Diabetes mellitus


 

Last updated: 2017-11-10 14:56:46
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1. Summary

 

Issue number

1 = highest priority

Strategic issue?

What needs to be done?

1

The number and proportion of people being diagnosed with diabetes in Stockton-on-Tees is rising each year.

This is increasing demand upon existing primary, community and specialist services, requiring judicious use of existing capacity and resources.

A whole systems approach is required to prevent diabetes by ensuring people are empowered to make better choices in terms of diet and lifestyle; creating healthy environments (e.g. active transport) which enable people to be active and healthy.

An integrated community based model should be considered to ensure a cohesive approach to diabetes care. Such a model would place the patient at the centre; so that they receive the care they need at the right place and at the right time.

2

It is estimated that 1.8% (n=2,635) of the population of Stockton-on-Tees has undiagnosed diabetes and 10.9% (n=17,175) have non-diabetic hyperglycaemia.

Implementation of improved processes and pathways to identify both undiagnosed diabetes cases and those who are at risk of developing diabetes.

Identify those with non-diabetic hyperglycaemia and prevent them from developing diabetes e.g. through community weight management and the national Diabetes Prevention Programme.

3

There is a variation in the quality of diabetes care in primary care and in the community.

Improve the achievement of NICE recommended diabetes treatment targets (HbA1c, cholesterol and blood pressure) and diabetes treatment processes to drive down variation between practices and improve the uptake of structured diabetes education.

Build further capacity and skills in primary care to reduce the variation of care.

Reduce inequalities in the uptake of the diabetic eye screening service.

Understand the inequalities and barriers of access to diabetic foot care.

 

Last updated: 10/11/17

2. Introduction

Diabetes is a common, chronic and complicated condition in which the body is unable to produce sufficient insulin to regulate blood glucose levels or where the insulin produced is unable to work effectively.

In England, the two main kinds of diabetes are:

Type 1 diabetes - which is commonly treated with insulin and often diagnosed in people aged under 30.

Type 2 diabetes – this usually appears in middle-aged or older people (although more frequently it is being diagnosed in younger overweight people) and is increasing in prevalence. This type of diabetes can be treated with diet alone, tablets or insulin injections and can be diagnosed at any age. Note that this JSNA will largely focus upon this type of diabetes.

People can also develop diabetes during pregnancy (gestational diabetes) and other rare forms also exist.

Diabetes is a life-long health condition. In the UK, there are almost 3.6 million people diagnosed with diabetes and it is estimated that there are around 1.1 million who have diabetes but don’t know it.

Type 2 diabetes contributes to increasing morbidity and mortality and is generating significant challenges for both the NHS and public health. The prevalence of this condition has risen markedly in the past decade and is consistently linked to both increasing trends in obesity and decreasing levels of physical activity. Whilst there have been some improvements in outcomes for individual patients through effective preventive and treatment strategies, there have not been similar improvements from a public health perspective – as is evident in increasing prevalence of the condition in children and adolescents.

Health spending on people with diabetes accounts for around 10% of total health expenditure. Around 80% of this spending goes on managing complications, most of which could be prevented. The average age of the UK population is expected to increase significantly over the coming decades and as Type 2 diabetes particularly affects older people, robust plans to meet the future needs of people with this illness are essential.

Other JSNA topics closely linked to this topic:

Older people

Sensory disabilities

Diet and nutrition

 

Physical inactivity

 

Obesity

 

 

Last updated: 10/11/17

3. Data and Intelligence

Prevalence

In 2015/16, 6.3% (n=10,055) of the population of Stockton-on-Tees were recorded (on GP systems) as having diabetes. This is fewer than the national average (6.5%), however, the number is rising each year.

The proportion of people diagnosed with diabetes varies between practices in Stockton-on-Tees from 2.2% to 7.5%.

It is estimated that 8.1% (n=12,690) of the population of Stockton-on-Tees has diabetes, therefore, approximately 1.8% (n=2,635) of the population are living with undiagnosed diabetes. The estimated number of people with diabetes in Stockton-on-Tees is due to increase to 9.2% (n=15,832) by the year 2035.

Treatment targets

In 2015/16, 72.8% of patients recorded as having diabetes in Stockton-on-Tees, with a record of good blood pressure control*; this is statistically significantly higher than the national average (70.4%).

The proportion of people with a record of good blood pressure control varies between practices in Stockton-on-Tees from 58.9% to 85.3%.

*Patients with diabetes in whom the last blood pressure is 140/80 mmHg or less in the preceding 12 months

In 2015/16, 60.6% of patients recorded as having diabetes in Stockton-on-Tees, with a record of good blood sugar control*; this is statistically similar to the national average (60.1%). The proportion of people with a record of good blood sugar control varies between practices in Stockton-on-Tees from 43.3% to 75.8%.

*Patients with diabetes in whom the last IFCC-HbA1c is 59 mmol/mol (equivalent to HbA1c of 7.5% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 12 months

In 2015/16, 73.0% of patients recorded as having diabetes in Stockton-on-Tees, with a record of good cholesterol control*; this is statistically significantly higher than the national average (70.0%).

The proportion of people with a record of good cholesterol control varies between practices in Stockton-on-Tees from 63.9% to 82.8%.

*Patients on the diabetes register whose last measured cholesterol was 5mmol/l or less. The measurement should have been carried out in the preceding 12 months.

Care processes

Foot ulcers are a common complication in diabetes and contribute significantly to the need for hospital admissions, length of stay and if not treated successfully to amputations. Yearly foot checks are recommended. 83.4% of patients in Stockton-on-Tees had a record of a foot examination and risk classification in community and primary care; this is statistically significantly higher than the national average of 81.4%.

The proportion of people with a record of a foot examination and risk classification varies between practices in Stockton-on-Tees from 68.8% to 93.1%.

The National Institute for Health and Care Excellence (NICE) recommends nine care processes for diabetes.  These are five risk factors (body mass index, blood pressure, smoking, glucose levels (Hba1c) and cholesterol) and four tests to identify early complications (urine albumin creatinine ratio, serum creatinine, foot nerve and circulation examination and eye screening.

In 2015/15, in Hartlepool and Stockton-on-Tees CCG, 37.5% (England average 37.3%) of type 1 diabetes patients are recorded as having received all 8 care processes. For those patients with type 2 diabetes, 54.2% (England average 53.9%) received all 8 care processes.

Benchmarking

The NHS RightCare Commissioning for Value Focus Pack: Diabetes “Pathway on a page” from April 2016 compares diabetes services and outcomes in Stockton-on-Tees and Hartlepool to other similar areas across England.

The intention of the pathway is not to provide a definitive view on priorities but to help commissioners explore potential opportunities. These help commissioners to understand how performance in one part of the pathway may affect outcomes further along the pathway. Each indicator is shown as the percentage difference from the average of your 10 most similar CCGs.

The indicators are colour coded to show if the CCG has ‘better’ (green) or ‘worse’ (red) values than its peers. This is not always clear-cut, so (blue) is used where it is not possible to make this judgement.

The pathway shows that the following indicators in Stockton-on-Tees are worse than its 10 most similar CCGs:

·         % diabetes patients cholesterol <5 mmol/l;

·         % diabetes patients HbA1c is 64 mmol/mol;

·         % diabetes patients whose BP <150/90;

·         Non-elective spend;

·         Risk of MI in people with diabetes; and

·         Risk of stroke in people with diabetes.

For more information please visit the below website: https://www.england.nhs.uk/rightcare/intel/cfv/data-packs/north/#10                                                                                                                                

Diabetic eye screening

Diabetic retinopathy (DR) is the most common microvascular complication of diabetes and affects about a third of patients with diabetes. Diabetic eye screening is recommended yearly. The uptake of diabetic eye screening in North Tees Hospital Foundation Trust was 87% compared to the national average of 82%. A health equity audit has shown that uptake was lower in those living in more deprived areas particularly in Stockton Town Centre and for young people with only 60% of young people aged 25-34 attending for screening.

Almost two thirds (61%) of those who were never screened were males.

Diabetic eye screening uptake, North Tees and Hartlepool Hospitals NHS FT, by age, 2015/16.

Last updated: 09/05/18

4. Which population groups are at risk and why?

 

Age

Although type 1 diabetes can appear at any age, it is most commonly diagnosed in people aged under 30 and appears at two noticeable peaks; between children 4 and 7 years old and 10 and 14 years old.

Increasing age raises the risk for developing type 2 diabetes.

Gender

Whilst gestational diabetes is an additional risk factor for women, other forms of diabetes are not strongly linked to gender.

However, the NPDA 2015/16 notes twice as many female children and young people with type 2 diabetes (within the type 2 diabetes cohort) than males. The audit also noted higher prevalence of type 1 diabetes among male children and young people.

Socioeconomic status

The percentage of the population with type 2 diabetes is strongly associated with social deprivation (National Audit Office, 2015). People living within the 20% most deprived neighbourhoods in England are 56% more likely to have diabetes than those living in the least deprived areas.

NPDA 2015/16 noted that more young people with type 2 diabetes live in deprived areas.

Ethnicity

There is an increased risk in South-Asian, African and African-Caribbean ancestry. People from these ethnic groups also tend to develop the condition at a younger age.

Children and young people from Black and Asian ethnic backgrounds were more highly represented within the NPDA 2015/16 type 2 cohort.

Lifestyle

Diabetes is associated with low levels of physical activity and poor diet. Lifestyle choices, however, can often be a symptom of our contemporary environment as opposed to merely being a choice. Those living in obesogenic environments characterised by sedentary lifestyles are, therefore, more vulnerable.

Obesity (a key risk factor for developing type 2 diabetes) is rising and has led to an increase in the percentage of the adult population with diabetes. Approximately 90% of adults with type 2 diabetes are overweight or obese and being overweight is the main modifiable risk factor for this condition.

Family history

Those with a parent or sibling with diabetes have an increased risk of developing the condition.

 

Last updated: 10/11/17

5. Consultation and engagement

 

Issue number

1 = highest priority

Strategic Issue

1

No consultations or engagements available at present.

2

No consultations or engagements available at present.

3

Patient Diabetes Out-Patient Survey Report, February 2011 – carried out by North Tees and Hartlepool Foundation Trust (166 surveys)

79% of respondents had agreed a plan about how to manage their diabetes until their next appointment, however only 14% were offered a copy of their care plan.

50% of respondents stated that they had ‘definitely’ discussed the food they eat and any changes they could make to their diet.

78% of respondents stated that they had discussed their ideas into the best ways to manage their diabetes with clinic staff.

62% of respondents felt that they ‘definitely’ felt more confident about managing their diabetes as a result of their appointments.

57% of respondents said that they ‘definitely’ know the different treatment options available for their diabetes.

Diabetes Care survey 2015

People with Type 1 diabetes were significantly less likely to get their checks than people with Type 2. 69% of people with Type 1 say they are getting their legs and feet checked, compared to 80% of people with Type 2.

 

Last updated: 10/11/17

6. Strategic issues

 

Issue number

1 = highest priority

Strategic Issue

1

The number and proportion of people being diagnosed with diabetes in Stockton-on-Tees is rising each year.

This is increasing demand upon existing primary, community and specialist services, requiring judicious use of existing capacity and resources.

2

It is estimated that 1.8% (n=2,635) of the population of Stockton-on-Tees has undiagnosed diabetes and 10.9% (n=17,175) have non-diabetic hyperglycaemia.

3

There is a variation in the quality of diabetes care in primary care and in the community.

 

Last updated: 10/11/17

7. Evidence base

 

Issue number

1 = highest priority

 

 

1

Source/s

Government Office for Science (GOV)

Public Health England (PHE)

National Institute for Health and Care Excellence (NICE)

British Medical Journal (BMJ)

Diabetes UK

Title/s incl. web link/s

GOV: Foresight Report: Tackling Obesity, Future Choices. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf

PHE: Obesity and the environment: regulating the growth of fast food outlets.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/296248/Obesity_and_environment_March2014.pdf P1

NICE: Preventing Type 2 Diabetes

https://pathways.nice.org.uk/pathways/preventing-type-2-diabetes

BMJ: Associations between exposure to takeaway food outlets, takeaway food consumption, and body weight in Cambridgeshire, UK: population based, cross sectional study.

http://www.bmj.com/content/348/bmj.g1464

Diabetes UK: Best practice for commissioning diabetes services: an integrated care framework.

https://www.diabetes.org.uk/Documents/Position%20statements/best-practice-commissioning-diabetes-services-integrated-framework-0313.pdf

Summary/s

GOV: The complex relations between the social, economic and physical environments and individual factors that underlie the development of obesity.

PHE: A ‘healthy people, healthy places’ briefing.  This importance of action on obesity and a specific focus on fast food takeaways, and outlines the regulatory and other approaches that can be taken at local level.

NICE: Diabetes related guidelines, pathways, quality standards and advice.

BMJ: Peer reviewed article examining the association between environmental exposure to takeaway food outlets, takeaway food consumption, and body weight, while accounting for home, work place, and commuting route environments. It concludes that there is an environmental contribution to the consumption of takeaway foods, and especially to body mass index and the odds of being obese.

Diabetes UK: Practical guidance and key principles for professional groups to better commission and provide integrated care for people with diabetes.

2

Source/s

Health Inequalities National Support Team (HINST) 

NHS Health Check Programme

National Diabetes Prevention Programme (NDPP)

Title/s incl. web link/s

Health Inequalities (HINST) Enhanced Support Programme resource manual

http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_115113

NHS Health Check Programme

http://www.healthcheck.nhs.uk/commissioners_and_providers/evidence/

http://www.healthcheck.nhs.uk/document.php?o=1293

National Diabetes Prevention Programme (NDPP)

https://www.england.nhs.uk/diabetes/diabetes-prevention/resources/

https://www.gov.uk/government/publications/diabetes-prevention-programmes-evidence-review

Summary/s

HINST: Systematic approaches to including as many people as possible with established disease onto general practice registers, and in doing so closing the gap between actual and expected numbers on chronic disease registers.

Two programmes that were developed as a result of this evidence were:

NHS Health Check Programme: The NHS health check provides a universal programme for people aged 40-74 to understand their risk of developing CVD. The programme includes a ‘diabetes filter’ which recommends HbA1c testing for everyone with a BMI over 30 (27.5 for South Asian).

NDPP: The NDPP offers a structured programme to reduce the risk of diabetes through dietary changes and physical activity for people with non- diabetic hyperglycaemia (HbA1c 42-47mmol/mol). The local programme is planned to start in 2018.

3

Source/s

National Institute for Health and Care Excellence (NICE)

Diabetes UK

Title/s incl. web link/s

NICE: Type 1 Diabetes in Adults

https://pathways.nice.org.uk/pathways/type-1-diabetes-in-adults

NICE: Type 2 Diabetes in Adults

https://pathways.nice.org.uk/pathways/type-2-diabetes-in-adults

NICE: Type 2 Diabetes in Children and Young People

https://pathways.nice.org.uk/pathways/diabetes-in-children-and-young-people

NICE: Foot care for people with Diabetes

https://pathways.nice.org.uk/pathways/foot-care-for-people-with-diabetes

Diabetes UK: Improving the delivery of adult diabetes care through integration.

https://www.diabetes.org.uk/Documents/About%20Us/What%20we%20say/Integrated%20diabetes%20care%20(PDF,%20648KB).pdf

Summary/s

NICE: Selection of diabetes pathways to understand the nature of integrated diabetes care.

Diabetes UK: A report concerning how diabetes care can be improved to achieve better outcomes for people with diabetes, emphasising the importance of commissioners and providers working together to evaluate and improve the delivery of the whole pathway of diabetes care.

       

 

Last updated: 10/11/17

8. What is being done and why?

Community

Local authority and Voluntary, Community and Social Enterprise (VCSE) organisations are key providers of:

  1. Transport and planning initiatives.
  2. Active lifestyle and leisure facilities.
  3. Exercise and weight management services including commissioning of NHS health checks and supporting physical activities in both work and school environments.
  4. Patient and community groups to support those with diabetes.

Stockton-on-Tees Borough Council promotes active transport to encourage physical activity in children and adults. This includes improvements to walking and cycling networks and cycle to work schemes as well as cycling and pedestrian training in primary schools.

People living in Stockton-on-Tees have access to several leisure centres and other offers to become more physically active such as walking and cycling activities and events.

The ‘Lite 4 life’ weight management programme is a group based intervention to support people to reduce weight and become more active.

The Active Health Exercise Referral scheme is a progressive exercise programme to help patients to manage their medical condition.

The Better Health at Work Award Programme promotes healthy lifestyle advice and interventions including healthy diet and healthy weight to employees of participating organisations.

Primary care

NHS Health Check/Healthy Heart Check is a free check-up of overall health which can assess whether the patient is at higher risk of certain conditions including type 2 diabetes. Many people have blood sugar levels above the normal range (often referred to as pre-diabetes or non-diabetic hyperglycaemia) and screening for this condition is routinely undertaken as part of this programme for adults aged 40 – 74.

GP Obesity Register/Quality and Outcomes Framework (QOF). The QOF has an indicator point for obesity, which requires that GPs establish and maintain a register of patients aged 18 or over with a BMI ≥25 in the preceding 12 months. Patients identified as being at increased risk of non-diabetic hyperglycaemia (i.e. those on obesity register) are offered a blood glucose test. This can identify asymptomatic cases. If blood test results fall within the non-diabetic hyperglycaemia (NDH) range, the patient is then placed on NDH register which is being developed in GP practices.

Each GP practice maintains a register of all patients aged 17 or over with diabetes, which specifies the type of diabetes where a diagnosis has been confirmed. QOF indicators relating to diabetes include control of blood pressure, cholesterol and blood sugar. Furthermore, GP practices ensure that systems and processes are in place so that patients diagnosed with diabetes are seen by a diabetes nurse twice each year.

An established programme which provides annual diabetic eye screening and foot checks takes place in Lawson Street Health Centre, Stockton-on-Tees. Patients are referred to these services by a primary care practitioner. There is a similar clinic at One-Life Hartlepool which additionally provides blood tests.

Diabetes Specialist Nurses also work in the community providing services for those patients who require additional support to manage their condition. Diabetes specialist nurses are responsible for, amongst other services, insulin starts and managing those with unstable diabetes. The diabetes specialist nurses also deliver a structured education programme (DESMOND) for those with type 2 diabetes. This provides information and learning centred upon understanding and self-managing type 2 diabetes and understanding the requirement to attend annual screening.

Secondary care

Diabetes specialist nurses, dieticians and podiatrists work alongside specialist consultants based in North Tees and Hartlepool NHS Trust to deliver the diabetes secondary care pathway. Consultants manage those with significant complications from their diabetes as well as any acute or planned admissions for adults and children. Specialist clinics for women with diabetes who are pregnant (or planning a pregnancy) are also available.

North Tees and Hartlepool NHS Foundation Trust runs a family group for those with (or affected by) diabetes in Stockton. The group offers support for people with diabetes by improving access to education and information, improving communications between patients and health professionals and offering recommendations and influencing decisions for the improvement of local services for people with diabetes. 

Last updated: 10/11/17

9. What needs are unmet?

 

Issue number

1 = highest priority

Unmet need

1

There currently isn’t a whole systems approach that ensures people are empowered to make better choices in terms of diet and lifestyle;

An integrated community based model of diabetes care is not currently available.

2

There is no structured pathway in Stockton-on-Tees to identify patients at risk of developing diabetes or those with undiagnosed diabetes and offer advice and intervention.

3

Due to variations across primary care provision (as a result of capacity, prioritisation and/or training), not all patients receive high quality of care.

There are inequalities in access and utilisation of diabetic eye screening and a need for better understanding of access and utilisation of diabetic foot care and structured education.

 

Last updated: 10/11/17

10. What is being done and why?

 

Issue number

1 = highest priority

What needs to be done?

Why?

1

A whole systems approach is required to prevent diabetes by ensuring people are empowered to make better choices in terms of diet and lifestyle; creating healthy environments (e.g. active transport) which enable people to be active and healthy.

An integrated community based model should be considered to ensure a cohesive approach to diabetes care. Such a model would place the patient at the centre; so that they receive the care they need at the right place and at the right time.

 

Stockton-on-Tees should be a ‘healthy town’ providing an environment that facilitates healthy living through active transport, accessible opportunities for physical activity and healthier eating. The impact on health should be considered in all policy-making and decisions of the local authority and other organisations and businesses.

 

Obesity and low levels of physical activity are key risk and contributory factors to type 2 diabetes. A whole systems approach is required to combat increasingly obesogenic environments.

 

Development of new service and funding models to ensure consistent referral pathways.

 

To ensure patients move seamlessly through an integrated pathway receiving the care they need in the right place at the right time.

2

Implementation of improved processes and pathways to identify both undiagnosed diabetes cases and those who are at risk of developing diabetes.

 

Identify those with non-diabetic hyperglycaemia and prevent them from developing diabetes e.g. through community weight management and the national Diabetes Prevention Programme.

All people at risk should be identified and provided with advice and intervention, for example, through the NHS health check and opportunistically through GP practices.

 

At risk patients should be routinely screened (through the NHS health check or through opportunistic screening) for non-diabetic hyperglycaemia.

 

Patients with non-diabetic hyperglycaemia should be referred to the National Diabetes Prevention Programme (or similar services).

 

All people with undiagnosed type 2 diabetes should be identified and referred to treatment in primary care. This is to prevent or delay development of type 2 diabetes and to diagnose early and offer appropriate treatment in order to control diabetes and prevent complications.

 

3

Improve the achievement of NICE recommended targets (HbA1c, cholesterol and blood pressure) and diabetes treatment process to drive down variation between practices and improve diabetes education uptake.

Provide further training to build capability in primary care system to reduce variation of care provided. Work with diabetic eye screening service to improve uptake of certain groups.

Improve the achievement of NICE recommended diabetes treatment targets (HbA1c, cholesterol and blood pressure) and diabetes treatment processes to drive down variation between practices and improve the uptake of structured diabetes education.

Build further capacity and skills in primary care to reduce the variation of care.

Reduce inequalities in the uptake of the diabetic eye screening service.

Understand the inequalities and barriers of access to diabetic foot care.

 

Last updated: 10/11/17

11. What additional needs assessment is required?

Further engagement and consultation with service users and other interested stakeholders in Stockton-on-Tees is required to gather views and opinions relating to diabetes prevention and care in the borough.

Work with providers to gather data regarding diabetic foot care and diabetes education programmes to increase engagement and equitable programme uptake.

Last updated: 10/11/17

12. References

Arredondo, A. (2014) ‘Type 2 diabetes and health care costs in Latin America: exploring the need for greater preventive medicine’, BMC Medicine, Vol.12:136. Available at http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0136-z

Diabetes UK (2016) ‘Diabetes UK Facts and Stats’. Available at https://www.diabetes.org.uk/Documents/Position%20statements/Diabetes%20UK%20Facts%20and%20Stats_Dec%202015.pdf

Kerr M (2011) Inpatient care for people with diabetes: The economic case for change. Insight Health Economics, Tunbridge Wells. Available at:

https://www.diabetes.org.uk/upload/News/Inpatient%20Care%20for%20People%20with%20Diabetes%20%20The%20Economic%20Case%20for%20Change%20Nov%202011.pdf

Jeerakathil et al (2007) ‘Short-term risk for stroke is doubled in persons with newly treated type 2 diabetes compared with persons without diabetes: a population-based cohort study’, Stroke, Vol. 38:6. Available at:

https://www.ncbi.nlm.nih.gov/pubmed/17478738

Kerr et al (2012) ‘Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs

and indirect societal and productivity costs’, Diabetic Medicine, Vol.29:7. Available at https://www.ncbi.nlm.nih.gov/pubmed/22537247

Leamon, S and Davies, M (2014) ‘Number of adults and children certified with sight impairment and severe sight impairment in England and Wales: April 2012 – March 2013; RNIB and Moorfields Hospital NHS Foundation Trust’. Available at

http://www.rnib.org.uk/knowledge-and-research-hub/research-reports/general-research/certified-england-wales-12-13

National Audit Office (2015) ‘The management of diabetes services in the NHS: progress review’. Available at

https://www.nao.org.uk/wp-content/uploads/2015/10/The-management-of-adult-diabetes-services-in-the-NHS-progress-review.pdf

National Paediatric Diabetes Audit (NPDA) 2015 – 2016, Royal College of Paediatrics and Child Health. Available at:

http://www.rcpch.ac.uk/national-paediatric-diabetes-audit-npda

Public Health England (2014) ‘Adult obesity and type 2 diabetes’. Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_obesity_and_type_2_diabetes_.pdf

Public Health England (2017) ‘NHS Diabetic Eye Screening Programmes (NDESPs) in Cumbria and the North-East 2015-2016’.

Sullivan, P.W., Morrato, E.H., Ghushchyan, V., Wyatt, H. and Hill, J. (2005) ‘Obesity, inactivity, and the prevalence of diabetes and diabetes-related cardiovascular comorbidities in the US, 2000-2002’, Diabetes Care, Vol. 28. Available at http://care.diabetesjournals.org/content/28/7/1599.full

Last updated: 10/11/17

13. Key contact

Name:   Dr Tanja Braun

Job title:    Consultant in Public Health

Organisation:  Stockton-on-Tees Borough Council

Phone number:  01642 528706

Contributor/s:  

Mick Shannon, Specialty Registrar in Public Health, Public Health England

James O’Donnell, Public Health Intelligence Specialist, Stockton Borough Council

Last updated: 10/11/17

Tanja.Braun@stockton.gov.uk