Epidemiology

The worldwide prevalence of chronic, non-communicable diseases (NCDs), attributable to and driven by cardiovascular disease (CVD), is estimated to cause an annual loss of more than 40 million lives (World Health Organization, 2017a). Worryingly, non-communicable diseases are increasingly a significant issue in low- and middle-income countries (LMICs) (World Health Organization, 2017a).

A number of shocking statistics illustrate the size of the problems we face with diabetes:

Type 2 diabetes statistics

The global prevalence of type 2 diabetes in adults almost doubled between 1980 and 2014 with increases more pronounced in men than women and in low- and middle-income countries compared to high-income countries (Kolb & Martin, 2017). The increase in the prevalence of type 2 diabetes is closely linked to the upsurge in obesity with up to 90% of type 2 diabetes being attributable to excess weight. In recent decades, a shift towards a more Western lifestyle with its decreased physical activity and overconsumption of affordable energy-dense food has tripled the rates of obesity in developing countries (Hossain et al., 2007). Today, more than 1.9 billion adults worldwide are overweight with 650 million of them being obese. Furthermore, at least 340 million children and adolescents worldwide are also overweight or obese (World Health Organization, 2018). However, more recent evidence suggests that the link between obesity and type 2 diabetes is more closely related to the presence of increased visceral obesity and/or ectopic fat rather than just simply a high body mass index (BMI). This supports the observation of increasing prevalence of type 2 diabetes in patients who have a normal or near normal BMI as a consequence of visceral obesity and ectopic fat combined with reduced muscle mass (Kolb & Martin, 2017). The pace of societal change has been rapid and has led to an epidemic of ‘diabesity’ as a result of complex interactions between (epi-)genetics and environmental factors. Environmental and lifestyle factors that increase the risk of type 2 diabetes include diet, physical activity, time sedentary, quality of sleep and depression (Kolb & Martin, 2017). 

The global human and financial costs of diabetes are mounting, however, preventing and effectively controlling diabetes brings significant and measurable benefits. Exploring locally tailored, effective interventions and investing in affordable and cost-effective solutions to prevent and treat diabetes is not only sensible but also feasible in all resource settings. It is well known that changes in lifestyle leading to effective weight loss significantly reduce the incidence of diabetes and other NCDs, however, they can be challenging to implement at an individual level. A 2018 open-label, cluster-randomised trial sought to determine the efficacy of an intensive weight management programme within the primary care setting for patients with type 2 diabetes. The programme involved withdrawal of antidiabetic and antihypertensive drugs and the implementation of a very low-calorie diet for 3–5 months before food was reintroduced. Changes in diet and structured support for long-term weight loss maintenance resulted in 46% of patients in the intervention arm achieving diabetes remission after 12 months versus 4% in the standard of care arm (Lean et al., 2018). While these results are encouraging, it has been highlighted that we should remain cautious regarding the long-term outcomes as weight loss has proven to be unsustainable previously (Ahmad & Alfaris, 2018). Meanwhile, the benefits of modern treatments should not be underestimated and access can be facilitated through coordinated access programmes offering modern pharmacological assets and capability-building, in partnership, to support less established healthcare systems. 

Key global challenges in the future will be to overcome these obstacles and implementation of acceptable, individualised, localised and global strategies to curb the rising tide of diabetes.

References