Diabetes

Diabetes is increasingly common among children and young people in the UK; while 90% of diabetes cases are Type 1, Type 2 is increasing in prevalence.

36,000 under 19 year olds in the UK with diabetes

Background

  • Diabetes is an increasingly common long term condition in children and young people. In 2019, there were an estimated 36,000 children in the UK with diabetes under the age of 19, up from 31,500 in 2015.1
    • Type 1 diabetes constitutes the vast majority (90%) of diabetes in children and young people. This is where the body is unable to produce any insulin. The prevalence of Type 1 diabetes is not associated with deprivation.2
    • Type 2 diabetes is much less common in children and young people. It occurs when the body produces some, but not sufficient, insulin; or is resistant to insulin. Type 2 diabetes is more common in obese or overweight people, and in those of South Asian and Afro-Caribbean ethnicity.3 Unlike Type 1 diabetes, prevalence is strongly associated with deprivation.2
  • Diabetes is associated with long term complications, especially if poorly controlled. Good control of blood sugar reduces the long term risks which include eye and kidney disease, heart disease and stroke.
  • Long term blood sugar control can be measured using the HbA1c blood test which identifies average plasma glucose concentration over the past three months. NICE guidance recommends maintaining an HBA1c of 48 mmol/mol or lower.4
  • Diabetic ketoacidosis (DKA) is a potentially life-threatening condition requiring emergency admission to hospital, and can be fatal if not promptly treated. It occurs when plasma blood sugar levels rise rapidly. DKA occurs almost exclusively in type 1 diabetes.
  • Data below are taken from the National Paediatric Diabetes Audit 2019, unless stated otherwise. This national audit receives data from paediatric diabetes units in England and Wales for 2017/18.

Key findings

  • There has been an improvement in recent years in national average HbA1c in England, Wales and Scotland amongst children and young people with diabetes. However, these are all substantially worse than the recommended target of 48mmol/mol:
    • England: Median HbA1c fell from 69.0 mmol/mol in 2013/14 to 64.0 mmol/mol in 2017/18
    • Wales: Mean HbA1c fell from 69.0 mmol/mol in 2013/14 to 64.5 mmol/mol in 2017/18
    • Scotland: Mean HbA1c fell from 70mmol/mol in 2013 to 68 mmol/mol in 2016,5 although these are not directly comparable with the England/Wales figures.
  • In England and Wales, hospital admissions for diabetes ketoacidosis (DKA) among children and young people with Type 1 diabetes in 2017/18 was 2.7% (3.6% in Wales, and 2.6% in England). This excludes children and young people who are admitted with DKA as part of their first presentation of diabetes. No previous comparable data are available due to a change in methodology.
  • Health inequalities persist in outcomes for children and young people with diabetes
    • In England and Wales in 2017/18, children and young people with type 1 diabetes living in the least deprived areas had better blood sugar control with a mean HbA1c of 64.2mmol/mol, compared to 70.9 mmol/mol for their peers in the most deprived areas.
    • In England in 2015/16, children and young people living in the most deprived areas were 60% more likely to have an emergency hospital admission for diabetes than those living in the least deprived. This inequality gap was greatest in the older age bands (14 to 19 years and 20 to 24 years).6

Children and young people were below the age of 25 on the first day of the audit year (1 April 2017 for the 2017/18 audit).

Children and young people were below the age of 25 on the first day of the audit year (1 April 2017 for the 2017/18 audit).

Children and young people were below the age of 25 on the first day of the audit year (1 April 2017 for the 2017/18 audit).

What does good look like?

Comprehensive delivery of care processes for children and young people with Type 1 diabetes. To further improve the percentage of those achieving an HbA1c <48 mmol/mol, a reduction in national average HbA1c and reduce emergency hospital admissions, it is vital that children and young people with diabetes receive the full gamut of recommended health checks to monitor their condition and support their self-management.2

Multidisciplinary paediatric diabetes team. Variation in resources, processes and clinical practice underlie much of the variation in outcomes. It is important to resource the full multi-disciplinary team (MDT) including psychology and dietetic input. RCPCH has developed a quality programme for paediatric diabetes units incorporating self- and peer-review and a quality improvement collaborative.7

Equitable access to diabetes technologies. Technologies developed to support the management of Type 1 diabetes including insulin pumps and glucose monitors are associated with improved outcomes. However there is inequity in uptake, regionally and at patient level, with lowest uptake among those children and young people of BAME backgrounds and those living in the most deprived areas.2

Providing support for optimal diabetes management at school is essential to achieving good diabetes outcome and minimising disruption to education, however many children and young people with diabetes and their families worry about schools’ ability to do so.8 Statutory guidance exists for supporting pupils with healthcare needs including diabetes in England9 and Wales10, but not in Northern Ireland or Scotland.

Tackle the risk factors behind the rise in Type 2 diabetes. Childhood obesity is a leading factor for developing Type 2 diabetes in adolescence. Bold action is needed to reduce obesity among children and young people in order to stem the rise in the number of children and young people with Type 2 diabetes. In 2017/18, 34% of children in Year 6 in England were either overweight or obese;11 there is an urgent need to implement obesity plans and strategies to halve childhood obesity by 2030.

Policy recommendations

  • NHS England should support the ongoing establishment of a UK wide clinical network for diabetes, as per the Long Term Plan commitment. Appropriate support and resources must be provided to support key network functions at national and regional levels. Networks should include links to mental health, education and transition and include input from both multidisciplinary professionals and family / young person engagement.
  • All paediatric diabetes units across England should engage with the National Paediatric Diabetes Audit (NPDA).
  • NHS Trusts in England receiving Best Practice Tariff funding for their paediatric diabetes service should ensure that this funding is channelled directly into the service and used to support optimal multidisciplinary team staffing and service provision.
  • NHS Digital should ensure that digital capacity in primary care and across child health professionals is strengthened with necessary IT systems so that information on a child’s weight is accessible to all child health professionals who need it, to enable early identification of type 2 diabetes.
  • NHS Scotland should support the ongoing establishment of a UK-wide clinical network for diabetes. Appropriate support and resources should be provided to support key network functions at national and regional levels. The network should include links to mental health, education and transition and include input from both multidisciplinary professionals and family / young person engagement.
  • RCPCH, Scottish Government and NHS Scotland should support the implementation of the National Paediatric Diabetes Audit (NPDA) to cover Health Boards in Scotland, or collect and report comparable data with accompanying action planning and quality improvement.
  • NHS Scotland should ensure digital capacity in primary care and across child health professionals is strengthened with the necessary IT systems so that information on children’s weight is accessible to all child health professionals who need it, to enable early identification of type 2 diabetes.
  • NHS Wales should support the ongoing establishment of a UK wide clinical network for diabetes. Appropriate support and resources should be provided to support key network functions at national and regional levels. The networks should include links to mental health, education and transition and include input from both multidisciplinary professionals and family / young person engagement.
  • All paediatric diabetes units in Wales should engage with the National Paediatric Diabetes Audit (NPDA).
  • NHS Wales should ensure that digital capacity in primary care and across child health professionals is strengthened with the necessary IT systems so that information on a child’s weight is accessible to all child health professionals who need it, to enable early identification of type 2 diabetes.
  • We welcome the Diabetes Network, which operates to support the implementation of the Department of Health’s Strategic Framework for Diabetes. The network should include links to mental health, education and transition and include input from both multidisciplinary professionals and family / young person engagement.
  • RCPCH, Northern Ireland Executive and HSC Northern Ireland should support the implementation of the NPDA to cover HSC Trusts in Northern Ireland, or collect and report comparable data with accompanying action planning and quality improvement.
  • We welcome the Public Health Association’s 2019 launch of the Diabetes Prevention Programme. Funding should be provided to continue this programme and reports should be published on the implementation.

What can health professionals do about this?

  • Transition. Adolescence is associated with sub-optimal diabetes management, so it is important to ensure a positive transition to adult diabetes services during this vulnerable time.
  • Audit data. Make sure your service is participating in the National Paediatrics Diabetes Audit and use the findings to understand what you are doing well, and how your service could be improved. Professionals in Scotland and Northern Ireland, two countries which are not currently participating in the National Paediatrics Diabetes Audi , should still monitor their service processes and outcomes to ensure they are providing comparable quality of care for their patients.
  • Early recognition of symptoms. Nearly a fifth of children and young people presenting to health professionals with Type 1 diabetes for the first time did so in DKA, a serious and potentially life-threatening complication of diabetes. Reducing this requires wider publich health messaging – health professionals should promote greater public awareness of the signs of onset of Type 1 diabetes, such as Diabetes UK’s ‘4T’s’ campaign (“Thirsty, Tired, Thinner, going to the Toilet a lot”).12
  • Resources:
    • NICE clinical guidance on management of diabetes13
    • Diabetes UK Resources for families and schools14

Contributing authors

  • Dr Ronny Cheung, RCPCH State of Child Health Clinical Lead
  • Rachael McKeown, RCPCH State of Child Health Project Manager
  • Holly Robinson, RCPCH Research & Quality Improvement Division
  • Dr Rakhee Shah, RCPCH State of Child Health Clinical Advisor

Royal College of Paediatrics and Child Health (2020) State of Child Health. London: RCPCH. [Available at: stateofchildhealth.rcpch.ac.uk]

References

(1)

Diabetes UK. Facts and stats.  2019. Available from: Diabetes UK (pdf)

(2)

RCPCH (2019) National Paediatric Diabetes Audit Core Report 2017/18. Available from: NPDA on RCPCH website

(3)

Stratton IM (2000) Association of glycaemia with macrovascular and microvascular complications of Type 2 diabetes: prospective observational study BMJ 321: 405-412.

(4)

National Institute for Health and Care Excellence (2015) Diabetes (type 1 and type 2) in children and young people: diagnosis and management  (NICE Guideline 18). Available from: NICE

(5)

Mair, C., et al. (2019) Glycaemic control trends in people with type 1 diabetes in Scotland 2004–2016 Diabetologia 62, 1375–1384.

(6)

Kossarova L, Cheung R, Hargreaves D, Keeble E. (2017) Admissions of inequality: Emergency hospital use for children and young people. December 2017: Nuffield Trust.

(7)

RCPCH National Diabetes Quality Programme. Available from: RCPCH

(8)

Streisand, R. & Monaghan, M. (2014) Young children with type 1 diabetes: challenges, research, and future directions. Curr Diab Rep 14: 520.

(9)

Department for Education (2015).  Supporting pupils at school with medical conditions. Available at: GOV.UK (pdf)

(10)

Welsh Government (2018) Supporting learners with healthcare needs. Available at: GOV.WALES (pdf)

(11)

NHS Digital (2019). National Child Measurement Programme, England – 2017/18 School Year.

(12)

Available from: Diabetes UK

(13)

NICE (2016). NG18  Diabetes (type 1 and type 2) in children and young people: diagnosis and management. Available from: NICE

(14)

Available from: Diabetes UK