Partha Kar: The time to tackle rising type 2 diabetes is T2DaY
BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2490 (Published 31 October 2023) Cite this as: BMJ 2023;383:p2490
- Partha Kar, consultant in diabetes and endocrinology
- drparthakar{at}gmail.com
Follow Partha on X/Twitter: @parthaskar
England’s 18-40 year olds with type 2 diabetes now exceed those with type 1.1 It’s worth pausing and reading that again. In adults under 40, a condition that’s usually associated with lower age groups and has an autoimmune aetiology is now outflanked by one usually associated with “middle age” and caused mainly by a combination of lifestyle, environmental, and societal factors.
Perhaps this is an indictment of a society which, in trying to avoid accusations of nanny state-ism, has got caught up in the toxic debate around diets and has ended up widening deprivation gaps. In total, about 4% of people with type 2 diabetes are now under 40. It’s a small proportion, but it’s worrying for three reasons.
First, the proportion of people with type 2 diabetes is rising most quickly in under 40s—about an 18% rise in cross sectional prevalence in the past five years, which compares with 11% in older age groups.2 Second, the presentation disproportionately affects people already at risk of health inequalities: those from socioeconomically deprived areas, minority ethnic groups, or people with obesity.
Third, the progression is aggressive, as studies point to a higher risk of microvascular and macrovascular complications (than with later onset type 2 diabetes),3 poorer pregnancy outcomes (relative to type 1 diabetes),4 and earlier mortality (≈14 years of life lost if diagnosed at age 30).5 People often have multimorbidity at diagnosis, and in those who don’t, multiple long term conditions can emerge quickly.
In recent years we’ve seen plenty of headlines about children with type 2 diabetes. Yet, in comparison with young adults who share the higher risks and morbid outcomes, children represent only about 1.3% of the early onset type 2 diabetes population.
Young adults have long been recognised as “distinct” in the delivery of type 1 diabetes services, and although the disease aetiologies are poles apart, young people with type 1 and type 2 diabetes share many of the same characteristics that may affect self-management. They’re often in education or of working age, with transitions in social life, family life, and relationships. Some have young families, and others are experiencing high levels of distress from managing a chronic condition and the related stigma.
And yet our services, to date, make no recognition of this. Perhaps this was inevitable when numbers were small, but now that about 140 000 adults have early onset type 2 diabetes with its associated risks, it’s time for a change.
Processes and targets
If you feel worried by these statistics, you’re not alone. The NHS Diabetes Programme first commissioned an audit of type 2 diabetes in young people in 2021,2 examining granularly the delivery of care and achievement of treatment targets in young adults in relation to later onset. As with young adults with type 1 diabetes, those with type 2 were least likely to receive all nine diabetes care processes and least likely to achieve the HbA1c treatment targets set out in NICE’s guideline on blood glucose management.6 In the 2023 analysis,1 cases of type 2 diabetes in under 40s had risen by almost 19%—relative to an 11% increase in older age groups—in the past five years.
Shivani Misra, a diabetes consultant and senior clinical lecturer at Imperial College London who has spent many years working in early onset type 2 diabetes in adults, recently published guidance on how to develop services to support such adults.7 She highlights the need to extend improvement beyond care processes and treatment targets to include pregnancy outcomes (previously shown in the National Pregnancy in Diabetes audit4) and to ensure correct diagnosis. The guidance from Misra and other clinicians has led to the T2DaY programme (Type 2 Diabetes in the Young),8 developed under the auspices of NHS England’s diabetes team. The first such endeavour in the world, it aims to tackle this area of high clinical significance.
The importance of socioeconomic deprivation can’t be overstated, nor the availability (or not) of healthy food options, space to exercise, or the headspace to look after oneself. When you’re worried about putting food on the table for your children or how to pay the next set of bills, personal wellbeing understandably takes a back seat. The clinical model and the NHS can deliver only so much, and the role of governments in tackling the bigger picture can’t be ignored.
Acknowledgments
I thank Shivani Misra for her advice in putting this article together and for providing helpful comments on the draft version.
Footnotes
Competing interests: See www.bmj.com/about-bmj/freelance-contributors. Partha Kar is national specialty adviser, diabetes with NHS England and is author of the MWRES Action Plan to tackle racism in the medical workforce.
Provenance and peer review: Commissioned; not externally peer reviewed.