifestyle interventions fail to deliver the significant weight loss as we expect. We do not have the numbers of qualified surgeons available nor the extra money in the NHS. 

The detail behind the recommendation for surgery is also interesting:

7.4Surgical intervention is only an option if all appropriate non-surgical measuresto achieve or maintain an adequate, clinically beneficial weight loss s havebeen tried and the person has been receiving or will receive intensivemanagement in a Tier 3 WMS.iii

There is no mention of using a Very Low Calorie Diet (VLCD), in the NHS diabetes prevention programme Tier guidance, such as Lipotrim.

VLCDs have a pivotal role to play in the prevention and treatment of type 2 diabetes, especially in the modern climate of rising prevalence of the disease and prolonged austerity. A private, patient funded weight management programme would have a zero running cost for the NHS. Lipotrim would therefore deliver cost savings this prevention programme is aiming to achieve without the implementation and running costs the NHS is having to fund.

What about pharmacists?

It is scandalous to see the undervalued network of pharmacies, with their highly trained pharmacists, have not been used to deliver this programme. The extended opening hours of pharmacies and the expertise of their pharmacists could have been utilised to enhance the availability and effectiveness of any national weight management programme. The recruiting and educating of new DPP trainers, coupled with the need for premises is unnecessary and frivolous. 



Pharmacy is already contributing to the tackling of type 2 diabetes through their every-day, opportunistic lifestyle interventions. The network of Lipotrim pharmacies are adding their own success stories with significant weight losses contributing to medication cessation.

Current successful evidence based pharmacy weight management programmes, such as Lipotrim, save the NHS money now and in the future, and should be harnessed, not ignored.

Contact Lipotrim today
UK        0800 413 735
lipotrim@lipotrim.co.uk  

The NHS National Diabetes Prevention Programme