FOCUS




Michel MARRE,MD, PhD
Service d’Endocrinologie Diabétologie Nutrition
Groupe Hospitalier Bichat – Claude Bernard
Paris, FRANCE

The role of scientific societies in the sharing of expertise
The Mediterranean Group for the Study of
Diabetes (MGSD) and the study on gestational diabetes in the Mediterranean region

by M. Marre,France

The Mediterranean Group for the Study of Diabetes (MGSD) was set up in 1985, on the initiative of Professor Molinatti from Turin, Italy, as a specific center of excellence in diabetes, grouping together well-recognized experts from Mediterranean countries to meet the unrequited needs of all health professionals in the Mediterranean area involved in the delivery of diabetes care. The MGSD, a member of the International Diabetes Federation since 1995, is a nonprofit, nonpolitical association of diabetologists from Mediterranean countries. The specific aim of the MGSD is to act as a bridge between both sides of Mediterranean basin by promoting an exchange of information and knowledge on diabetes research and care delivery, with special emphasis on epidemiology, education, and clinical therapy. While the countries involved share a common geographical basin, they have very different ethnic origins, languages, and dietary habits, offering a unique opportunity for comparison in the field of diabetes worldwide. Since its establishment, the MGSD has grown and become an association that attracts the medical community in the field of diabetes from the north and south banks of the Mediterranean Basin.Within this domain, theMGSD facilitates the exchange of diabetic knowledge and expertise in scientific research, in practical aspects of patient care, and in patient education.

Medicographia. 2011;33:77-82 (see French abstract on page 82)

The organization of specific scientific societies throughout the world into local networks of expertise is a very important development for multidisciplinary research groups, maintaining connections among specialists and promoting the sharing of experience and funding resources. Diabetes is no longer an epidemic that can be ignored: the disease is a widespread problem, increasing rapidly in every part of the world. We must unite to prevent diabetes, to improve diabetes care for the millions affected, and, ultimately, to find cost-effective ways of tackling one of the largest health problems we now face. The Mediterranean Group for the Study of Diabetes (MGSD) was set up to bring the medical community face to face with these issues and challenges.

Epidemiology of diabetes in the Mediterranean Basin

The Mediterranean area represents a unique regional example of interplay between varying ethnic and socio-economic groups. The region can be regarded as a single unit with a large number of common ethnic and cultural features, but it is heterogeneous in terms of socio-economic and demographic factors. Thus, most of the Northern Mediterranean countries (European coast) share the features of other industrialized countries, while most of the Southern Mediterranean (African coast) belongs to the developing world. The Mediterranean islands and Eastern Mediterranean countries (Asian coast) share a mixture of these features. In the Mediterranean Basin, epidemiologic evidence shows increases in both the incidence of diabetes and its complications. Thus, the disease, especially type 2 diabetes mellitus (T2DM), is evolving as a major health problem in this area. The prevalence of T2DM varies widely, while that of type 1 diabetes mellitus varies from0.01% to 0.85% in the various countries. There appears to be a relationship between T2DM prevalence and population density of the country and degree of urbanization.1


Logo of the Mediterranean Group for the Study of Diabetes (MGSD).

© 2008, Mediterranean Group for the Study of Diabetes


Diabetes is no longer an epidemic that can be ignored: the disease is a widespread problem, increasing rapidly in every part of the world.

We must unite to prevent diabetes, to improve diabetes care for the millions affected, and, ultimately, to find cost-effective ways of tackling one of the largest health problems we now face. © Stephen H. Sheffield/Getty Images.

_ Type 1 diabetes
In the Mediterranean and neighboring areas, the incidence rates of type 1 diabetes in children under the age of 15 years show wide variations. In Italy, the incidence of type 1 diabetes in children aged 0-14 years is 6-11.7 (per 100 000 per year), while in Sardinia the incidence is 34.4, one of the highest in Europe.2 In general, the highest incidence is among subjects aged 10-14 years and the lowest in children aged 0-5 years, for both genders. However, an earlier peak incidence in children aged 5-9 years is a common feature of insular Italian areas, but not of Northern Italy. In France, Levy- Marchal showed that the annual diabetes incidence rates for 1988 and 1995 were 7.17 and 9.28 per 100 000, respective respectively; this study included 2 million subjects under 20 years of age.3 Similar results have been reported in Spain (8-10.9 per 100 000 per year), and in Croatia and Slovenia (7.2 and 7.6 per 100 000 per year, respectively).2 The incidence in the Mediterranean countries is different from the incidence in Northern Europe; indeed, in Finland, Tuomilehto et al reported that for children under 14 years, the annual incidence rate in 2000 was 45 per 100 000.4 In contrast with other European countries, the incidence of the disease in the Mediterranean area does not follow any geographical pattern. Probably differences in environmental factors (diet, toxins, and viral infections), genetic susceptibility, or both are important for such a wide variation. As in other areas of the world, variation in incidence appears to be related to ethnicity, demonstrating the importance of the differential genetic susceptibility in different populations. Indeed Sardinians, who together with Finns have the highest incidence of type 1 diabetes in the world, have a high frequency of HLA haplotypes implicated in type 1 diabetes susceptibility and paucity of protective alleles when compared with other white populations.2 Moreover, the interactions between different genes and environmental factors may be important, as suggested by some studies performed in Israel. In contrast, studies in Sardinian migrants showed that the high incidence of type 1 diabetes is more a consequence of their genetic background than of environmental influences.5 This does not mean that environmental factors are not relevant in the etiology of type 1 diabetes, but rather that environmental triggers may have a major impact on genetically predisposed subjects. Worldwide a female excess is found in low-incidence populations, while the reverse is true in several high-incidence populations. In the Mediterranean countries, the male to female ratio is close to 1:1.


Mediterranean countries and their coastal regions.

© 2003, Plan Bleu/Gaussen & De Phillipis – FAO. All rights reserved.

_ Type 2 diabetes
T2DM is the major component of the worldwide diabetes epidemic. King et al6 reported that the prevalence of diabetes in adults aged 20 years and over was 7.5% in 1995, 7.8% in 2000, and will be 10% in 2025, in Italy. In Spain, a similar thing is happening; the prevalence of diabetes will rise from 7.2% in 1995 to 9.5% in 2025. In contrast, the same authors reported that in France and Croatia, there will only be a mod-erate increase in the prevalence of diabetes in the adult population: from 2.1% in 1995 and 2000 to 2.6% in 2025 in France, and from 4.4% to 5.1% in Croatia.6 In these countries, as in all the developed world, the majority of people with diabetes are aged 65 years. Moreover, several studies have found significantly higher prevalence rates in urban environments than in rural ones, within the same country. Comparisons of migrant populations living in rural and urban settings in the same country also show an excess of diabetes in urban communities. This aspect is actually not only very interesting, but highly relevant since we are witnessing an important migratory flow from developing countries to Europe. Since both the prevalence of T2DM and the mean age of patients are increasing in most European countries, there has been a consequent increase in the prevalence of cardiovascular and microvascular complications. Recent intervention trials have shown that improved glycemic control and aggressive treatment of hypertension can reduce the risk of macrovascular and microvascular complications.7,8


A finger prick test.

Recent intervention trials have shown that improved glycemic control and
aggressive treatment of hypertension can reduce the risk of macrovascular and
microvascular complications. © Wellcome Images.

The Mediterranean Diet

The relation between health and the Mediterranean Diet, defined as the “food pattern typical of some Mediterranean regions in the early 1960s, such as Crete, parts of the rest of Greece, and Southern Italy,” was initially evaluated cross-sectionally in the Seven Countries Study, where the morbidity from coronary heart disease was significantly less in Crete and Greece compared with Finland and the USA, and this was attributed to the dietary pattern and the resulting low serumcholesterol level.9 The follow-up of the various cohorts of the Seven Countries Study showed a relationship between mortality and various dietary parameters of the baseline examination.10 This relation has been further investigated in various epidemiological studies. In a population-based prospective study with 22 043 adult participants in Greece with a median follow-up of 44 months, better adherence to the Mediterranean Diet pattern (judged by a 2 unit increment in a scoring system on a 10-point scale) was associated with a reduction in overall mortality (hazard ratio [HR], 0.75). The reduction in mortality was also evident for both death due to coronary heart disease (adjusted HR, 0.67) and death due to cancer (adjusted HR, 0.76). Again no associations between mortality and individual components of the Mediterranean Diet Score were documented, suggesting that the combination of components rather than a particular component is important for the reduction of mortality.11


The beneficial effects on health of the Mediterranean Diet have been tested in various intervention studies.

It is difficult to conduct such studies since the complexity of dietary modifications makes it impossible to develop a double-blind intervention to analyze its effect on health.
© 2006-2010, Media Two, Inc. All rights reserved.

The effects of various important dietary components in the Mediterranean Diet in mortality in diabetic patients have not been extensively investigated. In a recent publication, the tenyear all-cause mortality of 1000 diabetic patients was related independently to saturated fat and egg consumption. There is no association between egg intake and mortality in the nondiabetic population, as has been shown in a special analysis of the above-mentioned Health Professionals Followup Study (HPFS). However, an association was found in this study in diabetic men, but not diabetic women. The effects of the Mediterranean Diet in diabetics warrant further research.12,13 The beneficial effects on health of the Mediterranean Diet have been tested in various intervention studies. It is difficult to conduct such studies since the complexity of dietary modifications makes it impossible to develop a double-blind intervention to analyze its effect on health.14

MGSD history

The MGSD was founded in 1985 with the aim of fostering collaboration and research in diabetes as well as providing the means of networking for health-care professionals working in different areas of the Mediterranean.

Two other considerations also inspired the founders of the MGSD: (i) the underrepresentation of the Mediterranean Basin in the major international diabetology associations, whether on a research or clinical basis; and (ii) linguistic specificity, French still being a lingua franca for many of the region’s specialists. So, the official languages of the association are English and French.

The missions of the MGSD have been defined in its constitutional text (12th July, 1985) as attempting to respond to the need for information and training in diabetology on both sides of the Mediterranean. The ultimate aim is that of ensuring equitable and optimal standards of diabetes care. The association is nonpolitical and runs on a nonprofit basis.

The aims of the MGSD

1. To promote, through congresses held every two years and by other suitable means, information and studies in the field of assistance to diabetic patients, with particular regard to self-management, prevention of complications, and social and legislative problems.
2. To coordinate and standardize research in the epidemiology of diabetes in Mediterranean countries.
3. To promote studies regarding patient education, upgrading these according to the needs of each country.

The MGSD in action

_ Communication
The main MGSD meeting, held every 2 years, provides an excellent forum for the discussion of original papers relating to specific issues in diabetes by means of either oral or poster presentations. Members mingle, meet, and talk, applaud the winners of the Hippocrates and Averroes prizes awarded for the two best abstracts, and conduct MGSD official business, the election of the board and the appointment of the president.

The last meeting, following those held in Rome, Athens, Nice, Madrid, Tunis, Rome, Marrakech, Lisbon, Nice, and Istanbul, was held in Malta in April 2009. Our next congress will take place in Gammarth in Tunisia from April 28 to May 1, 2011.

To round off these activities, the MGSD also boasts an information and communication organ, me.di@.news, which was initially available in paper form only, but which became digital in November 2002. A Web presence is obviously a mark of modernity, but also, and above all, it is a rapid and reliable method of communicating with the entire MGSD membership: in addition to me.di@.news, the MGSD offers abstracts, full-text articles, and slide presentations on specific topics on its Web site www.mgsd.org. The MGSD has also produced the Diabetes Pocket Manual. This was first published in 2000, and later updated in 2003. A new version will be published in 2011.

_ Training
As years went by and experience was gained, it appeared to successive presidents that the Group’s main mission was to provide quality information to health professionals in charge of diabetic patients and training to the youngest doctors in this field. Thus, in addition to the 2-yearly conference, fellowships are also offered to assist the organization of postgraduate courses within teams of international repute.

Although this was sufficient justification in itself for setting up the MGSD, the founders felt duty bound to develop their aims and working practices along similarly original lines. It soon became apparent that on top of conventional meetings that bring health professionals together and keep them abreast of the latest key developments in the specialty, there was little point, given the absence of adequate training and resources, in trying to set up topic-based study groups (eg, on the Mediterranean Diet, diabetes and migration) to produce clinical or epidemiologic studies.


The Mediterranean Group for the Study of Diabetes has initiated
an original study, “Gestational diabetes in the Mediterranean region:
prevalence, risk population, pregnancy outcome, and nutritional
contributors,” which involves more than 10 Mediterranean
countries.

The results, which are due in 2011, will appear in a number of international
publications.

For this reason, and thanks to the unflagging commitment of its successive presidents—Profs Molinatti (Italy), Alivisatos (Greece), Serrano Rios (Spain), Crepaldi (Italy), Drouin (France), Kadiri (Morocco), Charbonnel (France), and Duran- Garcia (Spain)—the MGSD sought to establish training programs empowering those entering the specialty with the requisite technical skills to conduct wide-ranging national studies.

_ Research
The relative high prevalence of T2DM should be reflected in a similarly elevated prevalence of gestational diabetes mellitus (GDM), since pregnancy uncovers any underlying insulin resistance. Maltese population data serve to illustrate this observation. The Maltese population has repeatedly been shown to have a marked increased prevalence of insulin resistance, which exhibits itself via an overall higher prevalence of diabetes mellitus and impaired glucose tolerance (IGT), mainly of the non–insulin-dependent variety. This higher prevalence of insulin resistance is reflected by a relatively high prevalence of GDM. Epidemiological studies15 have shown that the prevalence of GDM in the pregnant Maltese population is approximately 5.9%. There is a further 0.3% of the population who suffer from a preexisting form of diabetes. The nonpregnant Maltese population in the reproductive age group has been shown to have an overall diabetes mellitus/ impaired glucose tolerance prevalence of 2.2%, which contrasts significantly with the overall 6.2% figure reported for the pregnant population.

The MGSD has initiated an original study, “Gestational diabetes in the Mediterranean region: prevalence, risk population, pregnancy outcome, and nutritional contributors,” with the following objectives:

_ Primary objectives:
– to serve as a pilot study assessing the prevalence of GDM in the Mediterranean region.
– to identify the biological profile and risk factors of pregnant Mediterranean women with GDM

_ Secondary objectives:
– to relate the obstetric outcome to the carbohydrate metabolic profile.
– to investigate the rate of reversal of GDM to normal
– to assess the influence of nutritional dietary practices on the development of GDM in Mediterranean women.

This study involves more than 10 countries. Results are due in 2011 and should lead to a number of international communications and publications.

All in all, with some 525 members on its books and backed by a committed board and chairman, the MGSD, which has been a member of the International Diabetes Federation since 1995, has more than fulfilled its founders’ purpose in focusing on specifically Mediterranean issues in diabetes and the delivery of diabetes care. For its part too, Servier has been committed to providing financial and logistic support to the project since its inception. Each MGSD member is invited to inject his or her own input into supporting, expanding, and advertising the activities of not just “another” group, but a group which was set up to cater for the specific needs of a region, one most members call “home.” _

References
1. Prevalence estimates of diabetes mellitus (DM) – European Region. Diabetes Atlas. 2nd ed. Brussels, Belgium: International Diabetes Federation; 2003 [eversion from http://www.eatlas.idf.org. Accessed November 30, 2010].
2. Muntoni S, Muntoni S. New insights into the epidemiology of type 1 diabetes in Mediterranean countries. Diabetes Metab Res Rev. 1999;15:133-140.
3. Passa P. Diabetes trends in Europe. Diabetes Metab Res Rev. 2002;18:S3-S8.
4. Tuomilehto J, Karvonen M, Pitkaniemi J, et al. Record-high incidence of type 1 (insulin-dependent) diabetes mellitus in Finnish children. The Finnish Childhood Type 1 Diabetes Registry Group. Diabetologia. 1999;42:655-660.
5. Muntoni S, Fonte MT, Stoduto S, et al. Incidence of insulin-dependent diabetes mellitus among Sardinian-heritage children born in Lazio region, Italy. Lancet. 1997;349:160-162.
6. King H, Aubert R, Herman W. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care. 1998;21:1414-1431.
7. ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl JMed. 2008;358:2560-2572.
8. Zoungas S, de Galan B, Ninomiya T, et al. Combined effects of routine blood pressure lowering and intensive glucose control on macrovascular and microvascular outcomes in patients with type 2 diabetes. New results from the ADVANCE trial. Diabetes Care. 2009;32:2068-2074.
9. Kromhout D, Keys A, Aravanis C, et al. Food consumption patterns in the 1960s in seven countries. Am J Clin Nutr. 1989;49:889-894.
10. Alberti-Fidanza A, Fidanza F, Chiuchiù MP, Verducci G, Fruttini D. Dietary studies on two rural Italian population groups of the Seven Countries Study. 3. Trend of food and nutrient intake from 1960 to 1991. Eur J Clin Nutr. 1999;53:854-869.
11. Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. 2003;348:2599- 2608.
12. Hu F, Stampfer M, Rimm E, et al. A prospective study of egg consumption and risk of cardiovascular disease in men and women. JAMA. 1999;281:1387-1394.
13. Trichopoulou A, Psaltopoulou T, Orfanos P, Trichopoulos D. Diet and physical activity in relation to overall mortality amongst adult diabetics in a general population cohort. J Intern Med. 2006;259:583-591.
14. Serra-Majem L, Roman B, Estruch R. Scientific evidence of interventions using the Mediterranean diet: a systematic review. Nutr Rev. 2006;64(2 pt 2):S27-S47.
15. Savona-Ventura C, Schranz AG, Chazan B. The clinical significance of gestational impaired glucose tolerance in the Maltese population. Arch Perinatal Med. 1997;3: 55-64.

Keywords: Mediterranean Group for the Study of Diabetes; International Diabetes Federation; patient care; patient education; diabetes research; epidemiology; clinical therapy