This course will provide you with an overview of the most important health challenges facing the world today. You will gain insight into how challenges have changed over time, we will discuss the likely determinants of such changes and examine future projections. Successful international strategies and programs promoting human health will be highlighted and global health governance structures will be mapped and the role of the key actors explored.
5.4: Diabetes (V Narayan)
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From the course by University of Copenhagen
An Introduction to Global Health
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From the lesson
Non-Communicable Diseases and Injuries
In the third module we'll have a closer look at non-communicable diseases, in short NCDs, and examine the forces that are behind the global epidemic rise of NCDs such as diabetes. The module also includes a lesson about mental health and injuries - two major global health challenges that are often ignored when dealing with NCDs.
Meet the Instructors
Flemming KonradsenProfessor, Director
Copenhagen School of Global Health
[MUSIC]
Welcome Professor Venkat Narayan, welcome to Copenhagen.
Great to see you and great to have a chance to discuss diabetes with you.
Could you in brief please explain, what is diabetes?
>> Diabetes basically is a disease of poor glucose control and
metabolism, and there are two types of diabetes, type 1 and type 2.
Type 1 is largely believed to be due to poor insulin secretion whereas type
2 is believed to be due to poor insulin action, what we call insulin resistance.
But that distinction is becoming less clear now because
both types of diabetes are beginning to display both types of features.
But there are certain major differences.
Notably, type 1 largely occurs in young people, type 2 in young adult and adults.
But that too is changing because we are noticing type
2 diabetes also occurring in young people.
But essentially irregardless of the type,
both types of diabetes impose severe burdens and complications.
They affect the eye through retinopathy.
The affect the kidney by causing end-stage renal disease.
They cause heart attacks, strokes, and amputations.
So regardless, it'll also have a huge impact on life years lost.
A person with diabetes dies on average between
12 to 14 years earlier than a person without diabetes, so
they're both very serious conditions, type 1 and type 2.
>> For type 2 diabetes, how has that changed over time?
Type 2 diabetes is by far the most common form of diabetes, so
it affects about 95% of cases with diabetes are due to type 2.
And when we look at the global picture today,
the prevalence of type 2 diabetes has been increasing pretty much everywhere.
It was initially noticed in populations like the Pima Indians of Arizona, but
soon we started noticing it in the United States and Europe, etc.
And now we are seeing a huge increase in type 2 diabetes in low and
middle income countries across the world, including rural parts of low and
middle income countries.
So it's no longer a disease just of high income countries.
It's affecting low income countries.
It's no longer a disease of urban cities.
It's also affecting rural areas.
It's no longer a disease of rich people.
It's increasingly affecting poorer people too.
>> And if we are focusing on type 2 diabetes,
what are the projections at a global level, including regional differences.
>> There's an idea of International Diabetes Federation Task Force that
estimates the burden of diabetes and then makes projections.
What has been shocking is every time they make a projection, two years later
they'll have to revise it and show that the projections had been underestimates.
But currently the count is that about 400 million people with diabetes world wide,
and this could be as high as 600 million within the next 20 years.
But my own feeling having observed the epidemic for
20 years is that these may be underestimates too.
>> So in your perspective, why do we see such an alarming increase in
the number of cases of type 2 diabetes particularly?
>> That's a very good question, there are some factors that we understand and
there are others that we don't.
I mean, clearly among the factors that we understand, some are the very obvious one.
There has been a huge increase in overweight and obesity worldwide.
And that's probably driven by major changes in lifestyle factors.
For example, people are consuming larger amounts of refined carbohydrates,
not consuming enough fruits and vegetables,
and dietary patterns are changing very rapidly in most parts of the world.
And also, thanks to mechanized transportation and mechanized labor,
people are doing less physical activity as part of their work and
as part of their daily routines.
And because of the advent of television culture, computer use,
etc, people are increasingly more sedentary.
These are some of the established risk factors that changes, increases in
obesity, changes in dietary factors, changes in loss of physical activity etc.
That said, there are many factors that we don't seem to understand.
Especially in low and middle income countries where data are extremely scarce,
we are beginning to notice diabetes, type 2 diabetes, occurring even in thin people.
And not in small numbers but very large numbers.
The question is, why is that so?
It can't just be explained by obesity.
There might be other factors involved.
Obesity might be a contributory factor.
For example, there is the theory that children who are born
in impoverished circumstances due to generations of maternal and
child malnutrition, may be born with a disadvantage which,
on the one hand, makes them store body fat for survival.
But on the other hand,
they may also be insulin deficient because of the body is trying to save glucose for
the brain so that the children are born insulin deficient.
So then when you suddenly impose the modern life style in terms of changes in
diet and physical activity, these children, as young adults, don't have
the capacity to compensate and very quickly progress to developing diabetes.
But fundamentally, 90% of the burden of diabetes occurs in low and
middle income countries, but 95% of the research
that we know from about diabetes comes from high income countries.
This is a huge mismatch, so we really need to invest more in terms of research
in low and middle income countries to understand the epidemic better and to
understand some of these unique phenotypes such as diabetes in thin people occurring
in countries like India, Sub-Saharan Africa, other parts of Asia, etc.
>> So help me understand.
If we have a person with early stages of type 2 diabetes living in low,
middle, and high income areas, how is it the disease manifesting differently or
the prospects for the ill person?
How is that different?
>> For one thing, we need to notice that type 2 diabetes is
occurring a lot more frequently at younger ages in low and middle income countries.
And like I just said, we're also noticing that type 2 diabetes is also occurring
in thin people more often in low and middle income countries.
More worryingly, 50 to 80% of diabetes remains undiagnosed in low and
middle income countries which means by the time the disease comes to attention,
considerable organ damage has happened and often complications have set in.
So all of these pose very important questions,
both for new research and for prevention.
>> The groups you're describing related to obesity are thin people,
poor, urban as well as rural, and so on.
Is there any possibility for us to identify with such a wide group of people?
Any possibility for identifying high risk groups for type 2 diabetes?
>> I mean, sure. So
there are some basic things that can be done, like for
example a simple history, obtaining history on family history,
history of hypertension, just weighing a person.
All of the simple techniques can allow us to know who might be at risk.
But this alone is hardly sufficient.
We may have to test their glucoses.
And there are conditions which we call prediabetes.
Essentially, if the fasting glucose is between 100 And 125, or
the two hour post glucose challenge after a glucose tolerance test is between 140
and 199, these two groups, what we call impaired fasting glucose and
impaired glucose tolerance, are at high risk of developing diabetes.
So essentially, they're at very high risk of developing diabetes within the next two
to five years.
So these groups are important to identify and intervene upon.
And this is where a number of trials have been done.
>> So as I understand the literature, there's a lot of discussion
about the association between infections diseases and diabetes.
Maybe infection and non-communicable disease in more general.
Could you explain a little more about what this commability,
how does one influence the other?
>> It's been known for a very long time that people with diabetes are at high
risk for several kinds of infection.
Notably group B streptococcus,
fungal infections, urinary tract infections, and it's also been know
that once they develop infections, those infections tend to be much more resistant.
And this has often been attributed to high levels of glucose or
the way in which the diabetic state
impacts on cellular functions such as the white cell count, etc.
But more recently, there's also been increasing data
suggesting the coexistence of diabetes and tuberculosis.
In other words, people with diabetes are at high risk for developing tuberculosis.
But this becomes a particularly important problem for lower and
middle income countries, but both of these diseases are becoming extremely common.
So not only with people with diabetes develop tuberculosis,
once they develop tuberculosis, their prognosis tends to be worse.
And in countries of Sub-Saharan Africa, the other major problem is that
people with diabetes and HIV tend to have additional problems.
For one thing, the HIV treatments may increase the risk of diabetes.
And secondly, thanks to the success of ARP therapy in people with HIV,
they're living long enough to start developing diabetes.
So you're beginning to see a very complex pattern of communicable and
non-communicable diseases are coming together.
And this is why it's very important to start developing integrated models of care
where we don't treat infectious diseases and
non-communicable disease as separate entities.
But rather we treat them as if they occur in the same person and
in the same population, and we begin to integrate care for the two conditions.
>> In your perspective, what would be the most important priorities for
primary prevention of type 2 diabetes?
>> I would start from where the evidence is.
Over the last 15 years, there's been a considerable number of trials
demonstrating that in people with impaired glucose tolerance or
in people with prediabetes, if you can implement lifestyle interventions or
a drug, you can prevent progression to diabetes very considerably.
And that might also reduce several of the complications.
So I would start first by finding low cost ways
of identifying people with prediabetes and low cost community
driven ways of implementing lifestyle intervention for those people so that we
can immediately reap the benefits of the evidence that is currently available.
That would be the first high priority in my mind.
That said, as i earlier explained to you,
we are beginning to see a lot of diabetes, particularly in low and
middle income countries that is not simply explained by obesity.
That might be happening in thin people
which may be do to early beta cell failure or poor insulin secretion.
We need a lot of research to understand that phenotype better
because preventative strategies in those populations might be quite different.
Beyond these two measures, of course certain societal approaches are necessary.
For example,
we need approaches that promotes a culture that physical activity becomes the norm.
We need a culture where high quality nutrition becomes available,
increases in fruits and vegetables, we start subsidizing fruits and vegetables,
better quality carbohydrates away from refined carbohydrates, better
use of monosaturated and polysaturated fats and away from saturated fats.
I think all of these are going to be necessary.
So it's going to take a combination of individual level, clinical, and
societal interventions.
>> From a treatment and case management perspective for
those who have developed type 2 diabetes,
what would be the priorities including resource processing?
>> Interestingly, sitting in Copenhagen,
this country, Denmark did a famous trial called the Steno Diabetes Trial.
In Denmark, a country with universal healthcare with excellent education and
with excellent income levels, it was found that by implementing
a structured management program for people with diabetes,
they were able to reduce the rate of complications by more than 50%.
That tells you that even if access for care is available, you also need
structure and implementation of structure to reduce the rate of complications.
And indeed, in many high income countries,
we are beginning to see reductions in complication rates.
Now how can these lessons be transferred to results challenged environments?
In India and Pakistan, we are just completing a trial In 11 centers
among 1,200 patients with diabetes, implementing
certain very simple strategies to ensure that glucoses, blood pressure,
and lipids are well controlled, to ensure that eyes are examined every year,
to ensure that the feet are examined every year, and to ensure that
other complications of diabetes are tested for like urine for albumen, etc.
And to do this, essentially we are using two different approaches.
Number one, we developed what's called addition support software.
That guides management based on the best evidence and reminds the physician and
reminds the patient also about the various things that they need to be doing.
And secondly, we've introduced low cost care coordinators.
These are people who are good with communication and good at organization and
who are able to motivate the patient and also connect them to the system.
And we are finding that within two years, considerable improvement in
glucose levels, blood pressure levels, and lipid levels among people with diabetes.
So I think scaling up approaches such as these is what we need.
Essentially, we have to strengthen the health systems but
also coordinate care within the health systems and
emphasize quality of care and quality improvement strategies.
Those are extremely important.
And more important in lower and middle income countries is a need for
integrating care, like a person with diabetes is likely to have conditions
of heart problems, may be depression, may have infections.
So it's important that nothing is done in a silo and
that we integrate care adequately.
>> So one final question to you is related to
diabetes as an element of the overall global health agenda.
How do you see a focus on diabetes in relation
to overall priorities and overall global health?
>> For one thing, the recognition that diabetes is growing and
that it's a serious problem is happening.
Even in a poor country like Malawi, people are talking about the importance of
diabetes because it's actually affecting people.
On the other hand, when it comes to translation
of that recognition into resources, that hasn't happened adequately.
For example, 60% of the burden today, global burden,
is from non-communicable diseases.
>> Yet when you look at the investment, the healthcare health investments that go
into it, it's only 2% of the total investment.
So there is a gap between recognition and investment.
And a number of things need to happen.
I mean, the United Nations held a high level summit in 2011.
All the member states in a signed declaration to fight non-communicable
diseases, but that has not been translated into a fund such as a global fund for
non-communicable diseases.
That needs to happen.
And simple things can be done straight away.
For example, in majority of countries essential medications for
people with diabetes are not available at reasonable cost.
Making those available would be important.
Strengthening data systems in low and middle income countries through
surveillance and cohort studies would be important.
That needs to happen.
And like we discussed earlier, strengthening the health systems,
making sure quality of care is delivered should be made available.
All of this is possible, but this requires concerted global action,
global collaboration, and definitely investment of money.
>> Thank you so much for coming and explaining to us your perspectives and
insights to diabetes at a global level.
>> Thank you Flemming, it's been a pleasure.
[MUSIC]
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