Trends in diabetes: sounding the alarm
Authors: Etienne G Krug
Journal: The Lancet (2016)

Diabetes is a major cause of death and disability worldwide. In 2012 it caused as many deaths as HIV/AIDS (1·5 million).1WHOFact sheet no 310; the top 10 causes of death, updated May 2014. World Health Organization, Geneva2015Google Scholar Disability resulting from diabetes has grown substantially since 1990, with particularly large increases among people aged 15–69 years.2Global Burden of Disease Study 2013 CollaboratorsGlobal, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2015; 386: 743-800Summary Full Text Full Text PDF PubMed Scopus (4424) Google Scholar People with all types of diabetes are at risk of developing a range of complications that can endanger their health and survival, and the high costs of care increase the risk of catastrophic medical expenditure.3Smith-Spangler CM1 Bhattacharya J Goldhaber-Fiebert JD Diabetes, its treatment, and catastrophic medical spending in 35 developing countries.Diabetes Care. 2012; 35: 319-326Crossref PubMed Scopus (61) Google Scholar Diabetes is the theme of this year's World Health Day on April 7, and WHO has published the Global Report on Diabetes to raise awareness and spark momentum for action at the necessary scale. In The Lancet, the NCD Risk Factor Collaboration (NCD-RisC)4NCD Risk Factor Collaboration (NCD-RisC)Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participants.Lancet. 2016; (published online April 6.)http://dx.doi.org/10.1016/S0140-6736(16)00618-8Google Scholar presents a robust and timely analysis of trends in diabetes prevalence. They provide updated, consistent, and comparable estimates of age-standardised prevalence of diabetes since 1980, derived from 751 population-based measurement studies involving nearly 4·4 million participants. These are the first global estimates and trend analyses published since adoption of the voluntary target to halt the rise in diabetes and obesity (against the 2010 baseline) by 2025. The news is not good. NCD-RisC estimates that the number of people with diabetes quadrupled between 1980 and 2014. Age-standardised prevalence among adult men doubled during that time (from 4·3% [95% credible interval 2·4–7·0] to 9·0% [7·2–11·1]), and age-standardised prevalence among adult women increased by 60% (5·0% [2·9–7·9] to 7·9% [6·4–9·7]). Diabetes prevalence either increased or remained the same in every country. Given these trends, the authors calculate that only a few countries, mostly in western Europe, have even a chance of meeting the target to halt the rise in diabetes by 2025—a sobering wake-up call. With diabetes in the World Health Day spotlight the question is, how will the world and its leaders respond to the alarm? NCD-RisC notes that reducing the global health and economic impact of diabetes requires action to prevent or delay the onset of type 2 diabetes, which accounts for the majority of diabetes worldwide. Overweight and obesity, together with physical inactivity, are responsible for a substantial proportion of the global diabetes burden.5GBD 2013 Risk Factors CollaboratorsGlobal, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2015; 386: 2287-2323Summary Full Text Full Text PDF PubMed Scopus (1919) Google Scholar Changes at population level to improve access to healthy foods and beverages, and to opportunities for physical activity, facilitate positive behaviour change and are likely to have an impact on the occurrence of type 2 diabetes.6WHOGlobal report on diabetes. World Health Organization, Geneva2016Google Scholar The intermediate approach proposed by the authors—supportive intervention to promote changes in diet and physical activity among people at high risk of type 2 diabetes, possibly accompanied by the use of medications—is backed by strong evidence of effectiveness.7Merlotti C Morabito A Pontiroli AE Prevention of type 2 diabetes; a systematic review and meta-analysis of different intervention strategies.Diabetes Obes Metab. 2014; 16: 719-727Crossref PubMed Scopus (109) Google Scholar, 8Uusitupa M Peltonen M Lindstrom J et al.Ten-year mortality and cardiovascular morbidity in the Finnish Diabetes Prevention Study—secondary analysis of the randomized trial.PLoS One. 2009; 4: e5656Crossref PubMed Scopus (149) Google Scholar, 9Li G Zhang P Wang J et al.The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study.Lancet. 2008; 371: 1783-1789Summary Full Text Full Text PDF PubMed Scopus (1150) Google Scholar, 10Knowler WC Barrett-Connor E Fowler SE et al.Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.N Engl J Med. 2002; 346: 393-403Crossref PubMed Scopus (14500) Google Scholar, 11Orozco LJ Buchleitner AM Gimenez-Perez G Roqué I Figuls M Richter B Mauricio D Exercise or exercise and diet for preventing type 2 diabetes mellitus.Cochrane Database Syst Rev. 2008; 3 (CD003054.)Google Scholar The ultimate advisability of targeted interventions for people at high risk depends heavily on local context, such as availability of sufficient human and financial resources, as well as essential equipment and technology, to manage the approach at the primary-care level. Hundreds of millions of people live with diabetes today. Many of them do not know it, and many of those who do lack access to the necessary medicines or information. Action to build the capacity of health systems to improve diabetes management and reduce complications is a matter of urgency. Access to effective treatment must be expanded through the use of standardised protocols and the implementation of measures to improve the availability of essential technologies for diagnosis and management of diabetes (such as blood glucose measurement) in primary health-care settings, and essential medicines such as life-saving insulin.12WHOPackage of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings. World Health Organization, Geneva2010Google Scholar Diabetes management should be part of overall non-communicable disease management and incorporated into the package of essential services included in universal health coverage. The prevalence estimates provided by NCD-RisC sound the alarm for large-scale, effective action to reduce the health and economic impact of diabetes. Improvements in prevention and management, together with better surveillance, should be prioritised in response to this call. I declare no competing interests. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participantsSince 1980, age-standardised diabetes prevalence in adults has increased, or at best remained unchanged, in every country. Together with population growth and ageing, this rise has led to a near quadrupling of the number of adults with diabetes worldwide. The burden of diabetes, both in terms of prevalence and number of adults affected, has increased faster in low-income and middle-income countries than in high-income countries. Full-Text PDF Open AccessBeat diabetes: an urgent call for global actionThe theme of this year's World Health Day on April 7—Beat diabetes—adds to a 2011 UN initiative to stem the rise in prevalence of diabetes by 2025, as well as to reduce premature deaths from non-communicable diseases, part of Sustainable Development Goal 3. In today's Lancet, the NCD Risk-Factor Collaboration (NCD-RisC) report that in 2014, an estimated 422 million people worldwide were living with diabetes—roughly a four-fold increase over the past 35 years. The NCD-RisC pooled data from 751 studies that measured either fasting plasma glucose or haemoglobin A1c to determine global and regional trends in diabetes prevalence. Full-Text PDF Mental illness: the forgotten burden on diabetes populations?In April, The Lancet discussed the high cost of diabetes and an urgent call for action. The Comment by Etienne Krug (April 9, p 1485)1 focuses on physical interventions without mentioning the burden of mental illness in diabetes, in which depression and diabetes distress are common. Depression also has a bidirectional relationship with type 2 diabetes, showing causative and consequential implications: mental health is an essential consideration in diabetes prevention and management. Full-Text PDF