Written evidence submitted by Novo Nordisk UK (CBP0072)

 

 

Summary and reason for giving evidence

 

 

 

 

 

 

 

 

 

 

  1. What is the anticipated size of the backlog and pent-up demand from patients for different healthcare services?

 

1.1              Researchers estimate that almost 60,000 people in the UK had missed or

delayed diagnoses of type 2 diabetes during the first stage of the pandemic between March and December 2020.[7]   In April 2020 alone, there was an estimated drop of 70% in recorded diagnoses of the condition compared to expected rates.7 

 

The research, funded by the National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, also found the number of HbA1c blood tests to monitor the clinical management of diabetes fell by 77% in England during April 2020, warning that treating clinicians often rely solely on HbA1c data to make treatment decisions.  The researchers stress that, “We observed reductions in new prescriptions for insulin, especially in older individuals….suggesting a failure to intensify therapy in people with poorly controlled, long-term type 2 diabetes. There are already concerns about clinical inertia in diabetes management, with failures to escalate care when glucose control is poor. These HbA1c data indicate potential further delays that are predicted to cause avoidable diabetes-related long-term complications”.7  The research paper concludes that reductions in the diagnosis and monitoring of type 2 diabetes during the COVID-19 pandemic will have “important clinical and public health implications. It adds that, “Over the coming months, health care services will need to manage this predicted backlog, and the anticipated deterioration of blood glucose levels and cardiovascular risk factors due to delayed diagnoses and reduced monitoring of patients with established diabetes”. The paper goes on to highlight that the research shows older people, men, and those from areas of high deprivation are most adversely affected and could be specific groups to target for early intervention.7

 

1.2              Diabetes UK has reported similar disruption to care. The charity’s survey of

almost 4000 people with diabetes about their experiences during the COVID-19 outbreak found 1 in 3 had health consultations cancelled that have still not yet taken place, while 1 in 3 had not had contact with their diabetes team since the start of the pandemic.3   

 

1.3              COVID-19 has inevitably resulted in workforce pressures, with some healthcare professionals in primary care having been redeployed to provide support to patients within secondary care, impacting on follow up treatment for diabetes patients.[8] Clinicians were already warning in summer 2020 of significant backlogs of up to 12 months in regards to being able to carry out planned diabetes reviews.[9]

 

1.4              The Institute for Public Policy Research (IPPR) has found that the referral of patients to diabetes specialists, to access clinical expertise to help manage their condition, dropped by 22 per cent in the first wave of the pandemic and that while referrals are recovering, they remain a quarter below their expected volume.[10] 

 

1.5              The impact of COVID-19 on diabetes care has been unequal and has affected some people and communities more than others.  Diabetes UK has highlighted that data from the National Diabetes Audit between January and December 2020 shows that the number of people with type 1 diabetes who received all recommend eight care process checks to help monitor their diabetes fell by 29% in London and 46.7% in the North West, compared to the previous year. Similar regional variation is reported for type 2 diabetes, from a decrease of 32.7% in London to a decrease of 49.5% in the North West and with significant variation highlighted across clinical commissioning group areas too.3  Diabetes UK also reports that a lower proportion of people from ethnic minorities and the most deprived parts of the population received the eight care process checks3.

 

1.6              The charity has warned that the UK faces a “diabetes timebomb” as a result of COVID-19.[11] Stressing the importance of healthcare appointments to help identify early signs of complications amongst people with diabetes, Diabetes UK cautions that “disruption to diabetes care will inevitably have consequences and lead to more complications and deaths from diabetes.3   Diabetes already causes more than 2,300 cases of heart failure, 590 heart attacks, 770 strokes and 185 amputations in the UK each week, with diabetes care costing an estimated £19,000 per minute3.   Previous estimates have suggested that while around 10% of the total NHS budget in England is spent caring for diabetes patients, some 80% of this is spent treating potentially avoidable health complications associated with diabetes.1

 

 

 

 

1.7              In regards to obesity, which is responsible for up to 85% of a person’s risk of developing type 2 diabetes,3 services have also been disrupted. In England, in 2018 almost 63% of adults were living with excess weight – with a total of 28% of adults living with obesity.2 Nearly 80% of people with obesity with more complex health needs, who rely on specialist multidisciplinary Tier 3 weight management services to help manage their weight, reported cancellation or delays to their care during the pandemic.4

 

1.8              These delays to care risk exacerbating a situation where there is already geographical variation in services. There is significant variation in the availability of, and access to, Tier 3 weight management services across England. A 2018 survey found that only just over half of Clinical Commissioning Groups (CCGs) commission these services to support people with obesity living with more complex health needs.[12]  With regards to diabetes, the NHS Long Term Plan pledges to drive down variation between local areas in regards to the number of people with diabetes meeting the recommended treatment targets.[13] 

 

1.9              In addition, obesity and diabetes are not health issues where their impact is felt equally within the population. People with obesity in the most deprived areas are over three times as likely to be admitted to hospital as a direct result of their obesity.[14] People living with diabetes in the most deprived households are also twice as likely to develop complications of diabetes as those living in the least deprived.[15]

 

 

 

 

1.10              While the impact of the pandemic on services for the millions of people living with diabetes and obesity in the UK has been significant, they have faced a disproportionate risk of poorer outcomes from COVID-19. This has underlined the vital importance of the Government supporting the NHS to help people living with these chronic conditions to remain in good health.  During the first wave of the outbreak, one-third of COVID-19 deaths in England hospitals were amongst people with diabetes, with higher blood sugar levels and obesity found to heighten the risk of death, which was also found to be greater amongst those people with diabetes from minority ethnic groups and deprived areas. 5 People living with excess weight were also generally found to be at greater risk of hospitalisation, intensive care admission and death from COVID-19, with the risk growing as body mass index (BMI) increased.6 

 

1.11              It is perhaps not surprising that diabetes experts have reported additional stress amongst people living with diabetes, as a result of the pandemic, noting that this stress may be exacerbated by lack of communication about the provision of local services and people’s ability to access care if they have any clinical concerns. [16]

 

1.12              Recommendation 1: It is imperative that the Government supports the NHS to

address delays to care for people with both diabetes and obesity, to reduce their risk of developing significant longer-term health complications and to avoid exacerbating existing variation in health outcomes and local services.

 

 

 

 

 

 

 

 

 

  1. What capacity is available within the NHS to deal with the current backlog? To what extent are the required resources in place, including the right number of staff with the right skills mix, to address the backlog?

 

2.1              NHS staff have worked tirelessly during the pandemic, demonstrating professionalism and dedication to caring for patients in challenging circumstances.  However, COVID-19 has further highlighted pressures within the health service as a result of existing workforce challenges. [17]  

 

2.2              The NHS Long Term Plan commits to the development of specialist diabetes inpatient teams within hospitals, yet Diabetes UK has noted that even prior to COVID-19 some of these teams were being disbanded.3  The charity notes that the number of diabetes specialist nurses (DSNs) have also been falling over time, pointing to 2016 research that highlighted that over 50% of the DSNs working at that time were within 10 years of retirement.3

 

2.3              A large proportion of care delivered to people living with diabetes, the majority of whom (around 90%) live with type 2 diabetes1, is delivered within primary care services and relies on the primary care workforce having the necessary knowledge and skills to care for their patients, with the ability to call upon the support and expertise of clinical diabetes specialists when needed.[18]   One group of diabetes clinicians, who have developed new guidance on how the needs of diabetes patients could best be met within the new primary care networks (PCNs), notes the pressures faced by the NHS as a result of an ageing population and workforce and financial challenges and stresses that, “care management needs a coordinated multidisciplinary team (MDT) approach, that focuses on effective early care in primary and community settings to reduce pressure on acute services (and reduce the onset of diabetes complications).18

 

 

Having reviewed best practice and other evidence, the diabetes clinical experts recommend the establishment of a new Diabetes Support Team model within the PCNs to provide enhanced care to patients, as part of a multidisciplinary approach. The team is recommended to include a GP with an extended role in diabetes, a practice nurse with a special interest in diabetes and a clinical pharmacist.18 The recommendation from the clinicians notes that this approach could support hospital services, by providing an opportunity to move appropriate patient care into the community, whilst enhancing access to specialist services for those who require this and improving the integration of primary and secondary care services for people living with diabetes. 18

 

2.4              Giving the new integrated care systems (ICSs) the opportunity to implement an obesity care pathway, across different primary and secondary health and care providers, could also help local health systems provide more holistic and multidisciplinary support for people with the condition. It could also help to embed greater flexibility in the care pathway, so that people with obesity can access the right support at the right time. Psychological support is a critical factor in helping people with obesity, however there are insufficient trained psychologists/counsellors in the NHS to address this need. Multidisciplinary teams delivering tier 3 weight management services should ideally consist of a physician (including a consultant or GP with a special interest), a specialist nurse, a specialist dietitian, a psychologist, psychiatrist, and a physiotherapist.

 

2.5              Recommendation 2: Based on the recommendations of diabetes clinical experts, NHS England should explore making the establishment of a Diabetes Support Team a requirement for Primary Care Networks as part of the next GP Contract update, in order to ensure all patients with diabetes have access to holistic, multi-disciplinary care within primary care services and to additional support from diabetes specialists where they need this.

 

 

2.6              Recommendation 3: Novo Nordisk supports the recommendations in Diabetes UK’s recent report, Diabetes is Serious, calling for additional investment in the diabetes workforce and for Health Education England to lead a funded comprehensive workforce strategy, so that all health and care professionals have training and knowledge of diabetes to deliver good care3.

 

 

2.7              Recommendation 4: Integrated care systems (ICSs) should be supported to implement obesity care pathways, across different primary and secondary health and care providers, to help local health systems provide more holistic and multidisciplinary support for people with obesity, so that they receive care from the recommended range of healthcare professionals.

 

  1. How much financial investment will be needed to tackle the backlog over the short, medium, and long-term; and how should such investment be distributed? To what extent is the financial investment received to date adequate to manage the backlog?

 

3.1              In its recent report, Diabetes is Serious, Diabetes UK stresses the importance of the Government investing in diabetes care and prevention as a key element of their plans to develop health services in the wake of the COVID-19 pandemic. 3

 

3.2              There is a need to ensure the best possible use of NHS resources allocated to diabetes care, recognising the importance of investment in early intervention within the care pathway, to help slow the progression of diabetes and reduce the risk of people affected developing associated health complications. While the NHS spends around ten percent of its total budget on diabetes care, 80% of this funding is spent treating potentially avoidable health complications associated with diabetes.1 This has a significant impact on both people living with diabetes and NHS resources within secondary care. As referred to above, diabetes already causes more than 2,300 cases of heart failure, 590 heart attacks, 770 strokes and 185 amputations in the UK each week, with diabetes care costing the NHS an estimated £19,000 per minute.3

 

3.3              The Government announcement earlier this year of £70 million of funding for weight management services, in support of the 2020 Obesity Strategy, is a welcome first step towards ensuring people living with overweight and obesity can access support. However, it is vital that people living with obesity have access to a full range of weight management services, to ensure they can receive the treatment most appropriate for their needs. This includes those with more complex or severe obesity who require specialist support to reduce and manage their weight through specialist multidisciplinary weight management services (Tier 3 services).

 

There is currently significant variation in the provision of these Tier 3 services across the country, with only just over half of clinical commissioning groups (CCGs) commissioning them,12 resulting in a lack of access for people with obesity outside of these areas.  The Government has confirmed that of the £70 million announced in March 2021 to support the expansion of weight management services, just £4 million has been allocated to Tier 3 and 4 adult specialist weight management services in 2021/22[19].  With £35 million of the Obesity Strategy investment going to local authority weight management services (typically Tier 1 and 2 services), approximately £30 million remains unallocated - which could be used to further strengthen Tier 3 services. It is clear that additional  investment in specialist multidisciplinary weight management services is needed in order to deliver equitable access across the country for those who require it. A substantial part of the investment committed as part of the new Obesity Strategy’s remains unallocated and could be used to help address the backlog within these services.

 

3.4              In addition to any impact delays to care might have on the health of individuals and the resilience of the NHS to care for the growing number of people in the UK living with diabetes and obesity, the backlog also threatens to further deepen the detrimental economic impact of these chronic conditions.  One diabetes specialist from the University of Swansea has calculated that the potential saving over 10 years through lost workplace productivity avoided thanks to improved type 2 diabetes control is estimated to be £1.795bn across the UK – equivalent to around £1,500 per person[20].  Meanwhile, Public Health England has estimated that on average, obesity deprives an individual of an extra 9 years of life, preventing many from reaching retirement age[21]The Institute for Public Policy Research (IPPR) claims in addition that society could lose £405bn through lost productivity and reduced workforce participation as a result of the current number of children living with obesity.[22]

 

3.5              As well as a health imperative, there is therefore a strong economic case for investment in both primary prevention for type 2 diabetes and obesity (to help prevent people developing these conditions) and in secondary prevention (intervening earlier in the care of patients already living with diabetes or obesity to help reduce their risk of developing potentially avoidable and costly health complications).

 

3.6              Recommendation 5 : The Government and NHS England should invest more in both the prevention of type 2 diabetes and obesity and the care of people already living with diabetes and obesity, to help mitigate the potential development of costly health complications amongst the significant populations affected by these conditions.

 

  1. How might the organisation and work of the NHS and care services be reformed in order to effectively deal with the backlog, in the short-term, medium-term, and long-term?

 

4.1              The development of the new integrated care services (ICSs) provides an opportunity to empower local health and care systems to shape services in accordance with the needs of their populations, including an opportunity to improve support for people living with chronic conditions like diabetes and obesity.   However, it will be important to ensure this approach is complemented by concerted action at a national level to support integrated care systems (ICSs) to address these major health challenges. This must be regulated by an overarching framework to help avoid variation in standards of care and services at a local level, particularly as local services work to address the backlog and to address health inequalities.

 

4.2              Given the significant impact obesity has on health outcomes, we welcome the Government’s reassurance that ICSs will be instructed to include obesity as one of their primary framework objectives, although as yet there has been no announcement of any national plans to review the care pathway for weight management services in England, which could help to transform the delivery of services to affected patients and to address variation in access to services in the wake of the COVID-19 pandemic.

 

 

 

4.3              Like obesity, diabetes is one of the key health challenges outlined in the NHS Long Term Plan, which emphasises the need to address variation in treatment outcomes for people with diabetes, alongside ongoing efforts to reduce the risk of people developing type 2 diabetes by encouraging lifestyle changes. Given the need to improve health outcomes for people living with diabetes, which the COVID-19 pandemic has highlighted the importance of, local health and care systems should also be asked to include improving diabetes care as one of their key priorities.

 

4.4              Recommendation 6: Given the significant impact of diabetes and obesity on population health, NHS resources and wider society, NHS England should work with clinical experts to set out national standards of care for these chronic conditions, in order to avoid variation in patient outcomes across different integrated care systems (ICSs), while still allowing local systems to tailor services to the needs and circumstances of their respective populations.

 

4.5              Recommendation 7 : Novo Nordisk supports the recommendation from Diabetes UK for integrated care systems (ICS) to be supported to use available data and tools to prioritise the delivery of diabetes care services and to help catch up on the backlog of appointments caused by the pandemic, with ICS leaders required to ensure support is targeted at those in greatest need and to report on their progress by the end of 2021.

 

  1. What positive lessons can be learnt from how healthcare services have been redesigned during the pandemic? How could this support the future work of the NHS and care services?

 

5.1              During the pandemic, industry has worked effectively with the NHS and has helped support the delivery of health services. For example, Novo Nordisk worked closely with NHS England and Diabetes UK to help develop and set up a temporary dedicated Diabetes Advice Line to advise those people with diabetes who needed help with insulin.  We were pleased to support the advice line by volunteering the time and expertise of our qualified diabetes specialist nurses to assist people who needed advice to help them understand how to effectively manage their diabetes, whichever form of insulin they used.

 

 

 

 

5.2              Novo Nordisk welcomes the recommendation in the Government’s recently published Life Sciences Vision, suggesting that Government and NHS England, could collaborate with industry and medical research charities to deliver a programme of large studies to build real world evidence within healthcare settings, testing different treatments and solutions that could help address obesity.  This is another example of how industry could help support the NHS in its work to improve care and services for patients living with chronic conditions in the wake of the pandemic.

 

5.3              Recommendation 8: The benefits of industry and NHS partnerships should be actively and publicly encouraged by Government to support the NHS in restoring services post-pandemic, where this is appropriate.

 

  1. What can the Department of Health & Social Care, national bodies and local systems do to facilitate innovation as services evolve to meet emerging challenges?

 

6.1              By bringing together healthcare providers within their local geographies, the new integrated care systems (ICSs) will have the ability to monitor and develop services across whole care pathways and to assess their impact on improving health outcomes for patients being treated at any given point in the treatment cycle. This provides ICSs with the opportunity to take a longer-term view of how services need to develop across pathways of care, in order to support people living with chronic conditions to stay in the best possible health and to try and prevent them from developing further health complications. As described above, poorly treated diabetes and obesity have a significant impact on individuals, NHS resources and economic productivity and resilience.

 

 

 

 

 

 

6.2              Diabetes and obesity are linked to other significant comorbidities, including cardiovascular disease.[23] [24]  Cancer has also been linked to obesity24 and to diabetes, with researchers noting that cancer has now overtaken vascular disease as the leading cause of death amongst people with diabetes.[25]

 

6.3              Given the significant impact diabetes and obesity have on the lives of individuals, the NHS and wider society, and the link between these chronic conditions and other significant health challenges, it is imperative that the new ICSs invest in the care and treatment of people living with diabetes and obesity across whole care pathways, so that they have access to the right treatment and innovations at the right time to help improve health outcomes. This includes earlier interventions to help address the risk of people with diabetes developing longer-term health complications, which can be reduced for people living with diabetes through timely therapeutic interventions to control their blood glucose, cholesterol and blood pressure.[26]

 

6.4              To avoid unnecessary variation in health outcomes across different ICSs, as described in recommendation 6 above, it will be important for national standards of care to be set out which local health systems can then determine how to implement in accordance with the needs and circumstances of their respective populations. By learning from and investing in identified best practice, ICSs will be able to tailor local services around the needs of their local areas, while ensuring there is an overarching framework to help avoid variation in standards of care and services at a local level.

 

 

 

 

 

About us

Novo Nordisk is a global healthcare company with over 95 years of innovation and leadership in diabetes care. We have a long history of innovation, leadership and expertise in diabetes and obesity care. Our purpose is to defeat diabetes, obesity rare blood and endocrine disorders. We do so by pioneering scientific breakthroughs, expanding access to our medicines and working to prevent and ultimately cure disease.  Novo Nordisk employs approximately 42,000 people in around 80 countries, with over 360 staff in the UK. We market our products in more than 170 countries, supplying over half the UK’s insulin.  We are committed to driving innovation and have invested over £47 million in research and development (R&D) in the UK since 2014.  

 

Sept 2021

 

 

 


[1] Diabetes UK. Diabetes Statistics. Available from: https://www.diabetes.org.uk/professionals/position-statements-reports/statistics

[2] NHS Digital, Statistics on Obesity, Physical Activity and Diet, England (2020). Available from: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/england-2020/part-3-adult-obesity-copy

[3] Diabetes UK. Diabetes is Serious. 2021. Available from: https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-07/Diabetes%20is%20Serious%20Report%20Final_0.pdf

[4] Public Health England (2020). Supporting weight management services during the COVID-19 pandemic. Phase 1 insights. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/915274/WMS_Report.pdf

[5] NHS England. NHS expands offer of help to people with diabetes during coronavirus outbreak. May 2020. Available at: https://www.england.nhs.uk/2020/05/nhs-expands-offer-of-help-to-people-with-diabetes-during-coronavirus-outbreak/

[6] Public Health England (2020). Excess weight and COVID-19: insights from new evidence. PHE publications gateway number GW-1405. Available at: https://www.gov.uk/government/publications/excess-weight-and-covid-19-insights-from-new-evidence

[7] Carr M., Wright, K., Ashcroft. D., Rutter, M. et al. Impact of COVID-19 on diagnoses, monitoring, and mortality in people with type 2 diabetes in the UK. The Lancet; 2021. Available from: https://doi.org/10.1016/S2213-8587(21)00116-9 and University of Manchester (press release). Type 2 diabetes missed or diagnosis delayed for 60,000 UK people in 2020 May 2021. Available from: https://www.manchester.ac.uk/discover/news/type-2-diabetes-missed-or-diagnosis-delayed-for-60000-uk-people-in-2020/

 

[8] Mills, L. Collaborating and adapting: How diabetes services have changed during the pandemic. Diabetes on the Net. March 2021. Available from: https://diabetesonthenet.com/diabetes-primary-care/collaborating-and-adapting-how-diabetes-services-have-changed-during-pandemic/

[9] Brown, P and Diggle J, How to prioritise primary care diabetes services during and post COVID-19 pandemic. Diabetes and Primary Care Vol 22 No 5. 2020. Available at: https://www.diabetesonthenet.com/journals/issue/620/article-details/how-prioritise-primary-care-diabetes-services-during-and-post-covid-19-pandemic

[10] Institute for Public Policy Research. State of Health and Care: The NHS Long Term Plan After COVID-19. March 2021. Available from : https://www.ippr.org/files/2021-03/state-of-health-and-care-mar21.pdf

[11] Daily Mail. Covid has caused 'diabetes timebomb': Almost 2.5million patients missed out on vital checks during pandemic, charity warns. July 2021. Available from: https://www.dailymail.co.uk/news/article-9762947/Covid-caused-diabetes-timebomb.html

 

[12] APPG on Obesity, (2018). The current landscape of obesity services. All-Party Parliamentary Group on Obesity. Available at: https://static1.squarespace.com/static/5975e650be6594496c79e2fb/t/5af9b5cb03ce64f8a7aa20e5/1526314445852/APPG+on+Obesity+-+Report+2018.pdf

[13] NHS England. NHS Long Term Plan. Available from: https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-quality-and-outcomes/better-care-for-major-health-conditions/diabetes/

[14] NHS Digital. Statistics on Obesity, Physical Activity and Diet, England 2021. Part One: Obesity-related hospital admissions. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/england-2021/part-1-obesity-related-hospital-admissions

[15] Diabetes UK. UKs poorest twice as likely to have diabetes and its complications. 2009. Available from: https://www.diabetes.org.uk/about_us/news_landing_page/uks-poorest-twice-as-likely-to-have-diabetes-and-its-complications

 

 

[16] Hambling C et al. COVID-19 and diabetes: Update for primary care in response to the ongoing coronavirus pandemic. Diabetes on the Net. Available from: https://diabetesonthenet.com/diabetes-primary-care/covid-19-and-diabetes-update-primary-care-response-ongoing-coronavirus-pandemic/?_gl=1*1bwv2ca*_ga*NjQ0NDc4Mzk4LjE1NzgzMDg5MTk.*_ga_WXPFK3W42Q*MTYyODE4ODU3MS4xNi4xLjE2MjgxODg4MjkuMzQ.&_ga=2.107289607.48384768.1628188572-644478398.1578308919

 

[17] Kings Fund. NHS workforce: our position. February 2021. Available from: https://www.kingsfund.org.uk/projects/positions/nhs-workforce

[18] Ali, S et al. Best Practice in the Delivery of Diabetes Care in the Primary Care Network. 2021.  Available from: https://diabetesonthenet.com/wp-content/uploads/Diabetes-in-the-Primary-Care-Network-Structure-April-2021.pdf?_gl=1*9l7syx*_ga*NjQ0NDc4Mzk4LjE1NzgzMDg5MTk.*_ga_WXPFK3W42Q*MTYzMDY4NjM4Ni4xOS4wLjE2MzA2ODYzODkuNTc.&_ga=2.232762198.838680321.1630686387-644478398.1578308919

 

 

[19] Hansard. Response to written parliamentary question from Alex Norris MP. 8 July 2021. Available from: https://questions-statements.parliament.uk/written-questions/detail/2021-06-23/21327/

[20] Bain S et al, Evaluating the burden of poor glycaemic control associated with therapeutic inertia in patients with type 2 diabetes in the UK; Journal of Medical Economics. 2020; 23(1): p.98-105; Available from: https://doi.org/10.1080/13696998. 2019.1645018

[21] Public Health England, (2017). Health matters: obesity and the food environment. Available at: https://www.gov.uk/government/publications/health-matters-obesity-and-the-food-environment/health-matters-obesity-and-the-food-environment--2 

[22] Institute for Public Policy Research. The Whole Society Approach: Making a Giant Leap on Childhood Health. August 2020. Available from: https://www.ippr.org/files/2020-08/a-whole-society-approach-aug-2020.pdf

 

[23] Nowakowska, M et al. The comorbidity burden of type 2 diabetes mellitus: patterns, clusters and predictions from a large English primary care cohort. BMC Medicine. 2019.  Available from: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1373-y

[24] Guh D et al. The incidence of co-morbidities related to obesity and overweight: A systematic review and meta-analysis. 2009. BMC Public Health. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-88

[25] Song, M. Cancer overtakes vascular disease as leading cause of excess death associated with diabetes. The Lancet Diabetes and Endicronology. March 2021. Available from: https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00016-4/fulltext

 

[26] Keng M et al.  Impact of achieving primary care targets in Type 2 diabetes on health outcomes and

healthcare costs. Diabetes, Obesity and Metabolism. 2019. Available from: https://doi.org/10.1111/dom.13821