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Although guidelines for best practice in diabetes care are readily available, including the IDF Global Guideline on Type 2 Diabetes, and there are several frameworks to guide their implementation, it remains a challenge in all countries to bridge the gap between actual and optimal care.
Investments in education and change
One important part of any solution is education. Diabetes-specific education is required for healthcare personnel and people with diabetes; and in addition training is needed to help them integrate new knowledge and transform old practices. The latter is essential if clinical outcomes for people with diabetes are to be improved. It has been shown that without a purposeful, planned method of changing clinical or personal behaviour, very little happens. Investment must be made not only to ensure specialized diabetes education is accessible to healthcare personnel and people with diabetes but also to ensure both groups are trained in how to implement change 1 2 .
Ministries of Health and health administrators need to recognize and give support to the special healthcare needs of people with diabetes 1 and this includes designing health systems that facilitate best practice 2 . Providing good diabetes care for a population requires the coordination of the health systems across three levels. At the centre of all care is the person with diabetes, their family and their immediate carers. At the middle level is the community and healthcare organizations within which care is delivered. Effective functioning across the providers needed to care for people with diabetes requires supporting policy and financial frameworks. The World Health Organisation’s Innovative Care for Chronic Conditions Framework 3 provides guidance on the relationships between, and the contents of, these three levels. This framework was designed to be helpful within different resource settings, rich to poor, and has been developed with suggested methods of quality improvement to incrementally strengthen health systems for diabetes and other chronic diseases (see Beyond Access to Insulin).
Modern improvement processes have had positive results in many countries, including Canada, USA, United Kingdom, Ghana, Malawi, South Africa, Russia and Peru. A critical factor in their success is that they develop and implement solutions specific to the realities of their settings 2 . Reorganization of current resources or addition of new resources may be required to fill overt gaps in care, such as interdisciplinary teams specially trained to provide diabetes self-management education and follow-up or access to essential medicines packaged with education to support their use. The advancement of diabetes care relies not only on increased knowledge and behaviour change but also on using proven methods to advance health systems to support best practice 4 .
Self-management education and support
"Diabetes self-management education (DSME) and ongoing self-management support are critical components of effective diabetes care, and significant contributors to metabolic and psychological outcomes." 5 In many areas of the world people with diabetes cannot access this essential treatment. Interactive DSME is essential for people with diabetes to understand their condition, protect themselves from harm and make lifestyle changes to optimize their health. To design an accessible programme, funding needs to be provided for healthcare personnel with specialized training in DSME. Programmes must be locally affordable, offered in areas accessible to the target population, delivered at appropriate literacy levels and be culturally relevant. Diabetes self-management education and diabetes self-management support must be available and accessible for people with diabetes if optimal outcomes are to be achieved 5 .
People with diabetes have the right to understand their disease, make informed choices and receive care based on best practice. They must be part of the team that manages their condition.This can only be achieved if interdisciplinary teams and people with diabetes have the information and tools to make changes based on best practice and recognized improvement strategies are used to support meaningful system change.
Text box 4.4 Survey on diabetes education practices
A survey was carried out by the IDF Consultative Section on Diabetes Education in 2008 to gain a deeper appreciation for diabetes education practices worldwide and to provide a preliminary look at diabetes education in specific areas. The purpose of the survey was to capture responses from providers regarding practice setting, descriptions of diabetes teams, resources for diabetes education, community services and barriers to diabetes education.
The survey questionnaire was based on the structural and process standards for diabetes health education defined in the IDF’s International Consensus Standards for Diabetes Education 6 , which provide a benchmark against which the quality of DSME programmes can be evaluated.
The surveys were completed by healthcare professionals selected to participate in train-the-trainer sessions. The survey respondents represented healthcare institutions in the IDF African, European, Middle East and North African, North America and Caribbean, and South and Central American Regions.
Survey results
The survey results provide preliminary data on the status of diabetes education in the different regions. Forty-five out of 55 participants responded, giving a response rate of 82%. Respondents represented 26 countries in the five regions.
The results indicated that diabetes education was integrated into national diabetes programmes in two-thirds of the countries which had such a programme. The results also showed that diabetes education was practised in a variety of settings by many different healthcare providers. When asked about the most significant barriers to diabetes education, lack of resources in terms of the number of diabetes educators from the systems perspective was most often cited (see Figure 4.1). Another important barrier was that people with diabetes did not have time or support from employers to pursue diabetes education. The results also confirm that despite the presence of national diabetes programmes, people with diabetes may not have access to adequate education and care.
These data are limited by the sample chosen to participate and should not be considered statistically representative. However, the respondents do provide insight into their perception of diabetes education in their country. Despite the limitations of the survey, the results demonstrate a clear need for increased numbers of diabetes educators and support for diabetes self-management education for people with diabetes.
1: World Health Organization. Innovative Care for Chronic Conditions: Building Blocks for Action. Global Report. Geneva: World Health Organization; 2002. http://www.who.int/diabetesactiononline/about/icccreport/en/ 2: Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282 (15): 1458-1465. 3: Jordan EJE, Pruitt SD, Bengoa R, et al. Improving the quality of health care for chronic conditions. Quality and Safety in Health Care 2004; 13 (4): 299-305. 4: World Health Organization. 2008-2013 Action Plan for the Global Strategy for the prevention and control of non-communicable disease. Geneva: World Health Organization; 2008. www.who.int/nmh/Actionplan-PC-NCD-2008.pdf 5: Berwick DM. Lessons from developing nations on improving health care. BMJ 2004; 328 (7448): 1124-1129. 6: IDF Consultative Section on Diabetes Education International Consensus Standards for Diabetes Education 2003
The ultimate goal of diabetes therapy is to prevent diabetes complications, such as kidney and heart diseases, in order to improve quality of life and life expectancy. There is excellent evidence that the development of complications can be significantly reduced and their progress and impact limited once they have developed 1 .
Tailoring approaches to the person with diabetes
On a day to day basis most decisions that affect the risk of complications are made by people with diabetes themselves, not by health professionals. Therefore, structured diabetes education to empower people with diabetes, and their carers, to manage their condition is crucial (see Diabetes Education). Lifestyle measures such as eating healthily, maintaining a normal weight, regular physical activity, and not smoking are central to diabetes management, and could lead to improvements in blood glucose, lipids and blood pressure and a reduced risk of complications. In addition, medication often has an important role to play, particularly for the control of blood glucose, lipids and blood pressure.
The IDF Global Guideline for Type 2 Diabetes 1 provides an evidence-based framework for setting targets for glucose, blood pressure and lipids, and titrating treatment in order to achieve them. Oral glucose lowering medication is prescribed when lifestyle measures are insufficient to achieve blood glucose control. For most people metformin, which increases sensitivity to insulin, is the drug of first choice followed by a sulfonylurea, which stimulates insulin release. These drugs have been used in the management of diabetes for decades. If these drugs fail to control blood glucose then other options include thiazolidinediones (increase sensitivity to insulin) and alpha glucosidase inhibitors (decrease rate of glucose absorption from the gut). Newer options include the so-called GLP-1 (glucagon-like peptide) mimetics and DPP-4 (dipeptidyl peptidase 4) inhibitors, both of which increase insulin release. At this time experience with these newer agents is limited but they may have a more prominent role in the future.
Overtime the insulin-producing cells within the pancreas of people with type 2 diabetes deteriorate and eventually in most people insulin is needed as other measures are not sufficient to control blood glucose. Insulin analogues may offer some advantages, particularly with respect to hypoglycaemia and weight gain. The introduction of insulin requires close cooperation between the person with diabetes and health carers.
Tailoring approaches to the resources available
Diabetes care does not need to be expensive to be highly effective. In work carried out for the World Bank and World Health Organization 2 interventions for diabetes were classified into three levels based on an assessment of their feasibility and cost effectiveness in developing country settings. Interventions in the first level were found to be highly cost effective or even cost saving, and included moderate blood glucose and blood pressure control and foot care. Recognizing that most people with diabetes live in developing countries, the IDF Global Guideline provides guidance appropriate to three different levels of resource availability.
Screening for undetected diabetes
Type 2 diabetes has a long asymptomatic phase, which frequently goes undetected but during which diabetes complications are developing, and can be present in half or more people with diabetes at diagnosis. Thus, early detection and treatment could help reduce the burden of diabetes complications, and evidence suggests that earlier intensive treatment is indeed effective. However, issues such as who to screen, and what to do with those found to be at high risk of developing diabetes are unresolved. The solutions to these issues will differ between countries, dependent on factors that include the prevalence of undiagnosed diabetes, and the available healthcare resources.
The background paper, Challenges of Type 2 Diabetes, on which this summary is based is available in the Downloads section.
Box 4.3 Areas of individual diabetes care requiring regular review
Assessment topic
Self-care knowledge and beliefs
Lifestyle adaptation and wishes (including nutrition, physical activity, smoking)
Psychological status
Self-monitoring skills and equipment
Body weight trends
Blood glucose control
Blood pressure control
Blood lipid control
Cardiovascular risk
Neuropathy
Erectile dysfunction
Foot condition
Eyes
Kidneys
Pre-pregnancy advice (as appropriate)
Medication review
1: International Diabetes Federation. Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation; 2005. http://www.idf.org/node/1285?unode=B7462CCB-3A4C-472C-80E4-710074D74AD3 2: Narayan KV, Kanaya PZA, Williams D, et al. Diabetes: The Pandemic and Potential Solutions. In Jamison D, Breman J, Measham A, et al, editors. Disease control priorities in developing countries.Second Edition. World Bank/Oxford University Press; 2006. p591-604.
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The Prevention of Type 2 Diabetes
The Prevention of Type 2 Diabetes
There is excellent evidence that type 2 diabetes can be prevented, or at least its onset delayed, in individuals at high risk. Most of the evidence is from studies that have included people with IGT. Behavioural modification and pharmacological interventions have both been shown to be effective, and to reduce the onset of new diabetes by up to 60% or more. Overall the evidence suggests that lifestyle counselling to support behavioural change, such as losing weight (for those overweight), increasing physical activity, and eating a healthy diet is more effective than pharmacological interventions 1 . For example, for around every six people at high risk treated with lifestyle counselling one new case of diabetes will be prevented over five years, whereas to prevent one new case with an oral diabetes drug, around 11 people will need to be treated. There is evidence that the lower risk of diabetes from lifestyle counselling persists long after its discontinuation, with results from a study in China showing that the benefits were still apparent 20 years later.
Translating findings from prevention trials into the community
The challenge now is to translate the findings from the well resourced research studies into diabetes prevention initiatives that are affordable and feasible in both low- and high-income countries. The challenge includes finding the most efficient and cost-effective ways to identify people at high risk of developing diabetes, and then providing an effective intervention that is feasible and affordable within the local setting. While there are examples of such initiatives they have tended to be small and poorly evaluated. It is also clear that an initiative developed for one population or group may not be appropriate for another population or group. Thus, community initiatives aimed at the prevention of type 2 diabetes in individuals at high risk need to be developed and evaluated for the specific settings in which they will be used.
National efforts to prevent diabetes
It is acknowledged that while it is important to identify individuals at high risk of developing diabetes for preventive efforts, this will have a limited impact on the rate of diabetes at a national level. What are also needed are measures that reduce the risk across the whole population. Evidence suggests that relatively small improvements in nutrition, reductions in obesity and increases in physical activity if applied across a whole population can have a large impact on the rates of diabetes, and other chronic diseases that share the same risk factors (such as cardiovascular disease and many cancers). Much more attention needs to be given as to how to achieve such population-wide changes. The DEHKO project in Finland 2 provides an example of a comprehensive approach to diabetes prevention and management, which aims to improve nutrition and physical activity across the population, identify and provide individualized support to those at high risk of diabetes and assist with the early detection and management of those who actually have diabetes (see Box 4.2).
Cost effectiveness of prevention
Economic evaluations of approaches to identifying and providing preventive measures to people at high risk of diabetes generally suggest that these are cost effective. However, most evaluations contain many uncertainties and there is a need for further work to examine the cost effectiveness of interventions in everyday practice. There is an even greater challenge in assessing the cost effectiveness of population-wide measures.
The background paper, The Prevention of Type 2 Diabetes, on which this summary is based is available in the Downloads section.
Box 4.1 National Diabetes Prevention Plans 3
Government initiatives should include: • Advocacy —Supporting national associations and non-government organizations —Promoting the economic case for prevention • Community support —Providing education in schools on nutrition and physical activity —Promoting opportunities for physical activity through urban design (e.g. to encourage cycling and walking) —Supporting sports facilities for the general population • Fiscal and legislative —Examining food pricing, labelling and advertising —Enforcing environmental and infrastructure regulation (e.g. urban planning and transportation policy to enhance physical activity) • Engagement of private sector —Promoting health in the workplace —Ensuring healthy food policies in food industry • Media communication —Improving level of knowledge and motivation of the population (press, TV and radio)
Box 4.2 Examples of Prevention Programmes
Finland
The Development Programme for the Prevention and Care of Diabetes in Finland (DEHKO 2000–2010) 2 was the first national diabetes programme to implement strategies for the prevention of type 2 diabetes on a population-wide scale. It is now in its final phase after nearly a decade of activity, but there are further plans for the future. DEHKO is a programme that is widely watched for the comprehensiveness in which it has worked towards reducing the incidence of type 2 diabetes in a population and, at the same time, raising the quality of diabetes care.
The FIN-D2D Project (2003–2008) within DEHKO and the follow-up project to D2D are specifically tasked with the implementation of the prevention programme for type 2 diabetes. The FIN-D2D Project has also developed new models for prevention to be disseminated to all primary healthcare centres and occupational healthcare units in Finland. The effectiveness and the cost-effectiveness of these new prevention and care practices are being evaluated. The project is now working towards making the prevention of diabetes and cardiovascular disease part of healthcare routine. More information on DEHKO, which is coordinated by the Finnish Diabetes Association, is available at www.diabetes.fi.
Latin America
A project to reduce the burden of type 2 diabetes by education and lifestyle interventions in people at high risk is currently underway in Latin America. The LATIN_PLAN project will implement an intervention programme at primary healthcare level in Argentina, Brazil, Colombia, Ecuador, Peru, Uruguay and Venezuela.
The project is based on current evidence and best practice in the prevention of type 2 diabetes, especially those found in the European diabetes prevention projects (DE-PLAN and IMAGE projects). It also will develop and implement a curriculum for training diabetes prevention managers in Latin America, who will provide a basis for long-term activities at population level, and guarantee sustainability and continuity at the community level. The project is coordinated by the Research Unit of the Hospital Universitario La Paz in Madrid, Spain. More information is available from de_plan@ceiis.e.telefonica.net.
1: Gillies CL, Abrams KR, Lambert PC, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ 2007; 334 (7588): 299. 2: Finnish Diabetes Association. Development Programme for the Prevention and Care of Diabetes in Finland DEHKO 2000-2010. 2009. http://www.diabetes.fi/sivu.php?artikkeli_id=831 3: Alberti KG, Zimmet P, Shaw J. International Diabetes Federation: a consensus on Type 2 diabetes prevention. Diabet Med 2007; 24 (5): 451-463.
Type 1 diabetes is rapidly increasing in children and adolescents in many countries, and evidence suggests that in a growing number of countries type 2 diabetes is now also being diagnosed in childhood.
Challenges of type 1 diabetes in children
Type 1 diabetes is one of the most common endocrine and metabolic conditions in childhood, and incidence is rapidly increasing especially among the youngest children. Insulin treatment is life-saving and lifelong. Self-discipline and adherence to a balanced diet are necessary if the disease is to be well managed. In many countries, especially in less privileged families, access to self-care tools and also to insulin is limited and this may lead to severe handicap and early death in children with diabetes.
Many children and adolescents find it difficult to cope emotionally with their condition. Diabetes causes them embarrassment, results in discrimination and limits social relationships. It may impact on school performance and family functioning. The financial burden may be aggravated by the costs of treatment and monitoring equipment.
Trends in incidence
Two international collaborative projects, the Diabetes Mondiale study (DiaMond) 1 and the Europe and Diabetes study (EURODIAB) 2 have been instrumental in monitoring trends in incidence through the establishment of population-based regional or national registries using standardized definitions, data collection forms and methods for validation.
The incidence of childhood onset type 1 diabetes is increasing in many countries in the world, at least in the under 15-year age group. There are strong indications of geographic differences in trends but the overall annual increase is estimated to be around 3%. There is evidence that incidence is increasing more steeply in some of the low prevalence countries such as those in central and eastern Europe. Moreover, several European studies have suggested that, in relative terms, increases are greatest in young children. There are clear indications that similar trends exist in many other parts of the world, but in sub-Saharan Africa incidence data are sparse or non–existent. Special efforts must be made to collect data, especially in those countries where diagnosis may be missed or neglected and, as a result, children die because they do not receive insulin.
Prevalence of type 1 diabetes in children
It is estimated that annually some 76,000 children aged under 15 years develop type 1 diabetes worldwide. Of the estimated 480,000 children with type 1 diabetes, 24% come from the South-East Asian Region, but the European Region, where the most reliable and up-to-date estimates of incidence are available, comes a close second (23%) (see Figure 2.4).
The continued mapping of global trends in incidence and prevalence of type 1 diabetes in all age groups, through use of data from existing and new registries, is thus important, and in conjunction with other scientific research may provide a logical basis for intervention studies and future primary prevention strategies which must be the ultimate goal.
The background paper, Diabetes in the Young, and country by country estimates on which the summary on type 1 diabetes in the young is based are available in the Downloads section.
Type 2 diabetes in the young
Type 2 diabetes in children and adolescents is on the increase in all countries, whether poor or rich. As with type 1 diabetes, many children with type 2 diabetes risk developing complications at an early age, which would place a significant burden on the family and society. There is growing recognition that type 2 diabetes in the young is becoming a global public health issue with a potentially serious health outcome 3 , in spite of the paucity of information in this area. A review of studies on type 2 diabetes in the young is available in the Diabetes Atlas, third edition 4 .
Map 2.4 New cases of type 1 diabetes in children, 0-14 years (cases per 100,000 aged 0-14 years per year), 2010
1: D.I.A.M.O.N.D. Project Group. Incidence and trends of childhood Type 1 diabetes worldwide 1990-1999. Diabet Med 2006; 23 (8): 857-866. 2: Patterson CC, Dahlquist GG, Gyürüs E, et al. Incidence trends for childhood type 1 diabetes in Europe during 1989-2003 and predicted new cases 2005-20: a multicentre prospective registration study. Lancet 2009; 373 (9680): 2027-2033. 3: Fagot-Campagna A, Narayan KM, Imperatore G. Type 2 diabetes in children. BMJ 2001; 322 (7283): 377-378. 4: International Diabetes Federation. The Diabetes Atlas.Third Edition. Brussels: International Diabetes Federation; 2006.
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Diabetes and Impaired Glucose Tolerance
Diabetes and Impaired Glucose Tolerance
Diabetes mellitus (DM) is now one of the most common non-communicable diseases globally. It is the fourth or fifth leading cause of death in most high-income countries and there is substantial evidence that it is epidemic in many economically developing and newly industrialized nations. Complications from diabetes, such as coronary artery and peripheral vascular disease, stroke, diabetic neuropathy, amputations, renal failure and blindness are resulting in increasing disability, reduced life expectancy and enormous health costs for virtually every society. Diabetes is undoubtedly one of the most challenging health problems in the 21st century.
The number of studies describing the epidemiology of diabetes over the last 20 years has been extraordinary. It is now recognized that it is the low- and middle income countries (LMCs) that face the greatest burden of diabetes. However, many governments and public health planners still remain largely unaware of the current magnitude, or, more importantly, the future potential for increases in diabetes and its serious complications in their own countries.
It has been a consistent finding of population-based diabetes studies that a substantial proportion of all people found to have diabetes had not been previously diagnosed. The uncovering of new cases when mass blood testing is undertaken is primarily because of the lack of symptoms associated with the early years of type 2 diabetes, meaning that those with diabetes may be unaware of their condition and therefore not seek medical attention for it.
In addition to diabetes, the condition of impaired glucose tolerance also constitutes a major public health problem, both because of its association with diabetes incidence and its own association with an increased risk of cardiovascular disease.
In this edition of the IDFDiabetes Atlas, the prevalence of diabetes mellitus and IGT has been estimated for each country for the years 2010 and 2030. Data are provided for 216 countries and territories, which have been allocated into one of the seven IDF regions: Africa (AFR), Europe (EUR), Middle East and North Africa (MENA), North America and Caribbean (NAC), South and Central America (SACA), South-East Asia (SEA), and the Western Pacific (WP).
The data presented for adults are for types 1 and 2 diabetes combined, and IGT. Only adults aged from 20 to 79 years are considered because the majority of all people who have diabetes and IGT are adults. Estimates for type 1 diabetes in children and adolescents are presented in the section on Diabetes in the Young.
Two sets of prevalence estimates have been provided in this report: the national, regional or global prevalence (the crude prevalence) and the comparative prevalence. The national, regional or global prevalence indicates the percentage of a particular population that has diabetes. It is appropriate for assessing the burden of diabetes for each country or region. The comparative prevalence is used for making comparisons between countries or regions. It has been calculated by assuming that every country or region has the same age profile (the age profile of the world population has been used). This reduces the effect of the differences of age between countries or regions, and makes this figure approriate for making comparisons.
The data presented here should be interpreted cautiously as general indicators of diabetes frequency, and the estimates will need to be revised as new and better epidemiological information becomes available. Comparison of country, regional, and even global prevalence from one report to the next should be performed with extreme caution. Large changes in the prevalence or numbers of people with diabetes from one edition of the IDF Diabetes Atlas to another are usually due to the use of a more recent study rather than a change in the profile of diabetes within that country. Data sources for this edition include 34 new studies. Thus, the inclusion of recent, and more reliable research brings us closer to the actual rates of diabetes, but these limitations need to be always considered. The key purpose of reports such as these is to stimulate action in the form of preventive and management programmes, as well as further research.
The background paper, Diabetes and Impaired Glucose Tolerance, and country by country estimates on which this summary is based are available in the Downloads section.
Diabetes is recognized as a group of heterogeneous disorders with the common elements of hyperglycaemia and glucoseinsulin deficiency, impaired effectiveness of insulin action, or both intolerance, due to 1 . Diabetes mellitus is classified on the basis of aetiology and clinical presentation of the disorder into four types.
Type 1 diabetes is sometimes called insulin-dependent, immune-mediated or juvenile-onset diabetes. It is caused by destruction of the insulin-producing cells of the pancreas, typically due to an auto-immune reaction, where they are attacked by the body's defense system. The beta cells of the pancreas therefore produce little or no insulin, the hormone that allows glucose to enter body cells. The reason why this occurs is not fully understood.
The disease can affect people of any age, but usually occurs in children or young adults. Type 1 diabetes is one of the most common endocrine and metabolic conditions in childhood. People with type 1 diabetes need injections of insulin every day in order to control the levels of glucose in their blood. Without insulin, people with type 1 diabetes will die.
The onset of type 1 diabetes is often sudden and dramatic and can include symptoms such as:
abnormal thirst and a dry mouth
frequent urination
extreme tiredness/lack of energy
constant hunger
sudden weight loss
slow-healing wounds
recurrent infections
blurred vision
The incidence of type 1 diabetes is increasing, the reasons for which are unclear but are likely to be mainly due to changes in environmental risk factors. Environmental risk factors, increased height and weight development, increased maternal age at delivery, and possibly some aspects of diet and exposure to some viral infections may initiate autoimmunity or accelerate an already ongoing beta cell destruction.
Type 2 diabetes
Type 2 diabetes is characterized by insulin resistance and relative insulin deficiency, either of which may be present at the time that diabetes becomes clinically manifest. The diagnosis of type 2 diabetes usually occurs after the age of 40 years but could occur earlier, especially in populations with high diabetes prevalence. There are increasing reports of children developing type 2 diabetes. Type 2 diabetes can remain undetected, i.e. asymptomatic, for many years and the diagnosis is often made from associated complications or incidentally through an abnormal blood or urine glucose test.
Type 2 diabetes is often, but not always, associated with obesity, which itself can cause insulin resistance and lead to elevated blood glucose levels. It is strongly familial, but major susceptibility genes have not yet been identified. There are several possible factors in the development of type 2 diabetes. These include:
Obesity, diet and physical inactivity
Increasing age
Insulin resistance
Family history of diabetes
Less than optimum intrauterine environment
Ethnicity
In contrast to type 1 diabetes, people with type 2 diabetes are not dependent on exogenous insulin and are not ketosis-prone, but may require insulin for control of hyperglycaemia if this is not achieved with diet alone or with oral hypoglycaemic agents.
The rising prevalence of type 2 diabetes is associated with rapid cultural and social changes, ageing populations, increasing urbanization, dietary changes, reduced physical activity and other unhealthy lifestyle and behavioural patterns 2 .
Gestational diabetes
Gestational diabetes mellitus (GDM) is a glucose intolerance of varying degrees of severity which starts or is first recognized during pregnancy. The definition applies regardless of whether insulin is used for treatment or if the condition persists after pregnancy.
Maintaining control of blood glucose levels significantly reduces the risk to the baby as an increased maternal glucose level could result in complications in the baby including large size at birth, birth trauma, hypoglycaemia and jaundice. Women who have had GDM have an increased risk of developing type 2 diabetes in later years. GDM is also associated with increased risk of obesity and abnormal glucose metabolism during childhood and adult life in the offspring.
In virtually every high-income country, diabetes is ranked among the leading causes of blindness, renal failure and lower limb amputation. Diabetes is also now one of the leading causes of death, largely because of a markedly increased risk of coronary heart disease and stroke (cardiovascular disease). In addition to the human suffering that diabetes-related complications cause, to those with diabetes but also to their carers, their economic costs are huge. Costs include those for healthcare, loss of earnings, and economic costs to the wider society in loss of productivity and associated lost opportunities for economic development.
Chronic elevation of blood glucose, even when no symptoms are present to alert the individual to the presence of diabetes, will eventually lead to tissue damage, with consequent, and often serious, disease. Whilst evidence of tissue damage can be found in many organ systems, it is the kidneys, eyes, peripheral nerves and vascular tree, which manifest the most significant, and sometimes fatal, diabetes complications (see Figure 1.1).
Unsatisfactory metabolic control in children can result in stunted growth, and exposure to both severe hypoglycaemia and chronic hyperglycaemia can adversely affect neurological development. Children are more sensitive to a lack of insulin than adults and are at a higher risk of a rapid and dramatic development of diabetic ketoacidosis (diabetic coma).
The mechanism by which diabetes leads to these complications is complex, and not yet fully understood, but involves the direct toxic effects of high glucose levels, along with the impact of elevated blood pressure, abnormal lipid levels and both functional and structural abnormalities of small blood vessels.
Cardiovascular disease is the major cause of death in diabetes, accounting in most populations for 50% or more of all diabetes fatalities, and much disability. The kinds of CVD that accompany diabetes include angina, myocardial infarction (heart attack), stroke, peripheral artery disease, and congestive heart failure (CHF).
Nephropathy
Diabetes is an increasingly important cause of renal failure, and indeed has now become the single most common cause of end stage renal disease, i.e. that which requires either dialysis or kidney transplantation, in the USAhttp://www.usrds.org/adr.htm] fade=[on] fadespeed=[0.05]"> 3 , and in other countries.
Neuropathy
When blood glucose and blood pressure are not controlled, diabetes can harm the nerves. Problems with digestion and urination, impotence, and many other functions can result, but the most commonly affected area is the feet and legs. Nerve damage in these areas is called peripheral neuropathy and could manifest in many ways including loss of feeling in the feet and toes. Loss of feeling is a particular risk because it can allow foot injuries to escape notice and treatment, leading to major infections and amputation.
Amputation Through effects on peripheral nerves and arteries, diabetes can lead to foot ulceration, infection and the need for amputation. People with diabetes carry a risk of amputation that may be more than 25 times greater than that seen in those without diabetes 4 .
Retinopathy Diabetes can harm sight and cause blindness in several ways. The most common cause of blindness in diabetes is macular oedema, caused by fluid build-up behind the retina of the eye. A more common complication is background and proliferative retinopathy, which can cause blindness as a result of repeated haemorrhages at the back of the eye. Diabetes also increases the risk of cataracts and glaucoma.
Impaired glucose tolerance
Impaired glucose tolerance (IGT) is an asymptomatic condition defined by elevated (though not diabetic) levels of blood glucose two hours after a 75g oral glucose challenge. Along with impaired fasting glucose (IFG), it is now recognized as being a stage in the transition from normality to diabetes. Not surprisingly, IGT shares many characteristics with type 2 diabetes, being associated with obesity, advancing age, insulin resistance and an insulin secretory defect.
Insulin
Insulin is the internal secretion of the pancreas formed by groups of cells called the islets of Langerhans. It is the hormone needed to enable glucose to enter the cells and provide energy. Insulin is also important in keeping blood glucose levels within acceptable limits.
Insulin is injected into the body by people with type 1 diabetes in whom the cells that produce insulin have been destroyed. This is the most common form of diabetes in children and young adults, and they depend on insulin for survival. Insulin may also be used by people with type 2 diabetes. In type 2 diabetes, the body needs more insulin than it can produce.
Since the landmark discovery of insulin by Frederick Banting and Charles Best in 1921, huge steps forward have been made in research and development in creating genetically engineered human insulin. Until relatively recently insulin was derived from a limited resource of the pancreas of cattle and pigs.
1: Harris M, Zimmet P. Classification of diabetes mellitus and other categories of glucose intolerance. In Alberti K, Zimmet P, Defronzo R, editors. International Textbook of Diabetes Mellitus.Second Edition. Chichester: John Wiley and Sons Ltd; 1997. p9-23. 2: World Health Organization. Prevention of diabetes mellitus. Report of a WHO Study Group. Geneva: World Health Organization; 1994. No. 844. 3: United States Renal Data System. Annual Data Report. 2002. http://www.usrds.org/adr.htm 4: Davis TM, Stratton IM, Fox CJ, et al. U.K. Prospective Diabetes Study 22. Effect of age at diagnosis on diabetic tissue damage during the first 6 years of NIDDM. Diabetes Care 1997; 20 (9): 1435-1441.
SHORTFACTS
What is diabetes?
Diabetes is an illness which occurs as a result of problems with the production and supply of insulin in the body.
Most of the food we eat is turned into glucose, a form of sugar. We use glucose as a source of energy to provide power for our muscles and other tissues. Our bodies transport glucose in our blood. In order for our muscles and other tissues to absorb glucose from our blood, we need a hormone called insulin. Without insulin, our bodies cannot obtain the necessary energy from our food.
Insulin is made in a large gland behind the stomach called the pancreas. It is released by cells called beta cells. When a person has diabetes, either their pancreas does not produce the insulin they need, or their body cannot use its own insulin effectively.
As a result, people with diabetes cannot use enough of the glucose in the food they eat. This leads to the amount of glucose in the blood increasing. This high level of glucose or "high blood sugar" is called hyperglycaemia. High levels of glucose in the blood can lead to serious complications.
At present there is no cure for diabetes.
The International Diabetes Federation estimates that more than 245 million people around the world have diabetes. This total is expected to rise to 380 million within 20 years. Each year a further 7 million people develop diabetes.
'Het verlangen om medicijnen in te nemen is misschien het belangrijkste verschilpunt tussen de mens en het dier.' (Sir William Osler (1849-1919))
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The background paper, Diabetes in the Young, and country by country estimates on which the summary on type 1 diabetes in the young is based are available in the 
