The number of people with diabetes has increased four-fold in the past 35 years and diabetes is now the seventh leading cause of years lived with disability worldwide.^1,2 The impact of diabetes on health systems and national economies is of growing concern. In 2015, the global cost of diabetes was estimated to be US$1.31 trillion, with direct medical costs accounting for two-thirds of the costs.³ It is a major driver of healthcare expenditure and poses a significant challenge to healthcare systems in Europe. 

Most of the economic burden of diabetes is due to the cost of managing diabetes-related complications.⁴ The Cost of Diabetes in Europe – Type II study reported that nearly three-quarters of people had at least one diabetes-related complication.⁵

The burden of diabetes

We undertook a systematic review to identify and summarise the existing evidence on the burden of diabetes in Ireland.⁶

Using data from four Irish nationally representative samples (Survey of Lifestyle, Attitudes and Nutrition [SLÁN] 1992, SLÁN 1998, SLÁN 2007 and The Irish Longitudinal Study on Ageing [TILDA] 2010) we estimated trends in diabetes prevalence by gender and age group. We found the national prevalence of diabetes significantly increased from 2.2% in 1998 to 5.2% in 2015.⁶

Prevalence

Based on TILDA data we estimated the prevalence of type 2 diabetes in adults aged 50 years and over as 8.4% and prevalence was higher in men (10.3%) than women (6.6%). It was found that the prevalence of macro- and microvascular complications among those with type 2 diabetes was 15.1% and 26% respectively.⁷

Blindness

Trends in blindness due to diabetic retinopathy among adults in Ireland aged 18-69 years were calculated using registration data from the National Council for the Blind of Ireland.⁸ In 2013, 9% of the risk of blindness in the entire population aged 18-49 years was attributable to diabetes. 

Need for health systems to reorganise

The human and economic cost of diabetes highlights the need for health systems to reorganise healthcare from acute reactionary services to systematic planned chronic disease management including systems level approaches to prevention.   

The SSB tax

In terms of system level approaches to prevention, at UCC we are assessing the impact of a sugar-sweetened beverage (SSB) tax on 10-year diabetes incidence in Ireland. 

Habitual consumption of SSBs is associated with type 2 diabetes incidence. A recent meta-analysis using data from 17 cohorts estimated an 18% increase in type 2 diabetes with higher SSB consumption.⁹ Using a risk prediction model, we are estimating individual 10-year risk of developing type 2 diabetes. 

SSB consumption and 10-year risk

We applied the risk prediction model to the SLÁN dataset to estimate 10-year incidence of diabetes if the current SSB consumption remains constant. Using these risk estimates, we modelled the potential impact of a reduction in SSB consumption on 10-year diabetes incidence. 

In Ireland, over 50% of the population consumes SSBs with a mean daily consumption of 38.1g. When applied to the national adult population in Ireland, we estimated that 2,334 cases of diabetes over a decade are potentially attributable to SSB consumption. 

Screening and treatment

Among those who have already developed diabetes, screening and diagnosis are needed to identify diabetes-related complications. Our work on trends in blindness and visual impairment due to diabetic retinopathy provides baseline data for comparison with the introduction of Retinascreen, the national screening and treatment programme. 

There is largely a consensus on what constitutes optimal diabetes care, yet gaps persist between the ideal and the reality. Access to a range of specialist health services is essential for those with diagnosed diabetes, and our work with diabetes nurse specialists has highlighted the variability of service provision nationally. A shortage of allied health professionals has previously been identified as a barrier to delivering diabetes care in Ireland.¹⁰

Variation in accessibility

Nurse specialists with referral access to podiatry services for example, varies from 76-96%; while psychologist services range from 7-42%.¹⁰ Using data from TILDA, we reported that less than a quarter of people with diabetes reported attending ancillary state services such as chiropody and dietetic services.¹¹

Bariatric surgery is both clinically and cost-effective, with the largest benefit among those with type 2 diabetes. Despite this, there is huge variation in provision of this intervention between countries. Bariatric surgery is severely under-resourced in Ireland. 

We estimated the number of people in Ireland who would potentially benefit from bariatric surgery based on established clinical criteria using the TILDA dataset and the 2011 census population. Approximately 11,000 people with type 2 diabetes in Ireland are potentially eligible for bariatric surgery. Current public service provision of bariatric surgery in Ireland meets less than 0.1% of that need.¹²

Moving care to the community

In Ireland, as elsewhere in Europe, national policy in recent years has focused on moving from hospital-led management to delivering care in the community. Diabetes care is historically unstructured; however, formal primary care initiatives have developed across the country to improve the quality of care and service delivery at a local level. 

The longest running is the HSE Midland Diabetes Structured Care Programme (Midland Programme), established in 1997/1998. We examined the quality of this structured care programme by analysing trends in the processes of care performed for people with type 2 diabetes and found significant improvements over time.¹³

The reality is that many people are living with diabetes in Ireland today and we know a lot about how to treat or prevent it. We need to invest in prevention for the future and in providing quality care for people with diabetes now. 

References

1. Zhou B, Lu Y, Hajifathalian K, Bentham J, Di Cesare M, Danaei G, et al. Worldwide trends in diabetes since 1980: A pooled analysis of 751 population-based studies with 4.4 million participants. Lancet [Internet]. NCD Risk Factor Collaboration. Open Access article distributed under the terms of CC BY; 2016;387(10027):1513–30. Available from: http://dx.doi.org/10.1016/S0140-6736(16)00618-8
2. Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015; 386(9995): 743-800 
3. Bommer C, Heesemann E, Sagalova V, Manne-Goehler J, Atun R, Bärnighausen T, et al. The global economic burden of diabetes in adults aged 20–79 years: a cost-of-illness study. Lancet Diabetes Endocrinol [Internet]. 2017;3633:423–30. Available from: http://linkinghub.elsevier.com/retrieve/pii/S2213858717300979http://www.thelancet.com/pdfs/journals/landia/PIIS2213-8587(17)30097-9.pdf 
4. van Dieren S, Beulens JW, van der Schouw YT, Grobbee DE, Neal B. The global burden of diabetes and its complications: an emerging pandemic. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology. 2010; 17S1: S3-8
5. Jonsson B. Revealing the cost of Type II diabetes in Europe. Diabetologia. 2002; 45(7): S5-12
6. Tracy ML, Gilmartin M, O’Neill K, Fitzgerald AP, McHugh SM, Buckley CM, Canavan RJ, Kearney PM. Epidemiology of diabetes and complications among adults in the Republic of Ireland 1998-2015: a systematic review and meta-analysis. BMC Public Health, 2016; 16: 132
7. Tracy ML, McHugh SM, Buckley CM, Canavan RJ, Fitzgerald AP, Kearney PM. The prevalence of Type 2 diabetes and related complications in a nationally representative sample of adults aged 50 and over in the Republic of Ireland. Diabet. Med. 2016; 33: 441-445
8. Tracy ML, McHugh SM, Fitzgerald AP, Buckley CM, Canavan RJ, Kearney PM.Trends in blindness due to diabetic retinopathy among adults aged 18-69 years over a decade in Ireland. Diabetes Research and Clinical Practice 2016; 121: 1-8 
9. Imamura F, O’Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ 2015; 351: h3576
10. Riordan F, McHugh SM, Murphy K, Barrett J, Kearney PM. The role of nurse specialists in the delivery of integrated diabetes care: a cross-sectional survey of diabetes nurse specialist services. BMJ Open 2017; 7: e015049
11. Hugh SM, Tracey M, Gilmartin M, Fitzgerald AP, Kearney PM. OP33 Attendance and frequency of health service use among older people with diabetes: results from the irish longitudinal study of ageing (TILDA) J Epidemiol Community Health 2015;69:A22-A23
12. O’Neill KN, Finucane FM, le Roux CW, Fitzgerald AP, Kearney PM. Unmet need for bariatric surgery. Surg Obes Relat Dis. 2017; 13(6): 1052-1056
13. Audit Report of the HSE Midland Diabetes Structured Care Programme http://www.lenus.ie/hse/handle/10147/621484