Act Now To Turn The Tide Of Diabetes

A new study by the  Institute for Health Metrics and Evaluation (IHME) at the University of Washington shows that millions of people worldwide may be at risk of early death from diabetes and related cardiovascular illnesses because of poor diagnosis and ineffective treatment. The study titled " Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination surveys," published in the Bulletin of the World Health Organization's March edition, examines diabetes diagnosis, treatment, and management in 4 developing countries (Colombia, Iran, Mexico, Thailand) and 3 developed countries-- England, Scotland, , and the United States.

Its main objective was to study the effectiveness of the health system response to the challenge of diabetes across different settings and explore the inequalities in diabetes care that are attributable to socioeconomic factors.

Mexico stood out for its high prevalence of the disease, with 24% of males and 21% of females over the age of 35 years having diabetes. England and Scotland appeared to have the lowest prevalence rates. Prevalence was higher among males in England, Colombia, Mexico and the United States and among women in Iran and Thailand.

The study reveals that a substantial proportion of individuals with diabetes remained undiagnosed or untreated, both in developed and developing countries. The figures range from 24% of the women in Scotland and the USA to 62% of the men in Thailand. Within countries, the diagnosis rates were higher for women than men, with the largest difference seen in Colombia, where 15% more women than men with diabetes are diagnosed. Of those patients who are diagnosed, most are not being treated for other cardiovascular risks that could be just as dangerous to their health as uncontrolled blood sugar. In all countries except Thailand, a large fraction of individuals with diabetes – about 35% in England and Scotland and close to 50% in the United States – take medication to lower blood glucose, blood pressure and serum cholesterol, but without meeting treatment targets. In fact, the proportion of individuals with diabetes reaching International Diabetes Federation treatment targets for blood glucose, arterial blood pressure and serum cholesterol was found to be very low, ranging from 1% of male patients in Mexico to about 12% in the United States.

These low rates of diagnosis, treatment and control reflect many lost opportunities for reducing the global burden of diabetes which is estimated to be around 6.4%, with more than 280 million people in the world living with diabetes. Of those affected, the majority live in the developing world. Projections for 2010 were that diabetes would account for almost 4 million deaths worldwide. The number of adults with diabetes in developing countries is projected to rise by more than two-thirds between 2010 and 2030.

"Too many people are not being properly diagnosed with diabetes and related cardiovascular risk factors. Those who are diagnosed aren't being effectively treated," said Dr. Stephen Lim, one of the study's co-authors and an Associate Professor of Global Health at IHME. "This is a huge missed opportunity to lower the burden of disease in both rich and poor countries."

In most of the 7 countries under study, socio economic factors, like income and education, were not found to be significantly related to poor disease management (diagnosis, treatment and control), but health insurance did make diagnosis and treatment more likely. This seems to be an encouraging finding, given the large socio-economic inequalities seen in many health outcomes. In Thailand, however, low income and low educational level were significantly associated with lower rates of diabetes diagnosis and effective management, indicating a clear need for better strategies targeting the poor in that country.

"We were very surprised to see that wealth did not have a big impact on diagnosis and treatment," said Dr. Emmanuela Gakidou, the paper's lead author and an Associate Professor of Global Health at IHME. "And in the three countries ( Colombia, Mexico and US) where we had health insurance data, we thought it was noteworthy that health insurance actually played a much bigger role than wealth, especially in the US."

Clearly, both policy and research need to be strengthened in the future for improved diabetes management. Real progress at the population level in the management of diabetes will likely require a three pronged strategy as suggested by the researchers:

(i) Monitoring performance in meeting treatment targets.  Greater efforts to standardize and track the care of patients with diabetes and clear targets for physicians and patients are needed.
(ii) Expanding management of hypertension and hypercholesterolemia in individuals with diabetes. Offering incentives to providers and patients is a new but promising approach. These incentives should ideally be related to blood glucose outcomes rather than process measures.
(iii)Need for technological innovations in the delivery of and access to care of diabetes. Innovations in blood glucose monitoring and drug delivery could increase the proportion of individuals who remain within an optimal blood glucose range

Lifestyle intervention programmes, especially those that rely on dietary changes and increased physical activity, can also play an important role in diabetes management.

The researchers were candid enough to admit that the latest available data, on which this study is based, is not very recent. The survey years range from 2007 for Colombia to 2003-2004 for Thailand, England and Scotland. It is hoped that diagnosis and treatment guidelines must have changed for the better since then. Yet the study gives useful insight about factors plaguing efficient management of diabetes and associated cardiovascular risk factors. The findings also underscore the need for countries to tackle the growing problem of non communicable diseases (NCDs), in part by gathering better data.

"We don't have enough data from actual physical exams to accurately document the trend in most countries," said Dr. Rafael Lozano, a co-author on the paper and a Professor of Global Health at IHME. "We looked at surveys from nearly 200 countries and only could find data on blood glucose, cholesterol, or blood pressure in seven. We hope that in the build-up to the UN Summit on NCDs this September, countries will make a commitment to more surveys that take blood samples from a representative percentage of the population."

- Jittima Jantanamalaka and Shobha Shukla - CNS
(The authors are Directors of CNS Diabetes Media Initiative)

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CNS-Diabetes Media Initiative