Interview: How can today’s evidence-based proof in type 2 diabetes help us contain the diabetes epidemic?

Sir Michael HIRST,
International Diabetes Federation

How can today’s evidence-based proof in type 2 diabetes help us contain the diabetes epidemic?

Interview wi th M. Hirst, United Kingdom

Sir Michael Hirst was deputy chair of the International Steering Group for the campaign to secure a United Nations (UN) Resolution on Diabetes in 2006. From that vantage point, he reflects on what has subsequently been achieved in the wake of approval of the resolution by the General Assembly of the UN. The recent historic decision of the World Health Assembly to adopt the first ever global target to reduce by 25%preventable deaths from noncommunicable disease by 2025 is a welcome consequence of the global advocacy which has followed the UN resolution. He believes there is now unstoppable momentum for further action by member states to tackle the huge and growing economic, social, and human burden of diabetes and noncommunicable disease. He points to more focused advocacy in national and regional parliaments, urging national governments to invest in prevention strategies to slow the growth curve of new cases of type 2 diabetes—predicted in the absence of action to reach over 550 million by 2030. He has a clear view that clinicians, health care professionals, governments and health services, the pharmaceutical and food and drink industries, and people with diabetes all have a responsibility to work together to improve health outcomes and avoid the costly complications of diabetes. Sir Michael’s interest in diabetes started when his youngest child was diagnosed with type 1 while he was a member of the British Parliament. Successfully championing improved care for those with diabetes, he was invited to join the Board of Diabetes UK, eventually becoming its first nonmedical chair. In recognition of his work for diabetes, he was recently elected a fellow of the Royal College of Physicians of Edinburgh. Sir Michael became global president of the International Diabetes Federation in December 2012.

Medicographia. 2013;35:90-94 (see French abstract on page 94)

It has been six years since the general assembly of the United Nations supported a resolution to make diabetes a global priority for action. What do you think have been the major advances since then?

The historic decision of the 65th World Health Assembly (WHA) in Geneva last month, whereby governments adopted the first ever global target to reduce preventable deaths from noncommunicable disease by 25% by 2025, is not only hugely welcomed by the international diabetes community, but can trace its roots to the United Nations (UN) Resolution 61/225 in December 2006 to make diabetes a global priority for action.

As deputy chair of the International Working Group for the UN resolution campaign, I well recall the initial opposition— primarily of the developed world—to the principle of a disease- specific resolution. With superb diplomatic skill, the Bangladeshi Mission at the UN led the campaign, persuading the Group of 77 (the 132 low- and middle-income countries) to support the resolution. The resolution recognized the significance of diabetes as an avoidable disease which is ruinously costly to national health systems and also undermines the achievement of the Millennium Development Goals. While it formally established World Diabetes Day as a UN-observed opportunity to raise awareness of diabetes, it also mandated member states to develop national policies for the prevention, treatment, and care of diabetes. This was, and remains, the first and only UN resolution on a noncommunicable disease.

The skeptics argued that the resolution would achieve little. Experience since then has, however, confounded them. UNobserved World Diabetes Day has proved a rallying point for raising awareness of diabetes all over the world. Hundreds of iconic buildings and structures are lit blue, the international color of diabetes, and in most countries the day is marked and used as a means of political engagement, people with diabetes being strongly to the fore in the awareness activity.

The resolution provided a convenient means by which national diabetes associations could hold their own governments to account for action on prevention, treatment, and care. There are countless examples of national governments timing their announcements on improvements to diabetes care to coincide with World Diabetes Day. The European Parliament provides a splendid example of what can be achieved for diabetes through imaginative campaigning. There, the four cochairs of the European Union Diabetes Working Group succeed in raising diabetes as an issue each month, and on 14 March 2012, the European Parliament approved the establishment of a strategic plan for diabetes in its 27 member states.

Quite apart from markedly greater national awareness activity, the resolution has spawned regional and European collaboration to support policy initiatives on diabetes. The European Coalition on Diabetes (a partnership of the EURopean Alliance for DIAbetes research [EURADIA], the Federation of European Nurses in Diabetes [FEND], Primary Care Diabetes Europe [PCDE], and the International Diabetes Federation [IDF] Europe) successfully promotes diabetes as an issue on a pan-European basis. FEND and IDF Europe have jointly produced their excellent and informative Policy Puzzle, a powerful tool for those engaged on advocacy for national plans and their implementation.

More broadly, the passing of Resolution 61/225 has provided a significant boost to international programs like Life for a Child, which does valiant work in poorer countries, providing insulin and essential medicines for children with insulindependent diabetes. Patient education—so vital in maintaining good glycemic control—has likewise benefited from educational initiatives like the IDF’s successful Diabetes Conversation Maps used in low- and middle-income countries.

It was always inevitable that the global campaigners for diabetes would not be content to stop at the UN resolution, and would be emboldened to think and act in an even more ambitious way. Influential figures like Sir George Alleyne in the Caribbean, an area where the high diabetes prevalence leads to thousands of limb amputations and premature deaths through end-stage renal failure, strokes, and heart attacks, pressed for further discussion and action at the global level to combat noncommunicable disease. The NCD Alliance (Non Communicable Disease Alliance)—a partnership of the IDF, theWorld Heart Federation, the Union for Cancer Control, and the International Union Against Tuberculosis and Lung Disease— came together in 2009 as a vehicle to campaign for action on noncommunicable disease. The UN resolution three years earlier had shown that the UN General Assembly could be persuaded of the importance of health, especially as a development issue, and skillful campaigning resulted in the UN High-Level Meeting on noncommunicable disease in September 2011 which approved a political statement on action to be taken by national governments in combating noncommunicable disease.

The decision at the WHA in May 2012 to adopt a target to reduce preventable deaths from noncommunicable disease by 25% is a further fruit of the process. The resolution, which the WHA adopted, aims to reach consensus on targets relating to the four main risk factors for noncommunicable disease: tobacco use, harmful use of alcohol, unhealthy diet, and physical inactivity. The IDF has played a notable part in the NCD Alliance in influencing governments to support a balanced set of targets that will tackle prevention via the risk factors, and treatment through availability of essential medicines.

The process of raising awareness of the destructive potential of diabetes as a precondition for global action, officially recognized in the UN resolution, is now an irreversible one. The strength of the arguments in support of global action is not disputed, but the solutions to the diabetes pandemic are neither easy nor inexpensive. The cost, however, of not acting is far greater. The IDF Diabetes Atlas, 5th edition, confirms that the prevalence of type 2 diabetes is rising in every country, every year, and the prevalence of impaired glucose tolerance (IGT) is likewise rising inexorably.

As the world now turns its attention to the post-2015 development framework as the successor to the Millennium Development Goals (which were expressly mentioned in the UN Resolution on Diabetes), it is of absolute importance that health is accorded the priority it merits in the new framework.

It is planned to convene a meeting of Parliamentary Champions for Diabetes at the next World Diabetes Congress in Melbourne in December 2013. Such an occasion will provide a further stimulus to global action on diabetes.

Despite the conclusive evidence about the need for tight glycemic control, we can still see that the rate of glycemic control remains poor globally: what else can be done to further increase the type 2 diabetes control rate? And what are the responsibilities of the different health care players, from doctors to governments?
No one can doubt that the rate of glycemic control is poor on a global basis. Given, however, the inadequacies of health budgets in so many of the low- and middle- income countries, it would be surprising if it were not so.

A number of initiatives and changes in practice could play an important part in improving glycemic control rates.

Earlier diagnosis is critical. Of the 35 million people in Europe with diabetes, it is estimated that 13 million are undiagnosed. Further, an estimated 42 million people have IGT, and, undetected and untreated, are already on the conveyor belt to a type 2 diagnosis. It is surely perverse that the remuneration systems in primary care provide no incentive for treatment to postpone the development and diagnosis of type 2 diabetes, but reward once formally diagnosed. Several important studies confirm the cost-effectiveness of early diagnosis and intervention. If more general screening cannot currently be afforded, there should be cardiovascular screening for the high-risk groups: theminority communities,womenof childbearingyears, people with a family history of diabetes, and those whose lifestyles evidently render them more susceptible to developing diabetes.

The recent European Diabetes Forum in Copenhagen, hosted by the Danish Presidency and Organization for Economic Cooperation and Development (OECD), heard from Prof Kamlesh Khunti who is leading the development of National Institute for Health and Clinical Excellence (NICE) guidance on screening for diabetes. He confirmed that screening for diabetes satisfies the World Health Organization (WHO) criteria for screening programs, highlighting effective self-assessment tests: Finn Risk developed by the Finnish Diabetes Association, and the online self-assessment developed by Diabetes UK which has already been used by over 133 000 people, with iPhone apps now being developed. Prof Khunti welcomed the UK’s National Health Service (NHS) Health Check, to which an HbA1c test is now being added.

Individualized care, with a personal care plan, would certainly make a positive difference, especially if sustained by proper patient education and reduced barriers to reimbursement, but no one should forget that we live in an age of austerity. As a nonclinician, I am not qualified to offer a view on polypharmacy, but who could contest that appropriate therapeutic intervention is essential to optimize health outcomes, and not just glycemic control.

The responsibility for improving the rates of glycemic control is broad. There should be a competent multidisciplinary team in primary and secondary care, appropriately skilled and with continuing professional education. The often overlooked comorbidity of depression in diabetes requires better access to specialist support. Government has a significant responsibility— right across government, rather than just the health “silo.”

There is a vital role for public health in the primary prevention of diabetes, through encouragement of physical exercise and healthier diets, as well as the practical means to do so— better urban design, like Rio de Janeiro; safe places to walk and cycle, like Copenhagen; the elimination of trans fats, championed by Mayor Bloomberg in New York; tobacco-free public places; the reduction of salt in line with current WHO recommendations where the UK is already leading the world. The person with diabetes also has a key responsibility to follow the advice of his/her health care team, and make whenever possible the necessary changes to lifestyle and diet.

All this assumes access to essential medicines and diagnostic support, yet we know that there are too many countries in the world where such access does not exist or cannot be guaranteed. Global advocacy is required here. There are the newer, more expensive medicines and therapies which can help to optimize control, but which may obviously be too costly for poorer countries. Impatient as we may be to see wholesale improvement, real progress will take years to achieve unless there is a seismic shift in the allocation of resources from communicable to noncommunicable disease, and determined action by national governments.

The terms evidence-based and perception-based seem to explain the gap between international recommendations for the management of type 2 diabetes and current practice. Do you agree with this analysis? If yes, what can be done to move health care professionals towards evidence-based management of type 2 diabetes?
There are excellent recommendations for the management of type 2 diabetes. In reality, those of the American Diabetes Association (ADA), the Canadian Diabetes Association (CDA), the IDF, and the European Association for the Study of Diabetes (EASD) are broadly in line. Evidencebased recommendations do not, however, necessarily change practice, particularly where there are human and financial resource challenges.

Again, there is no single solution, no magic bullet. Sound professional education will help to close the gap, as will the monitoring of the individual practices in primary care, and the publication of outcomes. The lever of remuneration can help to reward achievement of targets in HbA1c, blood pressure, lipid control, clinics for eye care and pregnancy, all of which matter in improving outcomes.

The role of private health insurance in many European countries is important in relation to evidence-based practice. The financial interests of private health insurers should surely encourage them to monitor evidence-based practice.

Cost is a major factor in chronic disease management: can we today define a cost-effective management strategy for type 2 diabetes that at the same time satisfies the criteria of international recommendations?
Cost is indeed a major factor in chronic disease management. While those who champion the interests of those with type 2 diabetes, like the IDF and its member associations, want the best possible care, that has to be qualified as the best affordable care. Many of the international recommendations assume a multidisciplinary care team which does not exist in many countries, while in others, the reality of care falls short of the desired standard. Too many health policy makers fail to appreciate that the costs of dealing with the complications of diabetes far outweigh the costs of trying to keep patients regularly checked, well controlled, and as healthy as possible.

There are, for example, excellent international guidelines on diabetic foot care developed by the International Working Group on the Diabetic Foot, and which have been translated into 26 different languages—surely a most welcome example of the spread of knowledge and best practice to improve care, particularly in low- and middle-income countries. The implementation of these guidelines would result in a cost-effective management strategy for good foot care, thereby reducing expensive amputations and the devastating effects upon the patient and his/her family, and the patient’s ability to earn a living and contribute to society. Yet, in too many countries, there is insufficient and inadequately trained staff, and a lack of the physical resources to provide the level of care recommended by the international guidelines. The pragmatic response has to be to encourage wherever possible the spread of knowledge and best practice, in the hope that training and training the trainers can help to bring up standards and prevent or mitigate avoidable complications.

We need to recognize the particular challenge in low- and middle- income countries. Unless chronic disease like diabetes is mainstreamed, there is a strong risk that it will be sidelined or ignored in favor of the infectious diseases which have had so much more attention by WHO and national governments.

Following our conversation, it seems clear that we are in a continuous battle with type 2 diabetes. Do you think someday we will be able to win this battle?
It has been depressing to note the constant growth in prevalence of type 2 diabetes as successive editions of the IDF Diabetes Atlas are published. At the time of the UN resolution campaign in 2006, 248 million people were estimated to have diabetes. Six years later, that number had risen by 50% to 371 million, with an even larger number estimated to have IGT. More shocking is the fact that half of those with diabetes remain undiagnosed and by definition untreated. Silently, but lethally, the disease attacks the macrovascular andmicrovascular systemswith life-threateningconsequences.

The principal challenge to global health policymakers is to break this cycle and constrain the growth of new cases by effective primary prevention. The causes of diabetes are wellknown, as are the effective therapies, even if the resource is not always there to afford them. The actions which need to be taken have been identified, but compete with limited resources and the compelling nature of infectiousdiseases which can spook the political leaders. A wholesale shift in planning, resource, and action is needed if the growth curve is to reduce or even flatten. Finland stands out as an example of where concerted action for the past ten years under their Development Program for the Prevention and Care of Diabetes (DEHKO) has actually slowed the rate of new cases of type 2 diabetes.

I greatly admire the devoted work of clinicians and their health care professional colleagues in providing care and treatment for those with all forms of diabetes. Their success in helping people with diabetes to optimize their health outcomes, allied to the impressive range of medicines for diabetes, has enabled many patients to live longer and have more fulfilled lives than once would have been the case.

Advances in research, particularly into the epigenetics of type 2 diabetes, and more personalized medicine, identifying appropriate therapies for the genetics of the individual, should enhance both life expectancy and quality of life for the person with diabetes. But the battle against type 2 will never be won unless and until the world’s leaders waken up to the ruinously expensive cost of this chronic disease, nearly US $500 billion per annum, and to the fact that many of the cases of type 2 diabetes can be prevented. Radical, imaginative, and ambitious public health action requires to be matched with primary prevention strategies which identify high-risk groups as early as possible and intervene aggressively. Health policy makers—globally, regionally, and nationally—will require inspired vision and steely determination if the tide is ever to be turned in the unending battle of type 2 diabetes. _

Keywords: noncommunicable disease; resource challenges; type 2 diabetes; UN Resolution on Diabetes