Claims of 24,000 'excess' deaths from diabetes

As many as 24,000 people with diabetes are dying unnecessarily each year, many of the papers have reported today. This shock statistic was a conclusion from the National Diabetes Audit, the first ever report to look at deaths from the condition.

While this is a large number of deaths, it must be viewed in context – millions of people live with this potentially life-threatening long-term illness, yet it can be managed safely.

The National Diabetes Audit suggests that in England there are about 24,000 ‘excess deaths’ a year in people with diagnosed diabetes. This means that each year, around 24,000 more deaths occur among people with diabetes than would be expected to occur if their mortality risk was the same as that of the general population. A press release from the NHS Information Centre, which published the audit report, said these deaths could be avoided through better management of the condition.

What other risks did the National Diabetes Audit find?

The study found that the risk of death for a person with type 1 diabetes (where the insulin-producing cells of the body do not work at all) is 2.6 times higher than that of the general population. For people with type 2 diabetes (where the body does not produce enough insulin, or the body’s cells are not sensitive enough to insulin) it is 1.6 times higher.

In younger people, the difference in mortality rates is even bigger. For example, women between 15 and 34 years of age who have type 1 diabetes are nine times more likely to die than women in the general population, and women of this age with type 2 diabetes are six times more likely to die.

The report also found a strong link between deprivation and increased rates of early death. Among under-65s with diabetes, death rates among people from the most deprived backgrounds were double that of those from the least deprived. Death rates also vary according to where people live; London has the lowest mortality rates from both type 1 and 2 diabetes, while the highest mortality rates were in the north east of England.

The study’s lead clinician Dr Bob Young, consultant diabetologist and clinical lead for the National Diabetes Information Service, said, “For the first time we have a reliable measure of the huge impact of diabetes on early death. Many of these early deaths can be prevented. The rate of new diabetes is increasing every year. So, if there are no changes, the impact of diabetes on national mortality will increase. Doctors, nurses and the NHS working in partnership with people who have diabetes should be able to improve these grim statistics.”

What is the National Diabetes Audit?

The news is based on the National Diabetes Audit (NDA) Mortality Analysis 2007-2008. This report was prepared in partnership with various trusts, including The Healthcare Quality Improvement Partnership (HQIP), which promotes quality in healthcare, and the NHS Information Centre, the official source of health and social care data and information for England. The NDA covered four key components of the government’s National Service Framework (NSF) for Diabetes:

• checking whether everyone with diabetes was diagnosed and recorded on a practice diabetes register
• looking at whether those registered are receiving key elements of diabetes care (such as regular checks of blood glucose levels, or for protein in the urine)
• looking at the proportion of people registered to have diabetes who achieve the treatment targets for glucose control, blood pressure and blood cholesterol, as defined by NICE
• looking at the rates of acute and long-term complications of people with diabetes, including deaths from the condition, the focus of the current report

As part of this GP audit, all primary care trusts contributed data from 5,359 GP practices on 1.4 million people with diabetes. This figure represents 68% of the 2.1 million people estimated to have diabetes in England in 2007-2008 (the participation rate). The current analysis focuses on mortality from the condition, and has therefore also linked data from the NDA to formal death notifications through the NHS Information Centre Medical Research Information Service (MRIS) in order to include data for those people with diabetes not included in the GP audit.

What was the report’s main finding?

By following up the ‘cohort’ of 1.4 million people with diabetes over the next year, the researchers found 49,282 deaths. As the ‘participation rate’ (see above) was 68%, taking the estimated prevalence of diabetes in England, it was estimated that the total annual number of deaths of people with diabetes was between 70,000 and 75,000. This represents about 15-16% of the 460,000 deaths that occur annually in England.

Researchers estimated that in total there were about 16,000 more deaths among people with diabetes than would been expected if their mortality risk was the same as the general population. By linking these results to records of national death certificates (in order to include people with diabetes who did not participate in the audit) they estimated 24,000 excess deaths each year in people with diabetes.

The risk of death for patients with type 1 diabetes was estimated to be 2.6 times higher than that of the general population, and for people with type 2 diabetes the risk was estimated to be 1.6 times higher. Across the country there were variations in mortality, from 1,852 deaths out of 100,000 people with type 1 diabetes in London to a high of 2,351 out of 100,000 in the northeast. For type 2 diabetes the figures ranged from 1,246 out of 100,000 in London to 1,668 out of 100,000 in the northeast.

Why are so many people dying of diabetes?

The analysis itself did not look at the specific causes of death among people with diabetes. However, it is widely recognised that without proper management of this condition, there is a higher risk of death from several causes including critically high or low blood sugar, heart failure or kidney failure.

Diabetes is a long-term condition that affects the body’s ability to process glucose (sugar). Normally the amount of glucose in the blood is controlled by the hormone insulin, which helps break it down to produce energy. In people with diabetes, there is either not enough insulin to process the glucose or the body’s cells do not respond appropriately to the insulin produced. This results in glucose levels building up in the blood.

There are two types of diabetes: type 1 and 2. People with type 1 diabetes do not produce any insulin. People with type 2 diabetes do not make enough insulin, or the body’s cells are not sensitive enough to insulin. Having either type puts people at increased risk of several serious complications, including heart disease and stroke, circulation problems, nerve damage, foot ulcers, blindness and kidney damage.

It is important to note that this audit measured deaths among people with diabetes – it did not show whether diabetes caused their deaths. For example, diabetes is a risk factor for cardiovascular disease such as heart attack or stroke. Also, other cardiovascular risk factors that often co-exist in people with diabetes, such as overweight or obesity or high blood pressure. It is not possible to tell the direct cause of death from this data.

How is diabetes usually managed?

Diabetes management aims to keep blood glucose levels as normal as possible. People with type 1 diabetes need to have daily injections (or administration by pump) of insulin.

In people with type 2 diabetes, management depends upon the severity of the condition. A healthier diet and lifestyle alone can sometimes control the condition in people with early stage disease, although most people with type 2 eventually need to take medication to control their blood sugar. Some people with type 2 diabetes may also eventually need to take insulin. Medication may also be needed to reduce other associated risk factors for cardiovascular disease. For example, medications to reduce high blood pressure or control cholesterol.

Self-management of this condition is also crucial. People with diabetes need to be aware of and monitor blood glucose levels, maintain a healthy weight, eat a balanced diet, avoid smoking and have regular health checks.

How can these deaths be prevented?

Experts agree that people with diabetes can live long and healthy lives and reduce their risks of complications through appropriate self-management, as outlined above.

The charity Diabetes UK says that people with diabetes can sometimes feel overwhelmed with information about all the healthcare they require. Diabetes UK has drawn up a checklist of 15 ‘healthcare essentials’ to help people understand what care they should receive to reduce the risk of complications. These are:

• get your blood glucose levels measured at least once a year 
• have your blood pressure measured at least once a year
• have blood fats (cholesterol) measured every year 
• have your eyes screened for signs of eye damage (retinopathy) every year 
• have your legs and feet checked annually
• have your kidney functions monitored annually 
• have your weight checked and your waist measured
• get support if you are a smoker on how to quit
• receive care planning to meet your individual needs 
• attend an education course to help you understand and manage your diabetes 
• receive specialist paediatric care if you are a child or young person 
• receive high quality diabetes care if admitted to hospital 
• get information and specialist care if you are planning to have a baby
• see specialist diabetes healthcare professionals to help you manage your condition
• get emotional and psychological support from specialist healthcare professionals

Not every healthcare essential may apply to children with diabetes who may have different requirements.

Do I need to worry about this if I have diabetes?

The figures are alarming but they do highlight the need to make people with diabetes aware of the importance of self-management and of obtaining the level of healthcare they require to help them manage their condition. With the right care and support, people with diabetes can go on to live long and healthy lives.

If you have diabetes, key ways to delay or prevent complications include:

• maintaining a healthy weight by eating a balanced diet and taking regular physical exercise
• not smoking 
• checking your feet every day 
• having regular check-ups with your diabetes care team.