Experts outline action plan to address global diabetes epidemic
Click Here to Manage Email Alerts
The growing diabetes epidemic requires urgent actions to reduce disease burden worldwide, including new, team-based approaches and data-driven integrated care, according to an action plan published in The Lancet.
“Despite the wealth of knowledge amassed by the scientific community on how to diagnose and treat diabetes, there is a lack of action in translating that knowledge to practice to benefit people with diabetes,” Juliana C.N. Chan, MB, ChB, MD, FRCP, professor of medicine and therapeutics and founding director of the Hong Kong Institute of Diabetes and Obesity at the Chinese University of Hong Kong, told Healio. “In 2016, 44 global experts in the field of epidemiology, public health, clinical care and health economics from five continents were invited by The Lancet to synthesize new evidence and propose action plans to close the gaps in care, prevention, professional knowledge and data. For the last 4 years, these experts have performed an extensive review of available data to highlight the socio-biomedical nature of this epidemic, which calls for a societal-personalized solution by transforming the way diabetes care is delivered. This means early prevention and promoting self-management with ongoing data collection for decision-making.”
Data-driven care
The Lancet Commission on Diabetes highlighted the utility of structured data collection through quality improvement programs to improve care standards and monitor clinical outcomes. The action plan was published in advance of World Diabetes Day on Nov. 14.
“Where such structured data were available, we were able to show the decreasing trends of incidence of diabetes and its complications,” the researchers wrote. “By use of these databases, we also observed emerging trends and unmet needs in subpopulations. Apart from multiple morbidities, including frailty, depression and cognitive decline associated with aging and long disease duration, the high rates of cardiovascular-renal events and death in patients with young-onset diabetes associated with multiple causes and phenotypes reemphasize the importance of structured risk assessment and management to detect and intervene early.”
The researchers noted that social and care disparities are “major health care barriers” in many subpopulations globally, notably migrant, minority ethnicity and underserved populations in many high-income countries.
“Given the life course of diabetes, early prevention of obesity by promoting maternal and child health holds promise in curbing the epidemic of diabetes and other noncommunicable diseases that can go beyond our current generation,” the researchers wrote. “To implement what we have learned and created to benefit individuals with or at risk of having diabetes, and to make our health care sustainable, there is an urgent need to reorganize care by training nonphysician personnel and applying a team approach, assisted by information and communications technology, to deliver data-driven integrated care to empower self-management and reduce multiple risk factors.”
To achieve that goal, the researchers wrote that alignment among payers, planners and providers are needed to address the needs of patients.
The commission summarized the best evidence for effectively managing diabetes, which relies on six components:
- For patients with obesity, losing 15 kg of body weight or more can induce remission of type 2 diabetes for up to 2 years.
- Lowering HbA1c by 0.9%, systolic blood pressure by 10 mm Hg, LDL cholesterol by 39 mg/dL, or a combination of all three, can independently reduce the risk for cardiovascular disease, all-cause death, or both, by 10% to 20% in adults with type 2 diabetes.
- Mitigating multiple risk factors, including by use of statins and renin-angiotensin system inhibitors, can reduce the risk for CV or renal events by 20% to 40% in individuals with or at risk for diabetes.
- Using SGLT2 inhibitors and GLP-1 receptor agonists can reduce CV or renal events and death rates by up to 40%, independent of their effect on lowering blood glucose concentration.
- Using data-driven, team-based integrated care through the reorganization of health care provision can reduce CV and all-cause death among adults with type 2 diabetes by 20% to 60%.
- Implementing a structured lifestyle intervention and use of metformin can each prevent or delay type 2 diabetes in individuals with impaired glucose tolerance by 30% to 50%.
Increased COVID-19 risks
Chan said the COVID-19 pandemic has exposed the vulnerability of people with diabetes during emergencies in addition to their high risk for multiple disabilities and premature death.
“In U.K., 5% of people have diabetes while 30% of people who died from COVID-19 have diabetes,” Chan told Healio. “People with diabetes have at least a twofold higher risk for developing severe complications from COVID-19, including ICU admission, mechanical ventilation and premature death, especially among those with poorly controlled diabetes, multiple complications and social disadvantages.”
Chan said diabetes and COVID-19 are strongly related to interactions between the environment and human behavior, which can collapse the health care system and economy if the conditions are not detected early and treated promptly with ongoing surveillance.
“To achieve this, government leadership, scientific evidence and community mobilization are needed to achieve positive impacts,” Chan said.
In most countries, the growth in health care expenditures outpaces gross domestic product growth and now stands at $10 trillion, with more than 10% spent on diabetes, mainly on complications, Chan said. Most of the expenditures are spent in high-income countries with very little investment in lower- to middle-income countries, she said.
“By ensuring people with diabetes have continuing access to medications that reduce BP, blood glucose and blood cholesterol, including statins, together with a support system to ensure that these patients are detected and treated early, we can reduce the risk of heart disease, stroke, kidney failure and death by 20% to 60%,” Chan said. “In this report, we propose transforming diabetes care by changing the workflow and training nonmedical staff to collect data systematically and use the data to stratify risk, empower patients and inform decision-making, such as drug prescription. These data can also be used for quality assurance and surveillance purposes, which are needed to inform practices and policies.”
Building infrastructure and training nonmedical people in the community can reduce population risk and better identify high-risk individuals for structured lifestyle modification, including use of medications to prevent the onset of diabetes, Chan said.
“On a long-term basis, there is a need to use societal measures to reduce poverty, protect the environment and improve literacy to reduce the burden of diabetes and noncommunicable diseases,” Chan said. “To this end, the governments, health care payers, planners and philanthropists must invest in these strategies to avoid unsustainable health care costs in the future.”
For more information:
Juliana C.N. Chan, MB, ChB, MD, FRCP, can be reached at jchan@cuhk.edu.hk.
Perspective
Back to Top
Robert H. Eckel, MD
This is a well done analysis by an impressive group of researchers. The use of data-driven care is important — this puts the emphasis on an integrated approach to health care, which includes lifestyle management, a greater focus on nutrition quality, more emphasis on physical activity, foot care, and insulin management, among other factors. This is a broad statement, and comprehensive care is good to reduce risk for diabetes complications. However, I have reservations about some of the six components for effectively managing diabetes cited in the report. Sustained weight reduction for individuals with obesity by 15 kg or more would be wonderful, and I am not skeptical of the value. That said, getting people to lose weight is difficult to begin with; keeping the weight off for 2 years is another dilemma. For the person living with diabetes, 15 kg of weight loss is unrealistic. We know from multiple studies conducted around the world that people who lose 5% of their body weight through lifestyle can prevent type 2 diabetes.
Similarly, stating that reducing HbA1c by 0.9%, systolic blood pressure by 10 mm Hg, LDL cholesterol by 39 mg/dL, or a combination of all three, can independently reduce the risk for CVD, all-cause death, or both, by 10% to 20% is a nice recommendation and a direction we need to head for all people living with diabetes. However, the prediction for these outcomes is not evidence-based.
I agree that the use of SGLT2 inhibitors and GLP-1 receptor agonists can reduce CV or renal events and death rates by up to 40%. These drugs appear to work independent of lowering blood glucose, and ultimately, the blood glucose lowering capability of these drugs does not relate to the benefit.
The intent of these recommendations is good; however, the reality of meeting such goals remains a global challenge.
Collapse
Read more about
Click Here to Manage Email Alerts