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No longer confined to the aged, rates of type 2 diabetes are rising fast among all demographics. And with many cases going undiagnosed, your risk could could be greater than you realise
Rates of type 2 diabetes are rising at an “alarming” rate among the under-40s, according to Diabetes UK. Where once the condition was rarely seen in younger people, it’s thought that the number of under-40s affected could rise as high as 200,000 in the next five years. People with obesity are an estimated seven times more likely to be diagnosed with type 2 diabetes, although studies show that people of a healthy weight with high body fat are also at higher risk. We explore this worrying trend, speak to those who live with type 2 diabetes – and help you understand your odds.
“When I was training, type 2 diabetes was only seen in late middle age,” says Jane Armitage, a professor of epidemiology at Oxford University. “You saw it in 60-year-olds, and you saw it, rarely, in 40-year-olds. Now, I see it in teenagers.”
Back in 1996, just 1.4 million people were known to have the disease. Today, it is estimated to affect about 4.7 million, making it one of Britain’s biggest killers. But it’s a quiet one. Only 3.8 million have been diagnosed, leaving swaths of the population unaware. Diabetes currently costs the NHS around 10% of its budget, yet it’s cruelly underfunded. It was, until recently, thought to be incurable.
By damaging blood vessels, diabetes has the potential to cause problems in any part of the body. It can lead to blindness if it affects blood vessels in the retina; it can cause nerve damage if it affects those in your feet. It causes kidney damage, sometimes leading to renal failure. It increases the risk of heart attack and stroke. These effects are insidious: many people live with the disease for a full decade before they are diagnosed, and around a third of people already have complications – eye damage, kidney damage – by the time it’s identified. According to a report by Diabetes UK, type 2 sufferers can expect to live about 10 years less, on average, than people without it.
Yet, despite this grim litany, it remains in many ways a hidden illness. Sure, we’ve all heard of it, but people rarely run sponsored half-marathons for diabetes like they do for breast cancer or Alzheimer’s. It affects more people in the UK than all cancers and dementia put together, yet Diabetes UK, the nation’s largest diabetes charity, has an annual income of around £40m – compared to Cancer Research UK, which draws in more than £600m. All of which poses two questions: what’s driving this sharp rise? And, more pressingly, why aren’t we paying more attention to it?
There are two main kinds of diabetes. Type 1 is rarer, accounting for less than 10% of cases. It’s an autoimmune disease: your body’s defences attack the cells that produce the hormone insulin, which helps to control blood sugar levels. Type 2 is the one that most people think of when they say “diabetes”. It occurs when the body becomes less adept at producing insulin, or less sensitive to the hormone. There are many factors that influence type 2 diabetes. Your family history is important, as is your ethnicity. People of south Asian origin, for instance, are six times more likely to get the disease.
“The key factor is the nation’s creeping weight gain, and men are less likely to notice”
One big reason for the increase in rates is, ironically, we’re living longer. “In middle age, about one in 10 people have it, but by the time you’re 70, it’s one in five,” says Julia Critchley, a professor of epidemiology at St George’s, University of London. But the key factor is the nation’s creeping weight gain, and men are less likely to notice. Middle-aged men are disproportionately affected and are twice as likely as women to be living with diabetes undiagnosed. Some of this is biological: men need to gain far less weight to develop the disease. But it’s also habit. “Men simply don’t access their GPs as often as women,” says Alice Connolly, a dietitian who specialises in weight management and diabetes. “Since symptoms are often silent, most will find out they have diabetes as a result of investigations for something unrelated.” Statistics back this up: only 16% of people diagnosed have proactively asked for a test. We’re leaving a lot to chance – and, increasingly, luck is not on our side.
Then there’s our second question: why is it so under-resourced? According to Dan Howarth, head of care at Diabetes UK, much of this is simple stigma. Society can unjustly stereotype those with type 2 as “lazy people who don’t want to look after themselves”, he says, which, of course, is not the case. It’s the same reason that lung cancer receives less attention than breast cancer: people feel that the victims are to blame. Critchley concurs, citing “lack of understanding and victim blaming”.
In patients, or those at risk, this message can be internalised. Because diabetes is a disease of lifestyle, we might reason that it does not pose the same threat as something we perceive to be beyond our control, such as cancer or dementia. This lack of urgency is a problem, because type 2 can be managed effectively if it’s caught early. “Cardiovascular problems used to be the big killer [for those with type 2 disease],” says Armitage. “But recent data from Sweden shows that if you control your risk factors – don’t smoke, keep your blood pressure normal – the increased risk of heart problems is trivial.”
The trouble is that not everyone is able to control their risk factors. “We see awful complications,” says Howarth. “Diabetes causes an amputation every hour in the UK.” And that, in turn, means that although relatively small amounts of money are dedicated to prevention, vast amounts are spent on its harmful effects. He draws a comparison between the welcome injection of a £44m fund to improve treatment at early stages and the £12bn per year that is spent on diabetes, largely on dealing with preventable complications. Prevention, he says, is not only better than cure: it’s a damn sight cheaper, too.
Prevention may be the goal, but there have been major advances in treatment, too. It has recently been shown that a diagnosis is not always a life sentence. The Diabetes Remission Clinical Trial, funded by Diabetes UK, divided more than 200 volunteers into two groups. They gave half of them the best currently prescribed diabetes care, including medication and dietary advice. The other half were put on a strictly controlled diet: soups and shakes adding up to just 800kcal per day – about a third the usual quota for an adult man.
At the end of the 12-week study, 45% of the dieting group no longer met the diagnostic criteria for diabetes. Even more remarkably, when they checked up on the subjects two years later, they found that 70% of those who had gone into remission were still free of the disease.
“People of a healthy weight with high body fat are more likely to develop diabetes.”
“We don’t talk about reversing it,” cautions Howarth. “We stress the word remission. It means the disease has stopped causing the symptoms.” There’s plenty they don’t know – it has only been three years since the trial began, and it may be that the subjects still see complications after a decade or more. But Howarth is hopeful. This is a major breakthrough. Until relatively recently, the idea that patients could come off insulin was seen as wishful thinking. “Everyone thought I was nuts at the time,” says Sally Hope, a retired GP. Hope was diagnosed with type 2 diabetes more than two decades ago, aged just 40. She had recognised the symptoms – fatigue, thirst. “And I realised I needed to think about this”.
But her GP, unusually, didn’t put her on medication and instead suggested a change of diet, a suggestion that Hope didn’t take well. She wasn’t overweight and felt she ate fairly well. But then she noticed that she often defaulted to sugar and carbs without thinking about it – a shop-bought sandwich here, a shortbread there. “I cut out all of the sugar,” she says. “I was really strict.” She even swapped out pasta for grated veg to cut down on carbs. “And, just like that, my blood sugar went back to normal.” Since then, three of her own patients – all, she notes, doctors themselves – have gone into remission using diet.
So, what’s your move? If you haven’t got diabetes and want to avoid it, then weight control – or, more accurately, reducing the amount of fat around your midsection – is your best route. Although Hope found success by managing her carbohydrate intake, Connolly points out that carbs are not the sole culprit. “Our bodies are well equipped to process sugar when we’re healthy,” she says. Fruit, dairy and wholegrains, for example, have all been linked with a decreased risk of developing the disease, thanks in part to their high fibre and protein contents increasing satiety. Critchley agrees: “The key thing is losing weight. How you do it doesn’t make much difference.”
The word “weight” can often be something of a misnomer: a body mass index (BMI) within the normal range doesn’t offer you a free pass. According to a study in the British Medical Journal, people of a healthy weight with high body fat are more likely to develop diabetes than those classed as overweight, but who carry less fat. The former body shape, often dubbed “skinny fat”, can result from a number of factors, including chronic stress and sleep loss – all the things you know are bad for you, but that don’t necessarily show up in the mirror.
A full lifestyle overhaul won’t prove easy for everyone. We are not all blessed with equal willpower, and people living under challenging circumstances, such as those in poverty or with poor mental health, will always find it harder to make the necessary changes. Everyone quoted in this piece was keen to stress that, while individual responsibility has its part to play, we cannot collectively “will” our way out of the diabetes epidemic, and blaming people for their diagnoses is incorrect and counterproductive. “It’s a societal problem requiring societal responses,” says Critchley. “It’s incredibly hard to lose weight when there are so many factors obstructing us.” But, if there’s one thing we do know for sure, it’s that neglecting the problem will only feed it.
Yian was diagnosed with type 2 in 1990. “It got picked up by chance,” he says. “I went for a routine medical. I’ll never forget the way the doctor told me. He said, ‘You’re diabetic, old son.’ I was 21.”
Yian had been essentially symptom-free, but he was overweight. “I never watched what I ate. The doctor put me on metformin and insulin, and it should have prompted me to make lifestyle changes.”
As many before him have found, however, major overhauls aren’t easy. And Yian, by his own admission, didn’t take the diagnosis seriously enough: “I didn’t feel like I had to do anything, and carried on as normal. My weight continued to balloon. I wasn’t looking after myself.”
He peaked at 290kg and had a gastric bypass in 2010. Then, by eating more healthily and exercising, he lost half his weight. “I thought it would be the end of my problems,” he says, “but diabetes had already taken hold.”
The problems started with neuropathy – loss of sensation in his feet. He developed charcot foot, a weakening of the bones that can lead to disability. He has so far avoided amputation, but isn’t out of the woods and lost the sight in his right eye from retinopathy, a common complication. His wife, he says, is amazing – “nothing seems to faze her” – and they try to remain active. “I’m 50 years old,” Yian says. “I don’t want to feel like an old man.”
He feels there’s not enough information available about the risks of diabetes. “I didn’t realise how destructive diabetes can be if you don’t take it seriously. You need someone to tell you, ‘If you carry on, you will lose your eyesight, or the feeling in your fingers and feet.’”
He’s now committed to raising awareness, talking to Diabetes UK workshops and medical students. “I tell them the truth,” he says. “I never looked after myself, but now I do. If sharing my story can help others, that’s what I’ll do.”
Joe was diagnosed with type 2 diabetes in 2014. He had been largely symptom-free, just like Yian Jones and thousands of others before them, but following a consultation with his optician about changes in his prescription, he was advised to speak to his GP.
The diagnosis came as a shock. He was fairly fit at the time: “I did plenty of walking and played five-a-side a couple of times a week, although I was carrying a bit of excess weight,” he says.
Two years into his treatment, Joe was offered a chance to take part in the Diabetes Remission Clinical Trial: 12 weeks subsisting on low-calorie shakes and soup. “Not eating for three months isn’t something to enter into lightly, so I wanted to be sure I could see it through to the conclusion,” he says. “I don’t believe in doing things in half measures.”
The trial had a remarkable effect. Within the first week, Joe had lost 1.5kg. “After that, the weight loss became more dramatic.” Ten weeks later, he had lost more than a fifth of his bodyweight, from 93kg down to 73kg. His diabetes went into remission.
But, he says, that was the easy part. “The hard part was getting back to eating normally.” It took a major overhaul of his mindset – “I no longer feel I have to finish a meal if I’ve had enough” – and he expects it will be a lifelong effort. Joe is also much more active now, and says that at age 58 he is probably fitter than he was at 21.
When he retires from his job as an engineer, he plans to become a personal trainer and lifestyle coach. While he was lucky enough to have the willpower and support of his family to keep up his lifestyle changes, he believes society needs to do much more – to educate people about the risks of diabetes, to show how it can be beaten, and to reduce the temptations for people to overeat. “I think the food industry could be brought into line by the government,” he says.
“I saw my diagnosis as a bit of a death sentence,” says Daniel. He had been worried about diabetes for years, but wasn’t tested for it until 2017 when his blood pressure results came back high. “The doctor said, ‘Well, you are overweight.’ I felt like he was putting the blame on me.”
At the time, Daniel was suffering from agoraphobia (a fear of leaving the house) and anxiety. “I had a really sedentary lifestyle,” he says.
After his diagnosis, Daniel went into denial. “I had no idea how big an impact it can have, and the complications you’re at risk of,” he says. “There’s a lot of ignorance and people play down its seriousness. I just tried to forget about it. I continued to eat whatever I wanted and my weight peaked at 137kg.” He had been put on metformin tablets but didn’t like how they made him feel, so he stopped taking them.
At a routine eye screening, he was told he had retinopathy. “The thought of losing my eyesight terrified me,” he says. At first, he panicked. “I virtually stopped eating,” he says, “and lost 12kg in a month.” But it just made his anxiety worse.
He then put in a phone call to Diabetes UK, a call that he says “probably saved my life”. He was advised to eat a balanced diet of around 1,600kcal a day. He cut out pastries, switched from red meat to white and reduced his fat intake. “It was hard, especially when I saw other people eating things I wanted.”
After losing 32kg, he plateaued. “Then I knew I needed to throw myself into exercise to challenge my agoraphobia,” he says. He took up walking – “I aimed for 16,000 steps but it was often 25,000” – and now goes to the gym every day. He is now 92kg and has gone into full remission. “I was on top of the world when my consultant told me. She said she’d never seen such a turnaround in a year without metformin.”
Just as importantly, it has improved his confidence. “I’ve never felt fitter,” he says. “It’s been incredibly hard, but I’m proud of what I’ve achieved.”
This article was originally published in the October 2019 issue of Men’s Health UK. If you’re concerned about your risk, are over the age of 40, or are experiencing symptoms such as fatigue and constant thirst, take advantage of the free NHS Health Check. You can find out more here.