Seanad Éireann debate -
Wednesday, 5 Apr 2006

Vol. 183 No. 7

Diabetes Policy: Statements.

Minister of State at the Department of Health and Children (Mr. S. Power)

I thank Members for the opportunity to address the House on the important issue of diabetes. It is a chronic, progressive metabolic disease that impacts on almost every aspect of a person's life. Its prevalence is progressively higher in older ages groups, however, it can affect infants, children, young people and adults of all ages. There is a great deal of concern because diabetes is becoming more common throughout the developed world.

There are two different types of diabetes. Type 1 diabetes affects mainly young people and has a sudden, and sometimes life threatening, onset. It requires lifelong insulin. Type 2 diabetes is much more common and usually has its onset in middle age. It is associated with lifestyle factors and usually treated by a combination of behaviour changes and medication.

In the course of my presentation I wish to give an outline of the nature, prevalence and impact of diabetes; to describe the initiatives currently under way in regard to prevention; to outline the nature of diabetes care; and to inform Members of the national working group on diabetes and the model of care which will inform future diabetes services. Diabetes is a chronic, progressive metabolic disease. Type 1, or insulin dependent diabetes, accounts for approximately 10% of cases. This affects mainly young people and requires lifelong treatment with insulin.

Type 2 diabetes accounts for the remaining 90% of all cases and affects mainly middle aged or older people. The prevalence of type 2 diabetes is increasing due to a number of factors, including the ageing population and lifestyle issues such as obesity. It is estimated that there are approximately 140,000 people with diabetes in Ireland. Diabetes has a profound impact on lifestyle, work, well-being and life expectancy. Life expectancy is reduced by approximately 20 years in people with type 1 diabetes and up to ten years in people with type 2 diabetes. There are approximately 2,000 deaths annually from diabetes.

Diabetes also causes significant morbidity. Studies have estimated that type 2 diabetes is present for an average of seven years prior to the diagnosis, and up to half of people at this stage may have evidence of complications of diabetes. These complications include eye, kidney and nerve damage. Diabetes also causes vascular complications resulting in coronary heart disease, stroke and peripheral vascular disease, which are the main causes of premature death for people with diabetes.

Diabetes is the most common cause of blindness and amputations in the working population. Foot problems are the most common cause of diabetic admissions to hospital. Diabetes also confers additional risks in pregnancy, where there is an increased chance of losing the baby or of having a congenital abnormality. The increase in frequency of diabetes has led to an increase in hospital admissions. In the past three years, hospital admissions have increased by 32%, with almost 40,000 admissions annually.

There is consensus on the importance of early detection, diagnosis and treatment for people with diabetes. The complications of diabetes are preventable, but to do so diagnosis must be made as early as possible. The provision of services for people with diabetes is complex and care is provided by a wide range of professionals in a wide range of settings. These include general practitioners and their staff, community health staff and hospital specialist diabetes teams, as well as patients themselves and their carers. The achievement of good outcomes for people with diabetes is dependent on the provision of well-organised and integrated diabetes care.

The majority of patients, particularly those with type 2 diabetes, receive their care in the primary care setting. In this setting, there are obvious benefits of convenience, continuity of care and immediate access. Other patients, particularly type 1 diabetics, receive their care primarily in the hospital setting, usually from a physician with a specialist interest in diabetes or from an endocrinologist specialising in the treatment of diabetes. These consultants form part of a specialist team that includes, among others, the clinical nurse specialist in diabetes. A way of integrating this care is through the provision of shared care between the hospital specialist team and primary care. In shared care, roles and responsibilities are clearly understood, and it is supported by agreed protocols. This type of care has been shown to be particularly effective for the management of type 2 diabetes.

In late 2003, the Minister for Health and Children asked the chief medical officer of the Department of Health and Children to chair a working group consisting of the Department, service providers and the Diabetes Federation of Ireland. The membership of the group reflected the multidisciplinary nature of diabetes care and included representatives from the Irish College of General Practitioners, diabetes nurse specialists, the Diabetes Federation of Ireland, health boards and the Department of Health and Children.

As the terms of reference were drafted prior to the establishment of the HSE, the group determined that there should be two phases to the process, namely, a policy aspect which outlines a model of diabetes care and what services diabetes patients should receive, and an implementation phase which would be the responsibility of the Health Service Executive.

The strategy was intended as a high level policy document to set out a model for diabetes care together with a range of preventive and therapeutic services that diabetes patients should expect to receive. To achieve this, the report recommended the following: the development of population and high-risk approaches to prevent diabetes; the development of podiatry services as a priority issue to prevent foot care complications; the introduction of a diabetic retinopathy screening programme to prevent eye disease; the development of a diabetes register; the setting out of a model of high-quality care which describes what children and adults with diabetes shall expect to receive throughout their lifetime; that diabetes services should be prioritised and reflected in the national service plan of the Health Service Executive; and the development of "shared care" which described a model of care that is developed jointly between primary care and specialist services, and which has been shown to be most effective in diabetes prevention and the management of complications.

It also called for a planning and service delivery framework, involving diabetes service development groups with management responsibilities for planning and delivering services and clinical activities in service networks and the application of protocols to support better quality care. The policy guidance has been published on the Department of Health and Children website and the report forwarded to the HSE for implementation.

Diabetes has been acknowledged as a priority issue and the 2006 HSE service plan has identified that current policy guidelines will be translated into specific action plans with the initial focus on the development of a national diabetes service framework. The chief executive of the HSE has identified the establishment of expert advisory groups as a major step in the reform programme. The purpose of these groups is to facilitate key stakeholders, including the clinical and health community, patients, clients and service users in having an influential role in service development. One of the first expert advisory groups to be established will deal with diabetes.

Following the publication of the report, the recommendations have been considered by the management team of the primary, community and continuing care directorate. The management team has identified the following priorities for primary, community and continuing care services: to audit and assess current provision in the local health areas and the administrative areas; to identify best practice; the development of local registers; the identification of high-risk patients; the development of the working arrangements between the HSE and the voluntary sector; and the further roll-out of the screening programme for diabetic retinopathy.

Funding has been approved by the strategic planning and implementation unit of the HSE to develop a self-care and management network for patients with diabetes in each of the four administrative areas. This was one of the key recommendations of the report. Work is advanced in conjunction with the Disability Federation of Ireland in agreeing the allocation of the funding and the service level agreements for the development of the networks. Funding has also been prioritised in 2006 for the development of multidisciplinary community intervention teams for diabetes and work on the roll-out of these proposals is in progress.

The Department of Health and Children is currently implementing a number of strategies, the health promotion aspect of which is of direct benefit to diabetics. These strategies include the cardiovascular health strategy, the health promotion strategy and more recently the obesity strategy.

The cardiovascular health strategy makes 211 recommendations, of which approximately 50 relate to prevention of all cardiovascular diseases, including diabetes. The strategy does not deal with the identification or treatment of diabetes. However, the implementation of the health promotion aspect of Building Healthier Hearts is of direct benefit to diabetics. Some €60 million has been allocated to the strategy, employing approximately 800 professionals to date. Of this, €5 million has been allocated to health promotion employing almost 150 additional health promotion officers. Under the cardiovascular health strategy, a number of agencies and initiatives have been funded, and these include the Diabetes Federation of Ireland. Since 2002, the health promotion unit has provided an annual grant of €63,000 to the Diabetes Federation of Ireland to help fund its health promotion activities.

The national programme in general practice for the secondary prevention of cardiovascular disease, Heartwatch, commenced on 1 October 2002 and is being implemented by the HSE in partnership with the Irish College of General Practitioners and the Irish Heart Foundation. Heartwatch concentrates on secondary prevention of cardiovascular disease. In addition, 1,000 people with diabetes, who are at high risk of developing heart disease, living in the former Midland Health Board area are being included as part of the programme at a cost of approximately €200,000.

Building Healthier Hearts, published in July 1999, identified that secondary prevention for most patients with cardiovascular disease should be provided in the general practice setting. This service model is also relevant to patients with diabetes. The future of the programme will be informed by an independent evaluation currently being considered by the Department and the HSE.

Overweight and obese individuals are at an increased risk of type 2 non-insulin dependent diabetes. As much as 58% of type 2 diabetes is attributable to excess body fat. The report of the national task force on obesity, Obesity: The Policy Challenges, was presented to the Taoiseach in May 2005. The report contains 93 recommendations aimed at tackling overweight and obesity. Revenue funding of €3 million has been allocated to the Health Service Executive to progress the implementation of relevant recommendations of this report.

Intervention to prevent overweight and obesity improves quality of life and life expectancy and will also lead to a reduction in type 2 diabetes, some cancers, obesity-related psychological problems, hypertension and other cardiovascular risk factors. The following projects have been approved by the Health Service Executive to take place during 2006: the expansion of the healthy food made easy programme; the recruitment of four physical activity officers to target obesity in all settings; the provision of four specialist community dietician posts for obesity and weight management to support all initiatives; the purchasing of equipment for growth monitoring; and further progressing work with the food service sector on healthy food provision.

The HSE has allocated €400,000 to develop the service in St. Colmcille's Hospital in 2006. This will allow for the appointment of additional relevant staff and improvements to the physical infrastructure. The HSE also plans to consolidate the one existing obesity service that operates from St. Colmcille's Hospital, Loughlinstown, to support the development of additional centres based in Cork, Galway and north Dublin and to commence the development of a service for children based at Our Lady's Hospital for Sick Children, Crumlin.

Dr. Henry

I thank Senator Browne for allowing me to speak ahead of him. I also thank the Minister of State for his comprehensive statement but I was struck by the absence of certain things in it.

Haemochromatosis, as the Minister of State knows, is a genetic condition which is very common in this country. Approximately one in 300 people have it and one in 20 is a carrier. The gene must be present in both the mother and father for a person to develop full blown haemochromatosis. In my innocence, I thought the Vikings had brought it to Ireland but the Celtic curse, as it is sometimes called, is, in fact, a mutation which probably took place in the west of Ireland thousands of years ago. Wherever we have sent people, such as the ladies who went to Scandinavia with the Vikings or the Irish who emigrated to north America, we have spread the disease.

We have the highest levels of the disease in the world. In the US only 10% are carriers and Scandinavia has levels between the US and Ireland. It is a problem about which we must be vigilant because a number of people with haemochromatosis present first as diabetics. This is because it is a disease where people absorb more iron than they should. The excess iron is laid down in organs like the liver, where it causes cirrhosis, the kidney, which can give rise to serious kidney disease, and the pancreas, which can lead to diabetes. It can affect the joints where it leads to a condition resembling gout. It is important to keep it uppermost in our mind because we are the people most likely to suffer from it.

Often a person is diagnosed with diabetes and some years later undergoes a test for their level of blood ferritin, an iron-binding protein which reaches 300 in people who have haemochromatosis, and only then somebody decides they should be tested for the disease. At that stage they may have cirrhosis of the liver and cardiac irregularities, which are another common reason for presentation. We have the highest incidence of the disease in the world, a fact I would like to be stressed more in the diabetes strategy.

It is also important for the families of anyone who is found to have haemochromatosis after diagnosis of diabetes to be screened. Brothers and sisters will have a one in four chance of having it. It is very important to catch them because the treatment is quite easy. It is only necessary to take blood from sufferers every few weeks. The disease does normally not present until the complications arise and a person is in their 40s or 50s. Frequently those with cirrhosis of the liver are told they drank too much and do not get too much sympathy, but if there was a little more investigation and more thoughtful examination of their condition we might diagnose more people with haemochromatosis before they suffer the organ damage which causes diabetes, cirrhosis and cardiac irregularities.

If the family is checked for the disease or for being carriers insurance companies can become a bit unpleasant. We must be careful to monitor insurance companies in such cases. If it is good to diagnose the condition early, so that people can receive early treatment and avoid later problems such as diabetes, then insurance companies should not be allowed to penalise people. It will only deter them from being tested.

We also need to monitor food and food supplements for sufferers, particularly those referred to as "natural food products" because their labelling may not be as careful as we would like. It is bad enough for a person to retain iron without taking in even more in this way.

I am pleased the Minister of State linked the cardiovascular strategy to the diabetes strategy because it is very important. I was very proud this week to be on a radio advertisement, though I did not hear myself, for the Irish Heart Foundation, encouraging people to call a confidential helpline if they have a concern and do not want to visit a doctor. We should encourage people to ask questions early and the cardiovascular strategy has helped with that.

We must also be very careful about health promotions. We know from large surveys in the US that low-fat diets have not been very effective. It would have been preferable for people to have reduced their carbohydrate intake. It is important for people to realise that eating low-fat products is not the answer and that by so doing they might be fooling themselves.

The presentation in men and women with cardiovascular conditions is often different. Women are inclined to present with cardiovascular disease somewhat later than men. I believe it is because women do not complain so much. We in the medical profession do not think of cardiovascular disease affecting women in their 40s and 50s and are too ready to accept the protective effect of oestrogens, but we may have fooled ourselves on that score. It is important that the medical profession raises its sights and is not confined to what it thought in the past.

Obesity is a significant problem and the Minister of State has given prominence to it, in which everybody will support him. I have been on a diet for 40 years. I have not lost any weight but I try to walk a lot. Though I have a sore ankle at the moment, described as having occurred from too much walking, plenty of walking keeps one's blood sugar down, which is very important with regard to diabetes. If a person is overweight it is even more important to walk regularly because doing so has a protective effect. I hope the strategy promotes that as well.

I will return to podiatry. Has the Department managed to settle this ongoing row?

Mr. S. Power

I knew I should have left it out of the speech.

Dr. Henry

The Minister of State should put his best foot forward to settle it.

I was recently told by a diabetologist that virtually the only reason apart from serious accident or malignancy that a person in this country has a leg amputated is diabetes, and that is really dreadful. We have managed to cut down on smoking and other causes, and we must now get at this problem and make people realise how important it is that they look after their feet. They will have to be spared top-up fees and be able to see podiatrists more than twice a year. Once someone gets an ulcer on his or her foot, that person ends up in serious bother, being sent to hospital, which costs a fortune. I have been told that it takes at least six weeks in an acute bed before the person can be discharged. The Minister of State should imagine how many people he could have got off the trolleys in that time if he had managed to keep that person out of hospital. He can now make his name by doing so.

Mr. Glynn

Cuirim fáilte roimh an Aire. I very much welcome this debate, which I have requested for the past two years.

I am exercised about this situation for several reasons. I come from a health background, and the number of acquaintances who have developed diabetes in recent years is astounding. Views differ regarding the figures, but those that I have been given by the Diabetes Federation of Ireland suggest that approximately 250,000 diabetics have been diagnosed in Ireland, 90% of them type 2. By 2020, that figure will rise to 350,000. The Minister of State's speech has been most informative, and he has certainly hit many of the right buttons, stating that the incidence of diabetes is on the increase.

Diabetes has been described by at least one media outlet as the silent epidemic, but it has great implications for the health services. I regret that to date much of what has been done has been reactive rather than proactive. I was glad to hear the Minister of State speak, and many of the measures that he outlined will improve the situation. The establishment of an expert advisory group is extremely welcome, and I strongly endorse the input of the Diabetes Federation of Ireland.

This condition has several factors, some of which the Minister of State has brought up. The old saying is that we are what we eat, and the food industry has a pivotal role. Kelloggs has certainly reduced the number of components in its food products that would allow this condition to develop. If we are to win this great battle, it cannot be a matter for the medical or nursing professions or the health services alone. This battle is faced by society as a whole, and it will be won only if everyone pulls his or her weight.

Reference has been made, perhaps not today but in the past, to people commenting that they have never been to a doctor in their lives and feel great. It is important to remember that many of them are of my gender, and while they will regularly bring their car for a service, they will not visit their GP for a check-up. That is regrettable, as proactive measures are the only way in which we will address this growing epidemic.

In my early days as a member of the Midland Health Board, a young member of my family aged perhaps ten was diagnosed as a diabetic, one of ten new diabetics in Mullingar General Hospital at the time. I asked the director of community care whether diabetes was on the increase or whether the diagnostic procedures were better. I was informed that the latter was true, but that while the incidence was increasing it had not been detected. GPs can do a great deal, and they are doing their best. They cannot send out well-trained collies or other teams to bring people to them. However, people should go to their GPs to get themselves screened. Schools can also play a very important role in the area.

The former Minister for Health and Children, Deputy Martin, in 2004 established a working group to examine the issue and make recommendations for further action. The group's work has been informed by a wide range of available evidence nationally and internationally, including a major document produced by the Diabetes Federation of Ireland entitled Securing the Future. The national diabetes working group submitted its report to the Tánaiste and Minister for Health and Children, Deputy Harney, last summer. It was forwarded to the chief executive of the Health Service Executive in October 2005, and the HSE is giving this matter priority. This topic arose last Thursday as my colleague across the floor and others, including Senators Kate Walsh and O'Meara, were present. The situation received a certain acknowledgement.

We must also take on board the fact that not all parts of the country have the services of a consultant endocrinologist. The midland region, where I happen to reside, is among those without one. As chairman of the Midland Health Board, I remember receiving a deputation with the then deputy CEO with responsibility for community services. The point was made that there was an urgent need for a consultant endocrinologist in the midland region. There are now dialysis services there, but we still require an endocrinologist.

Type 1 diabetes, formerly known as insulin-dependent diabetes, develops where there is a lack of insulin in the body because the cells that made it have been destroyed. That type of diabetes usually appears before the age of 40 and is treated by insulin injections and diet. The causes of type 1 diabetes are complex and still not clearly understood. People with type 1 diabetes are thought to have an inherited or genetic predisposition to the condition that may remain dormant until activated by an environmental trigger such as a virus or chemical. That starts an attack on the immune system that results in the eventual destruction of the beta cells in the pancreas and subsequent loss of insulin production.

Type 2 diabetes, formerly known as non-insulin-dependent, develops when the body can still make some insulin, although not enough for its needs, or when the insulin that the body makes is not used properly. We must examine exactly what people do to help themselves. As Senator Henry has said, we must also consider all the services, such as those that deal with problems with the eyes and feet. Statistics have proven that the most common reason for amputation of the lower limbs is type 1 diabetes. Blindness is also a major side-effect of diabetes. There are cardiology and kidney problems and a plethora of others driven by this condition.

The cost implications of this condition to the economy regarding what it will draw down from health services are mind-boggling, and I do not believe that anyone has realised that. This can only be resolved by all sections of society working together. This crisis rivals that of tuberculosis in the early part of the last century.

Mr. Browne

I welcome the Minister of State to the House and compliment Senator Glynn for his persistence in this matter. Every week he has sought a debate on this topic and tonight he has been accommodated. I also compliment Senator Henry for her well chosen words. She might follow Deputy Twomey's example, leave the Independent benches and join Fine Gael now that we are on our way up and heading for Government. That, however, is an issue for another day.

Diabetes should make us ask if the Department of Health and Children should deal with health or with disease. I have asked that question many times. Are we the fire brigade extinguishing the blaze or are we preventing the fire in the first place? I hope we are the latter, that we are pro-active.

The Minister of State and I are taking part in the BUPA Ireland run on Sunday. We must put in place proper facilities for people to encourage them to exercise. The State cannot be held liable for every aspect of the individual's health but it has a responsibility to put proper sporting facilities in place. A school in Carlow applied for a prefabricated classroom but it was turned down and the Department of Education and Science advised the school to divide the school gym into two halves. How are the children supposed to exercise?

Co-ordinated thinking is required across all Departments, with proper sports facilities at primary and secondary level and on into adult life. We cannot criticise people for not taking exercise when the State does not provide enough facilities. We have a great network of GAA, rugby and soccer clubs but we must keep pushing the sports facilities to allow people to use them. I go running and every time I go out on the roads, I am taking my life in my hands. It is getting more dangerous. All urban areas should have proper running tracks. We must look at the bigger picture instead of spending millions of euro putting the fire out when lesser expenditure would help to prevent the fire in the first place.

It is estimated that 300,000 people have diabetes and around a third of those are undiagnosed. Fine Gael proposes a national screening programme which would ascertain the extent of the problem and make people aware of it so they can solve it. We recommend periodic health screening for specific age groups. There should be routine health checks and age and gender specific screening for each adult with urine analysis, blood pressure, cholestrol levels, body mass index and blood sugar levels tested.

These tests are simple and inexpensive but can be effective in detecting illnesses such as diabetes and heart disease. They can also be carried out in the local GP surgery. This national screening programme should begin at 20 years of age for women and 30 for men, with tests to be undertaken at five yearly intervals until age 50 for women, every three years after that until 70 and then every two years after that. For men the tests would be done every five years until age 60 and then every three years until 70, with biannual checks thereafter. We will also push a strong health promotion initiative aimed at reducing obesity and its associated problems such as heart disease and diabetes.

Senator Glynn's analogy about getting the car checked every year is perfect. People have no difficulty going to a mechanic for their cars but they do not do it for themselves, particularly men. We must get into the habit of going to the doctor on a regular basis and getting tested for diabetes and heart disease. That would help prevent many of the problems later in life.

Along with Senator Glynn, I met the delegation from the Diabetes Federation of Ireland and was impressed by the great work it does. I was surprised that it only received €63,000 for the year. That should be increased because its work is so worthwhile. A friend of mine with diabetes gets a magazine from the federation every month which contains very useful information. The organisation would certainly benefit from more money.

I did not understand the references the delegation made to podiatrists but there is a link between undiagnosed diabetes and amputation. That involves very significant costs and people do not want to lose a limb. The federation has recommended 70 podiatrists for the State and we should ensure that figure is met. Some people wait for two years between diagnosis and seeing a consultant. The ideal scenario would be one consultant for every 50,000 but at present we only have one for every 150,000.

Unfortunately we also need more paediatric consultants. I attended a talk in Trinity College Dublin by a consultant in St. James's Hospital. He pointed out that diabetes is common in older people but the very worrying trend is that type 2 diabetes, commonly found in people aged 50 and over, is now turning up in teenagers.

Senator Glynn was correct in his comments on food labelling and food types. In our busy lives we are bombarded with low fat diets and convenience foods but the labelling is not clear. Kellogg's was mentioned and while it has done some good work, I have seen different reports stating that the company's products are not as good as it claims. We no longer have time to analyse this information, we all know we should be cooking fresh vegetables and eating fruit but we do not do it. We should work at EU level to push for clear labelling of food produce and foods that claim to be low in fat should be genuinely tested.

I phoned a friend of mine who was diagnosed with diabetes at 50 years of age when I saw this debate was coming up and he sang the praises of the service locally. We must push health promotion advertising to explain the symptoms of diabetes because people are not aware they might have it. It is a major difficulty in every health area. My friend had to give up smoking, which he was not too happy about, but he is doing it. We must publicise the symptoms of diabetes and explain the link with blindness and amputation. There is a also need for dieticians.

I congratulate the Diabetes Federation of Ireland on the great work it is doing; it is holding a conference in Kilkenny on Sunday. I urge the Government to be pro-active because prevention is always better than the cure.

Ms K. Walsh

I welcome the opportunity to contribute to these statements. Members of the House know that I use statements on various issues to discuss diabetes. I regard it as an important subject. Therefore, I am delighted we are having this dedicated debate. I wish to pay tribute to my colleague, Senator Glynn. Since he discovered I was a diabetic he has been persistent in having diabetes spoken about in the House and, to a great extent, he has encouraged me to do the same. I do not wish to sound as if I am contradicting anyone but I have been a diabetic for 30 years and neither of my parents were diabetic.

Diabetes is an illness I have managed for 30 years and I wish to make four specific points. First, it has been noted that there are 250,000 diabetics in Ireland. Nine of out ten have type 2 diabetes. If the trend continues in this way, one third of men in Ireland will face increased risk of diabetes in the next ten years. I continue to stress the point that diabetes must not be thought of as a problem we face in the future. It is a real and current problem in Ireland. That we are having these statements is at least some recognition of that fact. I noted in this House in February that the Diabetes Federation of Ireland told the Oireachtas Joint Committee on Health and Children about the need for a national diabetes strategy. I am interested in hearing all views on this issue.

My second point relates to diagnosis. While 250,000 people in Ireland are diabetic, the further 100,000, who are currently undiagnosed, pose a specific challenge. Men, in particular, although not exclusively, are poor when it comes to regular check ups. Would this be as much of a problem if it were more widely known that undiagnosed type 2 diabetes is the primary cause of heart disease, kidney disease, lower limb amputation and blindness in those under 65? People must go for a check up. Diabetes is detected by a simple blood test which is quick and relatively painless, but so important. Until we begin to tire of stating this message, we have not said it often enough. People should check their family history of diabetes, look at their levels of physical activity and realise that the likelihood of developing diabetes goes up with age. I would have thought I did enough running around here to have fulfilled my exercise quota for the day but, according to Senators Glynn and Browne, and possibly Senator O'Meara, I have not done enough. I will not, however, walk to Celbridge.

My third point relates to the less well-known effects of diabetes. In 2003, it is estimated that there were 900 inpatient discharges for diabetes. This treatment cost over €3.5 million. That is a cost of over €4,500 for each diabetic. We cannot ignore the implications. Financial cost is not the most important issue but it cannot be ignored. My fourth point is that early diagnosis of diabetes will have profound consequences for our wider health service in that there will be fewer eye problems, lower levels of cardiovascular disease, fewer amputations and fewer cases of renal failure.

The Tánaiste and Minister for Health and Children has worked hard on this issue for all the right reasons. She has expressed her concern and, more importantly, her commitment to dealing with diabetes. We know that chronic illness must be managed in our communities. Admission to hospital for diabetes has increased by one third annually while we know the most appropriate way to deal with the illness is at community level.

As I stated in this House two months ago, I understand a major element of the negotiations held with doctors was on how chronic illness can be managed at primary care level. I commend the Tánaiste and Minister for Health and Children, the Ministers of State and the Department on their work and initiatives in dealing with diabetes. I also wish to repeat the most important messages. Diabetes is detected by a simple blood test, people should check their family history and levels of physical activity, and the likelihood of developing diabetes increases with age.

Ms O’Meara

I welcome the Minister of State and the opportunity to speak in this important debate. Like other Senators, I commend Senator Glynn on his perseverance in regard to this issue, his insistence on constantly raising it, bringing to public attention and having it considered. I was not aware of the figures until I read the Minister of State's speech and listened to other Senators. There is no question but that this is a serious public health issue.

I wish to limit my remarks to the growth of type 2 diabetes, because there is a major distinction between the two types. We need to consider the reasons for the growth of type 2 diabetes and the implications for the health service and, as other Senators said, the economic implications. The Minister of State did not mention the cost in his speech. How much does it cost to treat people with type 2 diabetes? While most are treated at primary care level, it must be possible to calculate the cost. The cost of cigarette smoking has been calculated, so I hope every effort is being made by the Department to calculate the cost to the taxpayer and the Exchequer of the growth of type 2 diabetes.

We need to consider the growth of childhood diabetes. As Senator Browne said, people who we would not have expected to develop diabetes until possibly their 60s are now developing it at a much younger age. There is a very worrying trend in regard to the growth of childhood diabetes which is linked to diet and exercise and which is preventable. In other words, we can do something about it, but clearly we are not doing so.

I am a parent and I know of the pressures on the modern family, which Senator Browne mentioned. There is often a tendency to buy fast food and put it in the microwave. When one eats such food one is unaware of the amount of added sugar and salt in it. Given our increased affluence and prosperity, more people go out to dinner and our diet has probably become less healthy. Growing up, we had a very plain eating regime but children nowadays would not put up with it. Fizzy drinks should be banned in schools and fizzy drinks machines should be removed from them. A clear message should be sent to children about healthy eating yet we are not doing enough in that regard.

I am very concerned about the growth of childhood diabetes. A task force on obesity has been established and, clearly, there is an issue in terms of weight, exercise and unhealthy lifestyle. We must look at how we will transform the situation because we are not doing enough in that regard. Every now and then, there is a spate of advertising, talk about the healthy eating pyramid, the fact we need to eat more of this and that, and about using the stairs instead of the lift. RTE also broadcasts good programmes on healthy living. However, we are only skimming the surface. We must recognise we have a major problem on our hands. Unless we treat it as a major problem, it will not be responded to as such. It will be regarded as a problem for somebody else to worry about.

Given that type 2 diabetes is preventable, it is inexcusable that we are not dealing with the issue. When we look at the issue of lifestyle, we probably need to look at the broader issue of the pressure families are under. It is possible families do not have enough time to cook a healthy meal — hence the increase in the consumption of fast food, the number of people going out to eat and the number of fast food outlets. While there is nothing wrong with having a burger and chips occasionally, we all know that in some cases it becomes the regular diet, which is not acceptable. Let us consider how we can make our schools and workplaces healthy. We are doing our children a disservice by not taking this matter seriously because they will be left with a lifetime of illness and possibly a reduced life expectancy.

I thank all those involved in bringing about this debate. I hope it will generate the kind of action that needs to be taken.

Dr. M. Hayes

I, too, welcome the Minister of State and pay tribute to Senator Glynn for his perseverance in bringing this important matter to light. Unfortunately Senator O'Meara stole my script and I will not repeat everything she said.

Mr. S. Power

The Senator needs the Minister for Justice, Equality and Law Reform.

Dr. M. Hayes

I commend to the Minister of State an interview with Jack Gilroy in last weekend's Sunday Independent. Mr. Gilroy is a former Dublin footballer who lost both legs as a result of diabetes. His story is quite harrowing and his problem stems from a sweet tooth.

Diabetes is an epidemic. Obesity is creeping up on us and if we do not get a grip on it, it will overwhelm the acute services. It will affect almost every field, including the renal, cardiovascular and ocular services. Money invested to address the problem now will save enormous sums in the future. Any analysis of health economics would lead one to this conclusion.

One worries when one sees the level of obesity among children, even those of ten years. It is caused by a combination of what they eat and a lack of exercise. Children are being driven to school whereas they walked in the old days. I can understand why parents drive their children to school but if they were encouraged to walk safely it would get rid of a lot of environmental pollution in addition to fat.

My wife was a supply teacher some years ago and introduced a rule that her pupils could drink nothing but water. The consequent lowering in the rate of hyperactivity among the children was amazing. When my own grandchildren are given sweets, they jump up and down for an hour thereafter.

It is important to encourage people to take the test for diabetes. If general practitioners were given a quota of patients to test for diabetes, collie dogs would not be needed. The general practitioners would bring the patients in themselves.

I did a study of acute hospital services in the North some years ago and also spent considerable time studying private practice. I noted a model example of the handling of diabetes at primary care level in a practice in Crossmaglen in south Armagh, the name of which I could circulate. There was an absolutely wonderful diabetes nurse and she was able to manage a high number of diabetics, even advanced diabetics, in the community, thereby keeping them out of hospital. The key was that she had a close relationship with an endocrinologist in a hospital, who was able to respond. The two must work together. I would commend this model to anyone looking for a model of good practice.

I congratulate the Minister of State on what has been done. The subject needs to be treated tremendously seriously. As Senator O'Meara stated, it is a question of lifestyle. As well as looking after diabetics, one must try to change people's lifestyles and encourage them to eat and live more healthily.

I support Senator Henry's plea for foot care services. Foot problems are the primary cause of immobility and there is more need for foot care services among diabetics than among any other group. Eye services are ancillary but both types of services are very important. I ask the Minister of State to tackle the problem of diabetes at school level and through primary care.

Minister of State at the Department of Health and Children (Mr. S. Power)

I thank Senator Glynn for arranging this debate and thank the other Senators for their very constructive and extremely helpful contributions. Diabetes is a very serious issue and one would like to think this debate will generate debate outside the House. The more exposure the subject gets, the better.

Senator Henry made a number of points and one would always have to respect her opinion on matters medical. She stressed the need for greater emphasis on haemochromatosis in the diabetes strategy. She and others referred to obesity and the need for increased physical activity. Physical activity can involve a practice as simple as walking. Unfortunately, for a variety of reasons, people are not walking nearly as much as they used to. We will have to change this situation.

Senator Glynn mentioned the expert advisory group. Its existence is an indication of the seriousness with which we are treating diabetes. He also mentioned the need for an extra endocrinologist in the Mullingar area. We appreciate the benefits this would afford and we will certainly consider it.

Senator Browne mentioned the necessity to increase the number of podiatrists and the issue of food labelling. He also mentioned the need for an information campaign on this matter. He referred to the experience of a friend who discovered he was a diabetic but who was very appreciative of the type of service available to him. It is heartening to know this type of service is available.

Senator Browne asked whether we are putting out the fire or preventing it. Unfortunately both approaches are required. Diabetics cannot be ignored and we do not want to ignore them, and it is therefore important to provide them with the service they need while encouraging others to take steps to prevent themselves from needing it. Their current lifestyle will determine how healthy they will be in later life.

Senator Kate Walsh, a diabetic, gave us some idea of the difficulties diabetics experience and also stressed the importance and value of early diagnosis. We all agree with her in this respect.

Senator O'Meara asked about costs. While I do not have the relevant figures to hand, I acknowledge that her question is important. Unfortunately when considering the provision of service, the cost always comes into the equation somewhere along the line. It can often determine the type or level of service provided. We should forget about the cost for a moment and consider the effect on the life of a person who develops diabetes, which is impossible to quantify. The Senator asked the question and we will try to get some more information. In 2003 it was estimated that we had 900 inpatient discharges for diabetics, for which the cost worked out at approximately €3.5 million, which represents a cost of slightly more than €4,500 per patient. I will try to get more specific and accurate figures. The Senator also mentioned the need to expand health promotion.

Senator Maurice Hayes spoke about his wife who banned fizzy drinks in the classroom and the obvious benefit in a short period. A number of schools have been very proactive in dealing with the matter. They have encouraged children with initiatives such as having a particular day when only healthy foods are allowed. Many parents have learnt from their children rather than the reverse. They are much more educated and aware than pupils would have been in previous years.

I thank the Members for their contributions. Diabetes is a lifelong condition that impacts on almost every aspect of life. It can affect all ages and cases have been diagnosed in babies as young as 12 months. Type 2 diabetes accounts for 90% of all cases and it is widely acknowledged that the increase in this disease can be attributed to our aging population and the rise in the incidence of obesity. The effect of the disease on the individual has been well documented. However, the impact on the health service is also substantial with, for example, an increase of 32% in hospital admissions in the past three years.

GPs and primary care services have an essential role in diagnosing and treating patients with diabetes. Early interventions can minimise many of the effects of the disease. An integrated service involving hospital and primary care will ensure the best outcome for patients and this in addition to other recommendations has been documented in the strategy produced by the Department of Health and Children. The response of the HSE to the strategy has been swift with the imminent establishment of an expert advisory group.

The HSE has identified priorities, including the development of a mechanism for the identification of high-risk patients and the expansion of the screening programme for diabetic retinopathy. Funding has been secured to develop a self-care and management network for patients with diabetes in each of the four administrative areas for the development of multidisciplinary community intervention teams for diabetes.

On the question of personal health, many things happen to people who become ill. This is one area in which people have certain control and their lifestyle choices will influence their health. We must encourage people to balance their lives in every respect and particularly in diet and physical activity. Both Government and local authorities must make it an easy option for people. With the long evenings it is much easier for people to take exercise. However, to cater for the winter nights, we need to ensure that we build housing estates with walkways that are well lit so that people can feel secure when taking exercise. Facilities such as walkways and playing pitches must be made more plentiful and accessible. It is our duty to encourage people to live healthier lifestyles, which is what we are trying to do. While we have had some success, it is important that we build on it.

The HSE has prioritised diabetes and the effects of this will become apparent as services become integrated and more accessible. I am optimistic that the rise in the incidence of diabetes can be halted and reversed and that the effects can be minimised and maintained at levels that enable people to go about their everyday lives.

Acting Chairman (Mr. Cummins)

When is it proposed to sit again?

Mr. Glynn

Tomorrow at 10.30 a.m.