Five Questions on the Diabetes Atlas

The newest edition of IDF’s Diabetes Atlas will be released on November 14, World Diabetes Day. Associate Professor Jonathan Shaw, Associate Director of the Baker IDI Heart and Diabetes Institute and Leonor Guariguata, biostatistician at IDF tell us about the spread of the diabetes epidemic according to the Diabetes Atlas.

1. What can we expect from the upcoming 6th edition of the Diabetes Atlas?
This edition of the Atlas will once again provide the most up to date information on the global burden of diabetes. With more studies from more countries, and improved methods of estimating the numbers of people with diabetes, the accuracy of the data continue to improve. The biggest challenge to producing accurate estimates continues to be the significant numbers of countries and areas of the world for which good local information on the numbers of people with diabetes is absent. This problem affects both developed and developing countries. Our estimates in these areas continue to be based on extrapolations of data from neighbouring countries and regions. We hope that highlighting these deficiencies will help to encourage governments and research organisations around the world to fill those gaps.

This edition will see the first-ever estimates of the prevalence of diabetes in pregnancy

This edition will also see the first-ever estimates of the prevalence of diabetes in pregnancy and gestational diabetes. We are seeing an emerging epidemic of high blood glucose in pregnancy that is affecting more and more women with potentially serious consequences if the condition is not diagnosed and managed in time.

2. Which countries or regions are most affected by the diabetes epidemic?
China and India continue to ‘lead the world’ in regards to the number of people with diabetes. Both countries have seen a 10-20-fold rise in the prevalence of diabetes (i.e. the percentage of the population with diabetes) over the last few decades, but are far from topping the list of countries with the highest prevalence. This dubious honour remains with a number of the small Pacific Island nations, followed by Middle Eastern and Caribbean countries. The dramatic rise in the prevalence of diabetes in the Middle East is fuelled by rapid lifestyle change, but is apparent not only in the rich Gulf States, but also in some of the less-developed countries such as Egypt and Lebanon. In addition to these national ‘hot-spots’, we need to continue to remember the heterogeneity within countries, especially those areas with indigenous populations. Indeed, some of the indigenous peoples in North and Central America, Australia and New Zealand have diabetes prevalence similar to those seen in the Pacific Island nations.

There is no doubt that the relentless changes in lifestyle across the world continue to fuel this epidemic.

3. In your view, what is the biggest global threat in our attempts to tackle the diabetes epidemic?
There is no doubt that the relentless changes in lifestyle across the world continue to fuel this epidemic. This is particularly relevant and challenging in the developing world, where the undoubted benefits of many aspects of modernisation make it so much more difficult to tackle the consequences of these changes for diseases like diabetes. Finding ways to continue to lift people out of poverty and bring the gifts of modern technology to every corner of the world is our greatest challenge.

A lack of awareness of diabetes for many parts of the world, and the common misconception of diabetes as a rich person’s disease are also fueling the epidemic and its consequences.

4. We often hear that diabetes is a development issue but what can be done in high-income/developed countries to tackle the type 2 epidemic?
Change has certainly been most rapid in developing countries, but the burden of diabetes is nevertheless already high in the developed world. Unhealthy patterns of diet and physical inactivity are now ingrained at both a personal and societal level. Addressing these will require activity on many fronts, including the provision of widely accessible diabetes prevention programmes, taxes and subsidies that make healthy food, rather than junk food, the cheaper option, working environments that promote standing rather than sitting, and transport systems and town planning that make walking, cycling and public transport more convenient options than the car. It is likely that to achieve any significant level of success, some of these changes will need to be supported by a regulatory and legislative framework.

For countries with high-functioning health systems, the focus needs to be turned not only on preventing new cases of diabetes, but also on providing treatment and managing diabetes. Even the most developed countries are failing miserably when it comes to treating people with diabetes. There are so many cost-effective measures we know work, they need to be applied and governments have to lead the way in terms of creating healthy environments with good access to care.

5. What do you view as the next step for diabetes epidemiology research?
We need to continue doing the simple things such as tracking the numbers of people with diabetes. We also need to continue to monitor the impact of diabetes on the traditional complications such as eye, kidney and heart disease, as well as examining the impact on the more recently recognised complications such as liver disease, sleep disturbance and cancer. Despite years of investigation, we still do not fully understand why social class has such a marked influence on diabetes and its complications. Epidemiological techniques can be very powerful tools in modelling to what extent different interventions will widen or narrow the social health inequalities. New and sophisticated epidemiological study designs are needed to explore some of the newer potential markers of the risk of diabetes and its complications, particularly in the arenas of epigenetics, lipidomics and the microbiome. The causes of the rise in incidence of type 1 diabetes is a further area that still needs further investigation.