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Diabetes in the cost-of-living crisis
As the NHS recovers from an unprecedented pandemic, a new public health emergency emerges. The UK has been hard hit by the cost-of-living crisis since late 2021 – where the cost of necessities exceeds the income of individuals and families.1 (Figure 1.) This is due to many factors, such as rising inflation, frozen wages and continuously rising daily costs. According to the Institute for Government, inflation is ‘eating into nominal wages, which leads to the “real” fall of income’.2 This economic crisis has sent shockwaves across society, with 92% of UK households reporting that their ‘daily expenses had increased’ compared with a year ago.3
Income and health
It is well known that income affects health – both physical and mental.4 (Figure 2.) In order to afford the basics of a healthy life, such as quality housing and food, a certain level of income is needed. Higher income allows more choices in life which often means better access to not only the healthy food options, but also optimising health through opportunities for exercise and access to fitness classes and gyms.
Across the entire economic distribution, higher income is associated with better health. The Health Foundation reports that people with lower incomes are more likely to report their health as either ‘bad’ or ‘very bad’. Additionally, nearly half (48%) of the poorest 40% of families in the UK have at least one person with poor health.5 The rising cost-of-living crisis has the ability to further worsen health outcomes for people with low income. From an inability to afford heating and being vulnerable to respiratory diseases, to the risk of malnourishment from low quality and quantity food intake, the cost-of-living crisis can have enormous impact. Furthermore, there is also a risk of mental health deterioration and build-up of psychological problems from the crisis.6
Impact on people with diabetes
In times of crises – health or economic – the most vulnerable of our population are usually disproportionally affected, such as those with chronic health conditions, like diabetes. This was evident in the outcomes during the height of the COVID-19 pandemic. Among the 4.25 million diabetes-related deaths during 2006–2021, there was a significant surge of more than 30% in mortality during the pandemic.7 Over time, the risk of micro- and macrovascular complications increases if glycaemic levels are sub-optimally managed.
From a health care professional perspective, the perceived impact of the cost-of-living crisis on people living with diabetes can be themed into the following seven categories.
Travelling to appointments and investigations
While the culture of virtual clinics is now formally embedded in the NHS, travelling to appointments is a preference in some age-groups, such as young adults.8 Furthermore, travel remains essential for investigations and annual checks for all people with diabetes. Factoring in travel costs could impact attendance at appointments and completion of recommended care processes.
Storage of insulin
Rising energy costs have resulted in a change in household attitudes and behaviour. A recent Food Standards Agency survey showed up to 18% of participants switched off their fridges and freezers and 27% changed settings to keep food warmer, in order to reduce energy bills.9 For people with diabetes on insulin therapy, such changes to reduce energy bills would have detrimental effects on the viability of insulin stored in fridges and, as a result, on glycaemic management.
Food affordability and insecurity
In the cost-of-living crisis, there has been a substantial rise in the use of food banks and charities due to rising cost of food supplies and increasing unaffordability. More people are having to choose between eating and heating. Almost a third of a population surveyed admitted to skipping meals, using food past the ‘use-by’ date or being unable make healthy food choices.9 Food choices and habits can have a major impact in the management of all types of diabetes, the rising incidence of obesity and cardiovascular risk.
Essential treatment for hypoglycaemia
The day-to-day management of hypoglycaemia involves consumption of a sugary snack, alongside dose alterations of insulin or oral hypoglycaemic agents. While the soft drink industry levy or ‘sugar tax’ has resulted in reduced obesity rates across the country,10 the cost of a drink with >5g of sugar comes with added taxation and cost. With rising food costs, the choice of the sugary snacks and, therefore, its impact on the timely management of hypoglycaemia would be severely limited. This may also be compounded by global shortages in supply.
Worsening the existing health inequalities
Multiple population datasets continue to show inequalities in diabetes-related outcomes within the deprivation indices.11, 12 The current crisis is acutely impacting young people, with more than a quarter of all children in the UK now living in poverty.13 Additionally, more than half of parents are cutting back on food spending. For children and young people with diabetes, the risks include malnourishment, challenging glycaemic management and performance at schools and colleges.
At the opposite end of the age spectrum, pensioners find their state pensions safeguarded via the ‘triple lock’, where pensions rise with inflation. However, a significant amount of the finances is spent on household bills and food supplies, with travel costs for health checks being unaffordable.14 The cost-of-living crisis will impact every person but, undoubtedly, affect the most vulnerable in the most deprived populations the most and, as a result, risks further worsening of the health-related inequalities.
Impact on mental health
Almost a third of people with type 1 diabetes live with some level of diabetes-related distress or mental health condition.15 The financial burden associated with the current crisis, along with little government support, brings along a significant risk of mental health deterioration. This has enormous consequences for people with diabetes and health services. Furthermore, consequences to the economy, health and social care, via workforce shortage due to sickness absences, will further add fuel to this burning crisis.
Impact on diabetes-related foot disease
Living in a warm home is proving unaffordable to many, due to soaring energy bills. For people living with diabetes-related foot disease, cold weather already carries a substantial risk of worsening neuropathic pain and vascular compromise. This risk would be compounded for those who switch off heating for long periods to avoid further rise in costs.
The urgent need
This public health emergency needs an urgent, collaborative effort from many areas to (a) mitigate the immediate, negative effects of the current crisis, and (b) focus efforts on long-term reduction of health inequalities for people with diabetes.
While there is a health care perspective into influencing factors, getting a person-with-diabetes-perspective via quality research is needed to fully understand areas where policy changes can be focused and mobilised.
Collaborative measures between governments, local councils and communities, and charities could focus on quality of heating in homes for the vulnerable, living with diabetes. Evidence suggests that every £1 spent on improving warmth in vulnerable homes can result in £4 in health benefits.3 This could not be more pertinent than in a long-term condition like diabetes.
Additionally, mechanisms are needed to maximise income in this crisis, particularly for those in low-income areas. This could be through improved campaigning of support available, particularly with housing and energy bills, and simplifying the application process. Furthermore, a targeted approach to reduce the cost of healthy food for people with diabetes is much needed. This, along with expansion of the free school meals to all children in primary school (at the outset), will help safeguard the health and well-being of those living with diabetes and prevent the detrimental complications of sub-optimal glycaemic levels.
Integrated diabetes care between different levels of health care providers is now embedded in many areas within the NHS. However, the focus needs to be shifted to the most vulnerable in society in this current cost-of-living crisis by improving access to screening programmes, health care checks and appointments. This could be done with increased appointment frequency closer to home, improved access to and utiIisation of technology for virtual appointments, via grants/funding from local charities and health boards.
Initiatives are already in place: the NHS England led ‘Core20Plus5’ approach in children and young people with diabetes – where the objective is improving uptake of technology in type 1 diabetes and care process measurement in type 2 diabetes in the most deprived areas to reduce health inequalities – is an encouraging start.16
Conclusion
A significant amount of the annual NHS budget is spent on dealing with complications of diabetes.17 The cost-of-living crisis is more than just a financial pinch – it is a public health emergency. The consequences can impact all aspects of diabetes care, for people living with the condition and for health care services. Urgent action is needed from all levels of influential organisations to mitigate the negative consequences, both in the short and long term.
