Preventing and managing diabetes: an exemplar for NCDs

Preventing and managing diabetes: an exemplar for NCDs A C3 briefing paper, December 2012 Summary Tackling the growing epidemic of diabetes demonstrates what is required to stem the rise in and rising costs of non communicable diseases (NCDs). Together, these diseases (primarily cardiovascular disease, many cancers, chronic respiratory disease, as well as diabetes) account for the great majority of death and disability in most regions of the world, but much of the suffering they cause could be prevented or delayed. Successful prevention of type 2 diabetes is dependent upon making it easier to be healthy, particularly tackling poor diet, lack of physical activity and obesity major risk factors for many other NCDs. An environment in which it is easier to make healthy choices that prevent diabetes will also facilitate decisions that prevent or delay many other diseases. Early detection of those at high risk of diabetes allows for timely treatment, and can be part of a health check programme. If diabetes is successfully managed, costly and irreversible complications which include other NCDs, such as heart disease and stroke can be delayed or prevented. The way in which people with (or at high risk of) diabetes can be empowered to self manage their condition can also act as an exemplar of how to take control of lifestyle and medication to prevent complications and address the mental health challenges of living with an NCD. Working to prevent diabetes and other NCDs, and to treat the early stages of diabetes before the complications such as cardiovascular diseases (CVD: heart disease and stroke) begin to manifest, will lead to significant savings: this is a win win for society and individuals. Introduction: diabetes and NCDs myriad links The extent to which diabetes 1 and other NCDs particularly CVD, cancer and chronic lung disease are disabling individuals and crippling health systems worldwide is well documented. For example, together they account for 86% of deaths and 77% of the disease burden in the World Health Organisation European Region. 1 The disease that is predicted to increase most sharply without urgent action is diabetes, both in developed and developing countries. This paper argues that the way in which diabetes can be prevented and treated can be realistically held up as an exemplar for preventing and treating major NCDs. Diabetes is a chronic and permanent condition, one of the leading causes of renal failure, blindness, amputation and CVD. This is increasingly expensive: as much as 10% of healthcare spending in countries such as England is already being spent on diabetes and its complications. 2 This increase is being driven by ageing of the population and by changing lifestyles: NCDs are increasingly affecting people at ever younger 1 Diabetes mellitus is a chronic condition that occurs when the body cannot produce enough or effectively use insulin. There are three main types of diabetes: type 1 diabetes, type 2 diabetes and gestational diabetes mellitus (GDM). See International Diabetes Federation, Diabetes Atlas: http://www.idf.org/diabetesatlas/5e/what is diabetes Director: Christine Hancock First Floor, 28 Margaret Street, London W1W 8RZ, United Kingdom; Tel +44 (0) 20 7637 4330; Fax +44 (0) 20 7637 4336 C3 Collaborating for Health is a registered charity (no. 1135930) and a company limited by guarantee (no. 6941278), registered in England and Wales.

ages, reducing productivity and incomes. NCDs also disproportionately affect the poorest in society, often the least empowered to lead healthy lives, as well as the least able to access help when they become ill. The economic impact of NCDs is enormous: between 2011 and 2030, the World Economic Forum and Harvard School of Public estimates that the anticipated economic burden (cumulative output loss) of the major NCDs to be around $30 trillion. 3 The tragedy is that much of the NCD burden could be prevented or delayed, and development of complications slowed through careful management. Complications of NCDs can be very distressing for individuals and particularly costly for health systems (costs greatly increase where there are comorbidities 4 ), so successful management of the major modifiable risk factors of diabetes and other NCDs to prevent complications is essential: managing blood pressure: hypertension is more prevalent in people with type 2 diabetes, with around 40 50% having blood pressure greater than 160/95 mm Hg. This is a powerful risk factor for stroke, 5 and CVD; 6 managing cholesterol: high cholesterol is also a risk factor for CVD and people with diabetes often have reduced function of good cholesterol and higher levels of bad cholesterol, making control of their cholesterol particularly important; reducing overweight: globally, 44% of the diabetes burden, 23% of the ischaemic heart disease burden and 7 41% of the burden of certain cancers are attributable to overweight and obesity. 7 An exemplar for prevention Rates of diabetes are predicted to rise sharply over the next few decades: a simulation by the National Heart Forum in the UK, for example, has estimated that the percentage increase in stroke between 2010 and 2050 will be around 23% but that the increase in diabetes could be as much as 98%. 8 Projected increases in the developing world are also frightening by 2030, estimates suggest that over 100 million people in India will have the disease, compared to 61.3 million in 2011. Working to prevent this increase in diabetes prevalence is urgent, and will have a particularly great impact on health of individuals and economies. The primary modifiable risk factors for the major NCDs are: poor diet (including the harmful use of alcohol), lack of physical activity and smoking. Studies from China, 9 Finland 10 and the United States 11 have all shown that lifestyle interventions are effective in delaying or preventing the development of type 2 diabetes (which accounts for around 90% of all cases of diabetes 12 ) and other NCDs reducing the likelihood of developing the disease by around a half and there are now diabetes prevention programmes in place in many countries, including Australia, Thailand, Germany and the United States. 13 Overweight (driven by poor diet and physical inactivity) is a major risk factor for type 2 diabetes cases of type 2 diabetes are even being diagnosed among obese children. 14 Keeping to a healthy weight, however, is also key in avoiding other diseases, including heart disease. Encouraging the consumption of a balanced diet high in fruit, vegetables and fibre and low in salt, sugar and fat helps to maintain a healthy weight (displacing other, potentially less healthy, food choices) and can work to prevent not only diabetes but also other diseases. For example, high consumption of red and processed meat has been shown to increase the risk of both diabetes and colon cancer. 15 People with diabetes are at increased risk of high cholesterol levels, so tackling the amount of unhealthy fats in the diet is essential. Finally, eating a diet high in sugar (and this includes alcohol) not only can lead to overweight, it also raises blood glucose levels, which makes it harder for people with diabetes to manage their condition. Around 27% of cases of type 2 diabetes could be prevented by reaching the recommended levels of physical activity (30 minutes of moderate physical activity, on five days of the week). 16 Lack of physical activity is also estimated to be responsible for 29% of cases of stroke 17 and the risk of colon cancer can be reduced by around 24% by participating in physical activity. 18 2 www.c3health.org

Primary and secondary prevention in Finland an holistic approach Finland has a strong history of initiatives to tackle lifestyle risk factors the North Karelia project, launched in 1972, was the first major study to focus on community based primary prevention of CVD, and saw a marked fall in deaths from coronary heart disease and stroke. * Building on this experience and the Finnish Diabetes Study, ** the FIN D2D programme to prevent type 2 diabetes ran from 2003 to 2008 as part of Finland s 10 year national diabetes prevention initiative (Dehko). The initiative brought together a wide variety of partners government ministries, NGOs and academics and FIN D2D was delivered through a network of 400 primary healthcare centres, at a cost of around 9 million. FIN D2D has three strands: a strategy of early detection through a screening programme; working with those at high risk to help them to remain free of diabetes; and working to improve lifestyles at population level. At least 10% of Finnish people were screened for diabetes risk as part of the project, identifying those at high risk by using the Finnish Diabetes Risk Score (FINDRISC), which could be done either by general practitioners, nurses and in pharmacies or by individuals on the internet. It is estimated that the prevalence of undetected diabetes may be as high as diagnosed diabetes, and those found to be at high risk were referred to the FIN D2D project, receiving both lifestyle counselling and help with weight loss, with individually tailored goals and group interventions either in primary care settings or externally, such as weight loss groups or smoking cessation. After a year, during which participants had an average of around three intervention visits to healthcare professionals, the programme showed significant health benefits. + Average weight loss was 1.3kg for men and 1.1kg for women, as well as falls in blood pressure and bad (LDL) cholesterol. Greater weight loss correlated with a greater reduction in risk of developing diabetes: among those who lost 5% or more of their body weight (17.9% of the study total) saw a fall of 69% in the risk of developing diabetes compared to those who maintained weight. There were also decreases of 4.4mmHg and 3.8mmHg in systolic and diastolic blood pressure (compared with falls of just 0.7mmHg and 1.1mmHg among those whose weight remained stable), which will have particular benefit for the risk of stroke. The population level aspect of FIN D2D took the form of education for health workers and a demonstration project for decision makers. New tools and good practice in prevention were disseminated, and awareness of the importance of maintaining good health (not only diabetes, but also obesity and CVD) rose country wide, with health fairs, media campaigns and articles in national and local newspapers, leading to 310,000 people completing the FINDRISC test online. A recent study suggests that obesity is no longer increasing in middle aged people and that morbid obesity decreased in the FIN D2D areas while increasing in control areas, which will, again, have beneficial effects on rates of other NCDs as well as diabetes. ++ There are plans for population surveys to assess other NCDs in 2012 and 2017. * P. Puska, The North Karelia Project: 30 years successfully preventing chronic diseases, Diabetes Voice (2008) special issue: 26 9: http://www.idf.org/sites/default/files/attachments/article_593_en.pdf ** J. Tuomilehto et al., Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance, N Engl J Med (2001) 344(18): 1343 50: http://www.nejm.org/doi/full/10.1056/nejm200105033441801 + For details, see T. Saaristo et al., Lifestyle intervention for prevention of type 2 diabetes in primary health care: one year follow up of the Finnish national diabetes prevention program (FIN D2D), Diabetes Care (2010) 33(10): 2146 51: http://care.diabetesjournals.org/content/early/2010/07/22/dc10 0410.full.pdf+html and T. Saaristo et al., National type 2 diabetes prevention programme in Finland FIN D2D, International Journal of Circumpolar Health (2007) 66:2: http://ijch.fi/issues/662/662_saaristo.pdf. ++ T. Salopuro et al., Population level effects of the national diabetes prevention programme (FIN D2D) on the body weight, the waist circumference, and the presence of obesity, BMC Public Health 2011 11(350): http://www.biomedcentral.com/content/pdf/1471 2458 11 350.pdf. Tobacco use is a major risk factor for CVD (it is responsible for around 19% of stroke, 19 and increases the chances of developing coronary heart disease two to three fold 20 ), and is the cause of over 70% of lung cancer and over 40% of chronic respiratory disease. 21 It is also an independent risk factor for 3 www.c3health.org

diabetes, 22 as smoking is associated with insulin resistance. Compared to non smokers with diabetes, people with diabetes who smoke have twice the risk of premature death smoking is a significant risk factor for death by coronary heart disease in people with type 2 diabetes, and it also raises the risk of development of macrovascular complications such as stroke. 23 In a new programme in the United States, the existing Diabetes Prevention Program has been adapted so that the key components can be delivered through a reality TV show (www.projectnotmedp.com), focusing on small lifestyle changes (primarily diet and physical activity). Six participants were chosen to take part in the show, and around 300 viewers then joined in from their own homes, participating over the 16 weeks the results will be published soon. However, even when we know what to do to stay healthy, it is often difficult to act in healthy ways so creating an environment in which it is easier to make healthy choices is essential. This requires crosscutting policy measures, using a mixture of legislation and voluntary initiatives that reach well beyond the health sector, working in partnership with a wide variety of stakeholders (industry, researchers, healthcare professionals, teachers, urban planners and others), for example to: ensure availability and access to healthy food (including reformulation of existing products, and the development and marketing of healthier options); restrict marketing on advertising to children of particular food products, and enforce bans on sales of alcohol and tobacco to children; consider alcohol pricing to discourage its harmful consumption; design the urban environment to encourage physical activity; and put in place anti tobacco measures such as taxation and bans on smoking in public places. All such steps, over the medium and long term, will help to prevent diabetes and other NCDs. In addition, many of these steps can also have co benefits for climate change, which itself threatens human health in myriad ways such as extreme weather events, impacts on harvests, and changing patterns of infectious disease. 24 Encouraging active travel swapping travel by car for walking or cycling and eating less red meat which is particularly carbon intensive not only improve physical health, but also reduce carbon dioxide emissions. In this way, diabetes prevention efforts are benefiting the health of the planet, as well as the individual. An exemplar for early detection Although well over half of all cases of type 2 diabetes could be prevented by tackling lifestyle choices, 25 some cases of type 2 and all cases of type 1 cannot be prevented, and rely on early detection and good management for the avoidance of the onset of complications, taking into account both the physical and mental impact of detection. Early detection of NCDs means that treatment can begin promptly and health check programmes are essential for early detection. Screening an entire population on a regular basis is not practical, but identifying, and providing health checks to those at high risk whether because of overweight, known impaired glucose tolerance, ethnicity or age is likely to be cost effective. One US study suggests that early detection could reduce healthcare costs by 7.3% for those with a body mass index (BMI) of 25 to 35 kg/m 2 and 21.5% for BMI over 35 kg/m 2 range. 26 As shown in the case study of the UK s NHS Health Check (see box), health checks for diabetes particularly BMI and blood pressure are also key in identifying a range of other NCDs. Pregnancy is also a good time to undertake health checks, as women are likely to be particularly amenable to improving their health and the health of their child. This is particularly important among women who are at high risk of gestational diabetes (GDM): women with GDM have up to a 70% increased chance of developing type 2 diabetes and CVD, 27 and their children are also at increased risk of diabetes and overweight. 4 www.c3health.org

Health checks in England England has been piloting a vascular check programme the NHS Health Check which assesses the risk of CVD and undertakes screening appropriate to the level of risk faced by the individual. * The health check is offered, free of charge, to everyone aged between 40 and 74, with an initial check of basics such as BMI, smoking status and blood pressure. Those identified as high risk of diabetes are then given a blood glucose test, and those with high blood pressure are assessed for hypertension, and where individuals are seen as at high risk of chronic kidney disease, further tests are carried out. Appropriate lifestyle interventions are then suggested, and medication prescribed as appropriate. ** The policy has not yet, however, been consistently rolled out around the country. * Putting Prevention First: NHS Health Check: Vascular Risk Assessment and Management Best Practice Guidelines (2009) http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_097489 ** See, in particular, the flow chart at ibid., p. 4. An exemplar for management Good secondary prevention drug treatments as well as lifestyle changes once diabetes has manifested can delay or avoid the need for tertiary care of complications. Co morbidity is common, and good management of diabetes has particularly clear positive externalities in preventing and tackling these comorbidities. Regulation of blood glucose is the key to treatment of diabetes, and statins (which lower cholesterol) and anti hypertension drugs are also often prescribed, which also tackle cardiovascular diseases. In England in 2006, 561 million was spent on prescription medicines for diabetes, but with the majority of the 9 billion annual cost of the disease arising from other areas such as complications including impaired sight, amputation and heart attack. 28 Monitoring and tracking the health of people with diabetes, for example through the use of a national register, will help to ensure both that people receive the treatment that is appropriate to them, wherever they are in the country, and can also have benefits in terms of collecting and assessing data on the extent of diabetes and other NCDs. Primary care in Israel Since 1999, a diabetes programme has been in place in Israel, run by one of the major health insurers, Clalit Health Services. It includes continuous medical education, improved national electronic health records and software to alert healthcare professionals as to when patient follow up is due. The scheme provides a way of ensuring that patient information can be consistently accessed and tracked, and requires only minimal training to use. The system helps to facilitate preventive care and faster and more accurate detection, increases the time that healthcare professionals can spend with patients, and reduces costs through reducing duplicate testing and unnecessary procedures. It now covers 70% of the population, and has seen significant results: the proportion of patients having the necessary blood tests increased four fold in the first 12 years of the programme and there were improvements in the proportion of those adequately controlling their cholesterol and blood glucose levels the proportion of patients with good control of their diabetes rose from 28% in 1999 to 53% in 2007. * Building on the quality indicators in this diabetes programme, a National Programme for Quality Indicators for Health was established in 2004. * See M. Goldfracht et al., Twelve year follow up of a population based primary care diabetes program in Israel, International Journal for Quality in Health Care (2011): http://intqhc.oxfordjournals.org/content/early/2011/08/10/intqhc.mzr051.full and dbmotion Case Study on the national scale electronic health record in Israel: http://www.dbmotion.com/multimedia/upl_doc/doc_161209_139333.pdf 5 www.c3health.org

Care needs to be integrated across the health system to improve previously uncoordinated and suboptimal services, including the use of guidelines to promote best practice and support care coordination, careful alignment of financial incentives to encourage collaborative working, the use of IT to support care, and, crucially, partnership and engagement between healthcare professionals (from GPs to specialist nurses and diabetes consultants) and people with diabetes. 29 Experiences of patients and the care outcomes for a variety of chronic conditions can be improved significantly by taking this approach 30 and as people with diabetes are at high risk of other NCDs, ensuring that their treatment is delivered in a holistic, rather than fragmented, way is likely to lead to improved health outcomes, taking better account of the synergies that exist between treatments of different diseases. Similarly, in developing countries, there is a real need to break down the silos between diseases often, funding has been channelled only into tackling infectious diseases such as AIDS and TB, which are the focus of the Millennium Development Goals, without addressing NCDs. Ensuring access to essential medicines for all these diseases using synergies such as utilising the same distribution channels, for example could greatly improve the outlook for economic development in developing countries. Of the estimated $21.8 billion global development assistance for health in 2007, less than 3 per cent $503 million was dedicated to NCD prevention and control, despite the huge burden that it places on health systems. 31 An exemplar for self management and patient empowerment The need for better management is clear: according to the Diabetes Attitudes, Wishes and Needs (DAWN) study of the psychosocial effects of diabetes, only 19.4% of people with type 1 diabetes and 16.2% with type 2 completely carry out all of the recommendations they had been given. 32 There is now evidence that treatment of diabetes is best delivered in partnership with the individual patient and their family, rather than being imposed on them. The aim should be for people with diabetes, and other NCDs, to be empowered to manage their disease, rather than allowing themselves to be managed by it this requires a strong and empowering relationship with healthcare professionals. New technologies can also assist with self management. Online support groups can help to overcome the mental strain of living with the disease, and allow the sharing of practical ideas on how best to manage the condition. In addition, mobile apps are available to help people to make decisions about food choices and physical activity, and manage their blood sugar or blood pressure. In developing countries, in particular, mobile technologies are increasing rapidly, with 6 billion of the world s population now having access to a mobile phone 5 billion of them in the developing world. 33 Presenting people with the disease with clear, and clearly explained, choices as to their care can also assist in overcoming the significant mental health challenges of diabetes and other NCDs: people with diabetes are about twice as likely as the rest of the population to suffer from depression. 34 Conclusions We know that in future diabetes will increase, due to ageing populations in many parts of the world, and rising obesity globally. The International Diabetes Federation estimates that the number of people with diabetes will rise from 366 million to 552 million. * Successful prevention of diabetes depends on a supportive physical and policy environment that encourages healthy lifestyles; successful treatment of diabetes requires proactive, planned care and management, with information and support for both patients and families. The challenge is scaling up the evidence into effective, national programmes in both developed and developing countries. Working to prevent diabetes will also help to prevent other NCDs (and, in some cases, tackle the drivers of climate change), and treating the early stages of diabetes will help to slow the development of complications such as CVD: this will lead to significant savings and is a win win win for society, individuals and planet. * IDF, Diabetes Atlas (5 th edition, 2011): http://www.idf.org/diabetesatlas/5e/the global burden 6 www.c3health.org

Endnotes 1 WHO Europe, The European Strategy for the Prevention and Control of Noncommunicable Diseases (2006): http://www.euro.who.int/ data/assets/pdf_file/0020/77510/rc56_edoc08.pdf 2 See, for example, Turning the Corner: Improving Diabetes Care (2006), p. 13: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_4136141. 3 World Economic Forum and Harvard School of Public Health, The Global Economic Burden of Non communicable Diseases (2011): http://www3.weforum.org/docs/wef_harvard_he_globaleconomicburdennoncommunicablediseases_2011.pdf p. 6. 4 i.e. simultaneous presence of more than one NCD. One study in the United States found that, compared with people with type 2 diabetes, those with type 2 diabetes and CVD had 38.9% higher total health care costs, 239.8% higher emergency department/hospitalisation costs, and 35.3% higher outpatient costs: R. Mody et al., Economic impact of cardiovascular comorbidity in patients with type 2 diabetes, J Diabetes Complications (2007), 21:75 83: http://www.ncbi.nlm.nih.gov/pubmed/17331855?dopt=abstract 5 M.J. O Donnell et al., Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case control study, The Lancet (2010) 376(9735): 112 23: http://image.thelancet.com/journals/lancet/article/piis0140 6736%2810%2960834 3/abstract 6 The risk of CVD doubles for every 10 point increase in diastolic blood pressure or every 20 point increase in systolic blood pressure: A.V. Chobanian et al., Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, Hypertension (2003) 42: 1206 52: http://hyper.ahajournals.org/content/42/6/1206 7 WHO, Global Health Risks: Mortality and Burden of Disease attributable to Selected Major Risks (2009), p. 18: http://www.who.int/healthinfo/global_burden_disease/globalhealthrisks_report_full.pdf 8 National Heart Forum, Micro Simulation of Obesity Trends 2006 2050, p. 31: http://nhfshare.heartforum.org.uk/rmassets/nhfreports/nhf_adultobese_long_170210.pdf 9 Guangwei Li, The long term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20 year follow up study, The Lancet (2008) 371: 1783 9: http://cmbi.bjmu.edu.cn/news/report/2008/china2008/1783 1789.pdf 10 J. Tuomilehto et al., Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance, N Engl J Med (2001) 344(18): 1343 50: http://www.nejm.org/doi/full/10.1056/nejm200105033441801 11 W.C. Knowler et al. (Diabetes Prevention Program Research Group), Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin, N Engl J Med (2002) 346: 393 403: http://www.nejm.org/doi/full/10.1056/nejmoa012512#t=articletop 12 CDC, Diabetes: Successes and Opportunities for Population Based Prevention and Control At A Glance 2011: http://www.cdc.gov/chronicdisease/resources/publications/aag/ddt.htm 13 For a rundown of many of the programmes, see P. Schwarz et al., Diabetes Prevention in Practice (Dresden WCPD, 2010). 14 See, for example, A. Fagot Campagna, Emergence of type 2 diabetes mellitus in children: epidemiological evidence, J Pediatr Endocrinol Metab (2000)13 Suppl 6: 1395 402: http://www.ncbi.nlm.nih.gov/pubmed/11202215/ and Diabetes UK, http://www.diabetes.org.uk/guide to diabetes/introduction todiabetes/what_is_diabetes/type_2_diabetes_in_children/ 15 A study in 2001 estimated that there is 12 17% elevated risk of colorectal cancer if daily consumption of total meat or red meat increases by 100g, and a daily increase of 25g of processed meat is associated with a 25% elevated risk: M.S. Sandhu et al., Systematic review of the prospective cohort studies on meat consumption and colorectal cancer risk: a meta analytical approach, Cancer Epidemiology, Biomarkers & Prevention (2001) 10(5): 439 46: http://www.ncbi.nlm.nih.gov/pubmed/11352852. A recent American Journal of Clinical Nutrition study showed that a daily 100g serving of unprocessed red meat is associated with a 19% increased risk of type 2 diabetes, and 50g daily of 7 www.c3health.org

processed meat (equivalent to two slices of bacon) was associated with a 51% greater risk: http://www.ajcn.org/content/early/2011/08/10/ajcn.111.018978.abstract 16 WHO, Global Health Risks, op cit., p. 18. 17 INTERSTROKE study, op cit. 18 K.Y. Wolin et al., Physical activity and colon cancer prevention: a meta analysis, British Journal of Cancer (2009) 100: 611 16: http://www.nature.com/bjc/journal/v100/n4/full/6604917a.html 19 INTERSTROKE study, op cit. 20 For example, http://www.who.int/cardiovascular_diseases/prevention_control/en/. 21 WHO, Global Health Risks, op cit., p. 21. 22 S.G. Wannamethee et al., Smoking as a modifiable risk factor for type 2 diabetes in middle aged men, Diabetes Care (2001) 24(9): 1590 5: http://www.ncbi.nlm.nih.gov/pubmed/11522704 23 D. Haire Joshu, Smoking and diabetes, Diabetes Care (1999) 22: 1887 98: http://care.diabetesjournals.org/content/22/11/1887.full.pdf 24 http://www.thelancet.com/climate change 25 World Health Organization, Preventing Chronic Diseases: A Vital Investment (2005), p. 18: http://www.who.int/chp/chronic_disease_report/contents/part1.pdf 26 See, for example, R Chatterjee et al., Screening for diabetes and prediabetes should be cost saving in high risk patients, abstract at American Diabetes Association 2010: http://www.medpagetoday.com/meetingcoverage/ada/20970 27 C. Kim et al., Gestational diabetes and the incidence of type 2 diabetes: a systematic review, Diabetes Care (2002) 25(10): 1862 8: http://care.diabetesjournals.org/content/25/10/1862.long and R. Retnakaran and B.R. Shah, Mild glucose intolerance in pregnancy and risk of cardiovascular disease: a population based cohort study, CMAJ (2009) 181(6 7): 371 6: http://www.ncbi.nlm.nih.gov/pubmed/19703913. 28 Diabetes UK, Diabetes in the UK 2010: Key Statistics on Diabetes (2010): http://www.diabetes.org.uk/professionals/publications reports and resources/reports statistics and casestudies/reports/diabetes in the UK 2010/ 29 The King s Fund, Clinical and Service Integration: The Route to Improved Outcomes (2010): www.kingsfund.org.uk/publications/clinical_and_service.html 30 See, for example, The King s Fund, Where Next for the NHS Reforms: the Case for Integrated Care (2011), pp. 6 7: http://www.kingsfund.org.uk/publications/articles/nhs_pause_paper.html 31 R. Nugent and A. Feigl, Where have all the donors gone? Scarce donor funding for non communicable diseases (2010): http://www.cgdev.org/content/publications/detail/1424546 32 The DAWN Study see, for example, M.M. Funnell, The Diabetes Attitudes, Wishes and Needs (DAWN) Study, Clinical Diabetes (2006) 24(4): 154 5: http://clinical.diabetesjournals.org/content/24/4/154.full 33 World Bank press release, July 2012: http://www.worldbank.org/en/news/2012/07/17/mobile phone accessreaches three quarters planets population 34 Diabetes: Finding Excellence Facing the Multi faceted Challenge of Diabetes (2007), p. 23: http://www.novonordisk.co.uk/images/2007/.pdfs/model_final_lr.pdf 8 www.c3health.org