May 2016

SOUTH BEARING THE BRUNT OF GLOBAL DIABETES BURDEN

The majority of those with diabetes is in the South-East Asia and Western Pacific Regions, accounting for approximately half the diabetes cases in the world.

By Kanaga Raja

            The number of people living with diabetes has almost quadrupled from 108 million in 1980 to an estimated 422 million adults in 2014, and its prevalence is rising faster in low- and middle-income countries than in high-income countries over the past decade, the World Health Organisation (WHO) has said.

            In its first global report on diabetes released in April, WHO said that diabetes caused 1.5 million deaths in 2012, with higher-than-optimal blood glucose causing an additional 2.2 million deaths, by increasing the risks of cardiovascular and other diseases.

            Forty-three percent of these 3.7 million deaths occur before the age of 70 years, and the percentage of deaths attributable to high blood glucose or diabetes that occurs prior to age 70 is higher in low- and middle-income countries than in high-income countries.

            The largest numbers of people with diabetes were estimated for the WHO South-East Asia and Western Pacific Regions, accounting for approximately half the diabetes cases in the world.

            The WHO Eastern Mediterranean Region has experienced the greatest rise in diabetes prevalence, and is now the WHO region with the highest prevalence (13.7%).

            According to the specialised United Nations agency, diabetes is a serious, chronic disease that occurs either when the pancreas does not produce enough insulin (a hormone that regulates blood sugar, or glucose), or when the body cannot effectively use the insulin it produces.

            The majority of people with diabetes are affected by type 2 diabetes (where the body cannot properly use the insulin it produces).

            According to WHO, Type 1 diabetes requires insulin injections for survival.

            In a preface to the report, WHO Director-General Dr Margaret Chan, said: "Diabetes is on the rise. No longer a disease of predominantly rich nations, the prevalence of diabetes is steadily increasing everywhere, most markedly in the world's middle-income countries."

            Unfortunately, she said, in many settings the lack of effective policies to create supportive environments for healthy lifestyles and the lack of access to quality health care means that the prevention and treatment of diabetes, particularly for people of modest means, are not being pursued.

            "Around one hundred years after the insulin hormone was discovered, the global report on diabetes shows that essential diabetes medicines and technologies, including insulin, needed for treatment are generally available in only one in three of the world's poorest countries," said Dr Etienne Krug, Director of the WHO's Department for the Management of Non-Communicable Diseases (NCDs), Disability, Violence and Injury Prevention.

            "Access to insulin is a matter of life or death for many people with diabetes. Improving access to insulin and NCD medicines in general should be a priority," Dr Krug said, in a WHO press release.

            According to the WHO report, diabetes of all types can lead to complications in many parts of the body and can increase the overall risk of premature death.

            "Possible complications include heart attack, stroke, kidney failure, leg amputation, vision loss and nerve damage. In pregnancy, poorly controlled diabetes increases the risk of fetal death and other complications."

            The lack of access to affordable insulin remains a key impediment to successful treatment and results in needless complications and premature deaths, said the report.

            Insulin and oral hypo-glycaemic agents are reported as generally available in only a minority of low-income countries.

            The report said that only 23% of low-income countries (six countries) report that insulin is generally available, in contrast to 96% of high-income countries (54 countries).

            "Moreover, essential medicines critical to gaining control of diabetes, such as agents to lower blood pressure and lipid levels, are frequently unavailable in low- and middle-income countries. Policy and programme interventions are needed to improve equitable access."

            WHO said the risk of type 2 diabetes is determined by an interplay of genetic and metabolic factors.

            "Ethnicity, family history of diabetes, and previous gestational diabetes combine with older age, overweight and obesity, unhealthy diet, physical inactivity and smoking to increase risk."

            Excess body fat, a summary measure of several aspects of diet and physical activity, is the strongest risk factor for type 2 diabetes, both in terms of clearest evidence base and largest relative risk.

            Overweight and obesity, together with physical inactivity, are estimated to cause a large proportion of the global diabetes burden.

            High intake of sugar-sweetened beverages, which contain considerable amounts of free sugars, increases the likelihood of being overweight or obese, particularly among children.

            "Recent evidence further suggests an association between high consumption of sugar-sweetened beverages and increased risk of type 2 diabetes," said the report.

            Diabetes imposes a large economic burden on the global health-care system and the wider global economy.

            This burden can be measured through direct medical costs, indirect costs associated with productivity loss, premature mortality and the negative impact of diabetes on nations' gross domestic product (GDP).

            According to the report, based on cost estimates from a recent systematic review, it has been estimated that the direct annual cost of diabetes to the world is more than US$827 billion.

            The International Diabetes Federation (IDF) estimates that total global health-care spending on diabetes more than tripled over the period 2003 to 2013 - the result of increases in the number of people with diabetes and increases in per capita diabetes spending.

            WHO said while the major diabetes cost drivers are hospital inpatient and outpatient care, "a contributing factor to this increase is the rise in expenditure on patented, branded medicines used to treat people with diabetes, including both new oral treatments for type 2 diabetes."

            "The increase in total global diabetes health expenditure is expected to continue. Low- and middle-income countries will carry a larger proportion of this future global health-care expenditure burden than high-income countries."

            One study estimates that losses in GDP worldwide from 2011 to 2030, including both the direct and indirect costs of diabetes, will total $1.7 trillion, comprising $900 billion for high-income countries and $800 billion for low- and middle-income countries.

            WHO underlined that to halt the rise in obesity and type 2 diabetes it is imperative to scale-up population-level prevention.

            "Policy measures are needed to increase access to affordable, healthy foods and beverages; to promote physical activity; and to reduce exposure to tobacco. Mass media campaigns and social marketing can influence positive change and make healthy behaviours more the norm."

            To reduce avoidable mortality from diabetes and improve outcomes, access to affordable treatment is critical, said the report, adding that lack of access to insulin in many countries and communities remains a critical impediment to successful treatment efforts.

            An assessment of insulin affordability found that one month of insulin treatment would cost the lowest-paid government worker the equivalent of 2.8 days of work in Brazil, 4.7 days in Pakistan, 6.1 days in Sri Lanka, 7.3 days in Nepal, and 19.6 days in Malawi.

            The report said that countries can take a series of actions to reduce the impact of diabetes, including:

* Establish national mechanisms such as high-level multi-sectoral commissions to ensure political commitment, resource allocation, effective leadership and advocacy for an integrated NCD response, with specific attention to diabetes.

* Build the capacity of ministries of health to exercise a strategic leadership role, engaging stakeholders across sectors and society. Set national targets and indicators to foster accountability. Ensure that national policies and plans addressing diabetes are fully costed and then funded and implemented.

* Prioritize actions to prevent people becoming overweight and obese, beginning before birth and in early childhood. Implement policies and programmes to promote breastfeeding and the consumption of healthy foods and to discourage the consumption of unhealthy foods, such as sugary sodas. Create supportive built and social environments for physical activity. A combination of fiscal policies, legislation, changes to the environment and raising awareness of health risks works best for promoting healthier diets and physical activity at the necessary scale.

* Strengthen the health system response to NCDs, including diabetes, particularly at primary care level. Implement guidelines and protocols to improve diagnosis and management of diabetes in primary health care. Establish policies and programmes to ensure equitable access to essential technologies for diagnosis and management. Make essential medicines such as human insulin available and affordable to all who need them.

* Address key gaps in the diabetes knowledge base. Outcome evaluations of innovative programmes intended to change behaviour are a particular need.

* Strengthen national capacity to collect, analyse and use representative data on the burden and trends of diabetes and its key risk factors. Develop, maintain and strengthen a diabetes registry if feasible and sustainable. – Third World Network Features.

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About the author: Kanaga Raja is the Editor of the South-North Development Monitor (SUNS) based in Geneva, Switzerland.

The above article is reproduced from SUNS #8218, 11 April 2016.

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