By Dr. Geoffrey Modest
There was a pretty striking and disturbing report by the World Health Organization on the global burden of diabetes (see http://apps.who.int/iris/bitstream/10665/204871/1/9789241565257_eng.pdf?ua=1 ).
Details:
- Estimated 422 million adults were living with diabetes in 2014 (vs 108 million in 1980), rising from 4.7% to 8.5% of the adult population in the world (e. 1 in 11).
- There were 1.5 million deaths in 2012 from diabetes and 2.2 million additional deaths associated with high blood sugar(largely from cardiovascular disease). 43% of these deaths occurred in people <70 yo
- Presence of diabetes is increasing more rapidly in low- and middle-income countries, including the % of deaths attributable to high blood sugar or diabetes. The most dramatic increase in diabetes from 1980-2014 was in the Eastern Mediterranean region, which increased from 6% to almost 14%, with most other regions going from 4-5% to around 8%. The region with the highest % of deaths from high blood sugar was the Eastern Mediterranean region, followed closely by the region of the Americas, South-East Asia region and Western Pacific region. The lowest were the African region and European region.
- Much of this change is associated with an increase in risk factors, esp. overweight/obesity. In 2014, more than 1 in 3 adults are overweight and 1 in 10 obese. In 2010 27% of women and 20% of men were “insufficiently physically active”. And in adolescents, 84% of girls and 78% of boys did not meet minimum requirements for the stricter definition of physical activity for their age. Of note, the regions with the most overweight (BMI>25) were the Americas and European. And there was a trend to increasing overweight going from low-income to high-income countries
- Not surprisingly, the ravages of diabetes lead to huge economic losses to the patients, their families, health systems (often already overburdened) and national economies (loss of work and wages). A study found that expected losses to Growth Domestic Product from 2011 to 2020, including both direct and indirect costs, will be on the order of $1.7 trillion (US $$), with $900 billion for high-income and $800 billion for low- and middle-income countries
- The WHO has the usual recommendations to prevent diabetes: exercise, eating healthily, not smoking, controlling blood pressure and lipids. But there need governmental public health initiatives/appropriate reinforcing policies, with population-based prevention
- Effective diabetes management requires early diagnosis, requiring good access for screening for blood sugar, as well as for microvascular and macrovascular damage, and access to appropriate meds
- Exercise recommendations are: at least 150 min of moderate-intensity aerobic exercise/wk (brisk walking, jogging, gardening) or at least 75 min of vigorous exercise/wk. older adults, same amount but to include balance and muscle strengthening activity. For those 5-17 yo, at last 60 min of moderate to vigorous exercise per day.
- They highlight Mexico, where the prevalence of overweight/obesity is >33% for kids and 70% for adults, has the highest prevalence of diabetes, and the highest per capita consumption of soft drinks in the world. in Jan 2014, the govt implemented a tax on drinks with added sugar, increasing their price 10%, and preliminary analysis suggests an 11.6% decrease in the quantity consumed
- Another was in Senegal, where the government used mobile technology to text people and encourage healthy eating during Ramadan, which the next year led to 12000 self-recruited users, highlighting interest and demand. And the WHO document has other examples of creative societal approaches
Why is diabetes increasing in low- and middle-income countries? One of the WHO medical leaders was interviewed on NPR and commented that probably the biggest change in these countries is the dramatic increases in migration from rural areas to cities. This urbanization leads to both decreasing exercise (less manual labor than in rural areas, less walking, more cars), eating more processed foods/fewer basic vegetables/etc., and the resultant increasing obesity.
But, needless to say, this is a huge shift, with noncommunicable diseases overtaking infectious diseases as the major causes of death in middle- to low-income countries, and with truly profound long-term implications for the people and societies overall. There are some good examples of people and governments taking public health initiatives to try to deal with this problem, and there is compelling urgency to develop and expand such initiatives…
See https://stg-blogs.bmj.com/bmjebmspotlight/2015/01/21/primary-care-corner-with-geoffrey-modest-md-community-wide-rural-cardiac-health-program/ for a really interesting blog on a small rural poor county in Maine which has developed a long-lasting and effective multi-dimensional community-wide cardiac health program