Diabetes Voice

G l o b a l p e r s p e c t i v e s o n d i a b e t e s

A message from India

The IDF World

Diabetes Day issue

v o l u m e 5 7 – d e c e m b e r 2 0 1 2

DiabetesVoice

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DiabetesVoiceDecember 2012 • Volume 57 • Issue 4 3

International Diabetes FederationPromoting diabetes care, prevention and a cure worldwide

Diabetes Voice is published quarterly and is freely available online at www.diabetesvoice.org. This publication is also available in French and Spanish.

Editor-in-Chief: Stephanie A Amiel, UK Managing Editor: Olivier Jacqmain, [email protected] Editor: Tim Nolan, [email protected] Advisory group: Pablo Aschner (Colombia), Ruth Colagiuri (Australia), Patricia Fokumlah (Cameroon), Attila József (Hungary), Viswanathan Mohan (India). Layout and printing: Ex Nihilo, Belgium, www.exnihilo.be

All correspondence and advertising enquiries should be addressed to the Managing Editor: International Diabetes Federation, Chaussée de La Hulpe 166, 1170 Brussels, Belgium Phone: +32-2-5431626 – Fax: +32-2-5385114 – [email protected]

© International Diabetes Federation, 2012 – All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permis-sion of the International Diabetes Federation (IDF). Requests to reproduce or translate IDF publications should be addressed to the IDF Communications Unit, Chaussée de la Hulpe 166, B-1170 Brussels, by fax +32-2-5385114, or by e-mail at [email protected].

The information in this magazine is for information purposes only. IDF makes no representations or warranties about the accuracy and reliability of any content in the magazine. Any opinions expressed are those of their authors, and do not necessarily represent the views of IDF. IDF shall not be liable for any loss or damage in connection with your use of this magazine. Through this magazine, you may link to third-party websites, which are not under IDF’s control. The inclusion of such links does not imply a recommendation or an endorsement by IDF of any material, information, products and services advertised on third-party websites, and IDF disclaims any liability with regard to your access of such linked websites and use of any products or services advertised there. While some information in Diabetes Voice is about medical issues, it is not medical advice and should not be construed as such.

ISSN: 1437-4064

Contents

d i a b e t e s v i e w s 4

n e w s i n b r i e f 6

v o i c e o f t H e Y o U n G l e a d e r saccess to good care – just one of many, many challenges 9 Sana Ajmal

t H e G l o b a l c a M p a i G ntracking the global epidemic – new estimates from the idf diabetes atlas Update for 2012 12Leonor Guariguata

awareness in action: a look back at world diabetes day 2012 16Lorenzo Piemonte and Isabella Platon

diabetes advocacy in 2012 – highlights, achievements and progress 20Katie Dain

H e a l t H d e l i v e r Ythe genetics behind type 2 diabetes – lessons from Gwas 24 Timothy M Frayling

lessons from the Hadza: poor diets wreck efforts to prevent obesity and diabetes 26Herman Pontzer

environmental factors in metabolic diseases – the invisible threat of food contaminants 30Jérôme Ruzzin and Anders Goksøyr

prescribing physical exercise – focus on a combined approach 34César Oliveira

c l i n i c a l c a r edepression and diabetes – a significant challenge for people with diabetes and healthcare providers 38Nia Coupe, Charlotte Garrett, Linda Gask

Managing diabetes during fasting – a focus on buddhist lent 42Tint Swe Latt and Sanjay Kalra

d i a b e t e s i n s o c i e t Ya ‘parma campaign’ for africa – a 42,000 km initiative against ketoacidosis 46Maurizio Vanelli and Cesare Beghi

the meteoric rise and rise of #gbdoc – a personal experience of what social media can do for peer support 49Paul Buchanan

DiabetesVoice December 2012 • Volume 57 • Issue 44

Diabetes views

Jean claude Mbanya is idf president for

the period 2009 to 2012. He is professor

of endocrinology at the University of

Yaounde, cameroon, and chief of the

endocrinology and Metabolic diseases

Unit at the Hospital central in Yaounde.

Just six years ago, it would have seemed too bad to be true. At the end of 2006, as I received the mandate from the global diabetes community – assembled at the IDF General Council meeting in Cape Town – to take up the role of IDF President-elect, some 246 million people were living with diabetes worldwide. By the time I took over the mantle of leader-ship in Montreal in 2009, that number had risen to 285 million. Today, according to the latest IDF estimates, released recently in an update of the IDF Diabetes Atlas, 371 million people worldwide have diabetes – and there are half as many again who are unaware that they have the disease (see Leonor Guariguata’s report on page 12 of this issue).

Let there be no confusion: the world is in the grip of a health emergency stoked by chronic non-communicable diseases. Without concerted global action to tackle the socioeconomic determinants, as well as the envi-ronmental factors, that are exacerbating the crisis in health worldwide, and particularly in our poorest communities, the epidemic will get a lot worse before it gets better – a staggering half a billion people will be affected by 2030.

Yet as I prepare to entrust the baton of Presidency to the very safe hands of Sir Michael Hirst (who will take office on the first day of 2013), and despite the deepening health crisis, I look back on a period of outstanding achievements for diabetes. Thanks largely to the efforts of IDF throughout the past triennium to realize our mission – to improve care, prevention and a cure for diabetes worldwide – diabetes has a new place in the world. The seeds of change sewn by the Federation – the messages that we broadcast to the world through the mass media and via global campaigns like World Diabetes Day; the knowledge and ideas we share in the pages of this magazine and on our website and through social media; the ever-growing, multi-disciplinary network of diabetes experts (with and without the con-dition) brought together by the IDF World Diabetes Congress; the tireless advocacy work and the countless speeches delivered at the highest political fora – are all bearing fruit.

Last year’s UN High-Level Meeting on NCDs transformed the global health and development agenda. When UN Member States adopted the Political Declaration that resulted from that summit, they agreed to a set of commitments that will catalyze the coordinated all-of-societies response the world badly needs. In May this year, the World Health Assembly adopted an historic target: a 25% reduction by 2025 in the number of people who die early from chronic disease, including diabetes. And just weeks ago, IDF and the diabetes community at large were able to celebrate a crucial victory when the Member States adopted a comprehensive set of targets to ensure this goal is reached (see the News in brief item on page 7). A founding member of, and prominent force within, the NCD Alliance, IDF played a leading role in the complex processes, the many rounds of negotiations and consultations, which led up to these game-changing decisions. The targets have marked a new era of action and accountability

for diabetes. However, this is only the beginning of a long and ardu-ous work that is ahead of us. We must hold governments accountable to their commitments, support them to implement the UN Political

Declaration, and drive progress towards these targets. (Please do not miss Katie Dain’s article with the back-story on

IDF’s advocacy work over the past year and into the future.)

At the close of the triennium, it is my duty, my honour and my pleasure to recognize the people who helped to make this a momentous period for diabetes. IDF Member Associations have been instrumental to enable us to take grassroots community action to a global platform. IDF’s dedicated personnel have worked tirelessly and efficiently throughout this period to ensure that the Federation played a leading role in global advocacy for diabetes. I salute the IDF Board and the Federation’s network of expert volunteers around the world, who drive our taskforces, inform our execu-tive office, and who choose to spend their free time striving to improve life for people with diabetes – and protect those at risk.

The editor-in-chief of Diabetes Voice for the past three years is foremost among this list of distinguished colleagues with an apparently insatiable appetite for hard work. Under Stephanie Amiel’s skilful leadership, this publication has enjoyed a very successful period, with its global readership growing across the regions and in all languages. Professor Amiel personi-fies the selflessness and esprit de corps that is the beating heart of IDF.

Of one thing we can be certain as IDF prepares to navigate the uncharted waters of 2013 and beyond: exciting times lay ahead. We have made great advances but we have a long and arduous journey ahead. We have started work in the next milestone in our sights. Diabetes and NCDs are absent from the current Millennium Development Goals (MDGs), and this has been an obstacle to establishing political priority and resources needed for diabetes and NCDs. The MDGs end in 2015 and as this deadline draws closer, the UN has launched an official process to define the post-2015 development agenda. The UN has started a ‘global conversation’ on what the world’s priorities are for after 2015. IDF and the NCD Alliance are leading a campaign to ensure diabetes and NCDs are at the heart of the future development agenda.

Diabetes needs the money pledged by governments to eradicate this major threat to socioeconomic development. Diabetes needs a grass-roots movement for a disease that takes a life every seven seconds. There is nothing for it: we must redouble our efforts!

I will remain united with you for diabetes.

A time to every purpose


at four very different factors that contribute to the diabetes epidemic – different but interacting. We can ignore none of them if we are to win our war.

In the last three years, we have tried to represent as many diabetes voices as we could. In the staggering rise and rise of type 2 diabetes, we have not – and must not – forget the needs of the many people with type 1 diabetes or with other less-common but still important types of diabetes. IDF represents and fights for everyone with diabetes, and for all those who care for them and work with them. It has been a great joy to make a small contribution to the work of IDF – and I look forward to hearing Diabetes Voice continue to fight the cause until the cause is no longer a problem and we have won!

My love to you all.

stephanie a amiel is the rd lawrence professor of diabetic Medicine at

King's college london and consultant physician to diabetes services at

King's college Hospital, UK.

Back in 2009, I was standing in the foyer on the first floor of the conference centre in Montreal – those of you lucky enough to have at-tended that meeting may remember the entrance on the ground floor at the corner and the wall of coloured glass panels that made gorgeous coloured patterns on the floor when the sun shone. Those colours were vivid and so is the memory of that moment. I was standing with a Past President of IDF and the new IDF President, and the latter, in the gently persuasive tones with which he reduces the mountain ranges to a row of mere mole-hills, invited me to become Editor-in-Chief of IDF's Diabetes Voice. I have to confess I hesitated. The honour was great – but so too was the challenge. With some misgivings, I said ‘yes’. (Most people do to the IDF President – you only have to consider the UN!)

That was three years ago and what a fantastic three years they have been. With the highly professional help of Managing Editor, Olivier Jacqmain, and Editor, Tim Nolan, and other unsung heroes in the IDF publications machine, we have brought to press – in more or less timely fashion – a regular series of issues, full of news, views and colour, which we hope you have found inspiring, informative and, occasionally, fun. We have certainly had fun producing them, the (many) panics and crises more than compensated by the extraordi-nary generosity of our contributors, who have given unstintingly of their expertise, and their time – and been patient with the sometimes outrageous demands we have made to them! I have been privileged to serve as your editor during the time when the rest of the world has woken up to the message of IDF and the international diabetes community has really begun to make its voice heard. I hope you feel that Diabetes Voice has helped in that achievement; if it has, I can be truly proud of my time with the magazine.

This month's issue, coming out at the end of the calendar year, con-tinues to wave the diabetes flag. Sadly, as our President makes clear in his column, we have not turned back the diabetes tide in the last three years, but as he also says, we have achieved some important milestones, putting flesh on the bones of the UN Resolution on dia-betes. And the world turned blue – in the politest possible way – for World Diabetes Day, with events in India the hub of a blue wheel that encompassed the globe.

The growing recognition of the emotional strains of living with diabetes and the need to address these is discussed in these pages. Personal stories have always been a highlight of our pages, as the words of people living with diabetes are more expressive than the most carefully reasoned science. Sana Ajmal's paper describing the success she has achieved working with her diabetes, also acknowledges the struggles she and others face every day; and on page 38, Nia Coupe and colleagues describe the new research and clinical interventions being developed for depression in diabetes – an under-diagnosed but important contributor to impaired quality of life and, if untreated, diabetes control. Meanwhile, in our Health delivery section, we look

Diabetes views

And the wheel keeps turning


The IDF Diabetes Atlas 5th edition 2012 update was launched on World Diabetes Day this year with revised estimates for the disease based on recent studies and updated popula-tion estimates.

The 2012 figures for diabetes prevalence among adults con-firm the bad news that the epidemic of diabetes continues to gather momentum worldwide, with the number of people with diabetes increasing in every country. There are now more than 371 million people with diabetes, and more than half that number again who are unaware that they have the disease. The Atlas puts the number of deaths due to diabetes

in 2012 at 4.8 million, and global healthcare spending on diabetes at USD 471 billion.

The new estimates take into account data from recent stud-ies in a number of countries, including Saudi Arabia, Japan, Micronesia, Chile, Pakistan, Senegal and Myanmar, and reflect the urgent need for concerted action to prevent type 2 diabetes.

Find a pullout poster update in the centre pages of this issue of Diabetes Voice. Visit www.idf.org and follow the links to download regional and country factsheets and a slide show of the key messages and principal findings.

IDF ATlAs new figuresnews in brief

WHO and governments target diabetes and NCDsThe World Health Organization (WHO) and national governments have for the first time agreed on a global target to halt the rise of dia-betes. After lengthy negotiations in Geneva, governments have es-tablished a Global Monitoring Framework, which includes nine tar-gets and 25 indicators on diabetes and NCDs. The definition of targets for reducing diabetes was postponed for further discussion at the UN High-Level Meeting on NCDs in September 2011, the process to establish a Global Monitoring Framework was post-poned until 2012. IDF and the NCD Alliance have played a central role throughout.

In May 2012, the first target to re-duce preventable death from NCDs by 25% by 2025 was adopted at the World Health Assembly. To this out-come target are added eight global targets for exposure and health sys-tems. These are as follows:

Outcome target for 2025■ Reduce NCD deaths by 25%

Exposure targets■ Halt the rise of diabetes and obesity■ Reduce prevalence of physical in-

activity by 10%■ Reduce the harmful use of alcohol

by at least 10%

■ Reduce average consumption of salt by 30%

■ Reduce the prevalence of tobacco use by 30%

■ Reduce the prevalence of high blood pressure by 25%

Health system response targets■ Achieve access to affordable basic

technologies and essential medi-cines, including generics, required to treat major NCDs for 80% of affected people worldwide

■ Achieve access for 50% of those requiring it to drug therapy and self-management education to pre-vent heart attack and stroke.

India was the focus of IDF's World Diabetes Day 2012 awareness-raising activities. The blue lighting campaign kicked off in early November, reaching people throughout India and providing a powerful symbol of solidarity for the World Diabetes Day cause.Numerous landmark na-tional monuments were lit up in blue for diabetes, including the Swaminarayan Akshardham Temple, Qutb Minar and Humayun Tomb (all in Delhi), the Sidhuvunayak Temple in Mumbai, the Victoria Memorial Hall in Kolkata and Shaniwada Fort in Pune.

This call to action resulted in screening drives and educa-tion campaigns throughout the country on 14 November,

led by the Minister of Health and Family Welfare, Ghulam Nabi Azad.

Mass celebrations were also rolled out during the month by local organizations, with activities that included diabe-tes screenings at hospitals and clinics, government offices, workplaces and community centres, physical activities, flash mobs and childrens' art competitions.

The campaign also received the support of several national celebrities, who were pinned with the blue circle.

Turn to page 16 for a full report.

INDIA Blueleading the way for World Diabetes Day

news in brief

7DiabetesVoicedecember 2012 • volume 57 • issue 4

December 2012 • Volume 57 • Issue 48 DiabetesVoice

news in brief

In many cases, when a person is diag-nosed with type 2 diabetes, the disease has already progressed over several years and microvascular damage – to the eyes, for example – has already oc-curred. Researchers in Sweden have now identified a promising candidate for a test that indicates who is at risk at an early stage, enabling early preventive treatment (Cell Metab 2012; 5: 625-33).

Scientists at Lund University Diabetes Centre demonstrated that people who have above-average levels of the protein SFRP4 in the blood have a five-fold higher risk of developing diabetes in the next few years than those with be-low-average levels. This is the first time a link has been established between SFRP4, which plays a role in inflam-matory processes in the body, and the risk of type 2 diabetes.

The level of circulating SFRP4 in the blood stream of people without dia-betes was measured three times at intervals of three years. 37% of those who had higher-than-average levels developed diabetes during the study

period. Among those with a lower-than-average level, only 9% developed the disease.

According to the researchers, SFRP4 is a strong risk marker that is present several years before diagnosis. Moreover, they identified the mechanisms behind the role of SFRP4 in impairing the secretion of insulin. The marker, which works in-dependently of other known risk factors for type 2 diabetes (like obesity and age), therefore reflects an ongoing disease process as well as increased risk.

The researchers argued that if increased risk of diabetes could be identified in adults of normal weight using a simple blood test, up to 10 years before the dis-ease develops, this could provide strong motivation to them to improve their lifestyle – and reduce the risk. They concluded that in the long term their findings might lead to new methods of treating type 2 diabetes by developing ways of blocking the protein SFRP4 in the insulin-producing beta cells and reducing inflammation, thereby pro-tecting the cells.

protein reveals risk many years in advance

In the previous issue of Diabetes Voice, ‘The People Issue’, the introduc-tion to the article 'Tour of Bolivia – and a breath of fresh air' mistakenly described Kyle Jaques Rose as a member of the Team Type 1 cycling outfit. Kyle Jacques Rose is in fact a former team member of Team Type 1, where he was a cyclist and director. We apologize for the error.

errAtum

sTem Cell DIsCOvery mAy leAD TO NeW THerApIesScientists at the University of Melbourne, Australia, have identified stem cells in the adult pancreas that can be turned into insulin producing cells, a discov-ery that might lead to new therapies (PLoS ONE; 7: e48977). The research, which was supported by the Juvenile Diabetes Research Foundation, the Australian National Health and Medical Research Council of Australia and the Government of the State of Victoria, provides further evidence that stem cells do not only occur in the embryo.

As well as identifying and isolating stem cells from an adult pancreas, the researchers developed a technique to transform these stem cells into insulin-producing cells that can secrete the hor-mone in response to glucose. Insulin-producing cells have previously been generated from cells in the pancreas with ‘stem cell-like’ properties but there have been problems with generating useful numbers and with reproducing the results from one lab to the next. In the new report, the scientists have pin-pointed the cell of origin of the insulin-producing cells and demonstrated that the number of these cells increases, as does their ability to become insulin-producing cells, in response to damage to the pancreas. This allows the hope that one day people with type 1 diabetes might be able to regenerate their own insulin-producing cells – if methods can be devised to overcome the immune attack on the insulin-producing cells that initially provokes diabetes.


protein reveals risk many years in advance

voiCe of the Young LeaDers

Access to good care – just one of many, many challenges

Sana Ajmal

in this section of Diabetes Voice, we focus on the

international diabetes Federation young leaders

project. here, we profile sana Ajmal, the group’s

vice-president, and a busy mother of two living in

rawalpindi, pakistan. her day-to-day is an ongoing feat of multi-tasking: the

constellation of duties and responsibilities of a family-

home builder vie with the demands of sana’s doctoral

studies, as well as her health advocacy work with the young

leaders – not to mention managing her type 1 diabetes.

I had been living with diabetes for more than a year before I received the correct diagnosis. Having slipped into a ketoaci-dosis coma, I was finally diagnosed with type 1 diabetes, aged 16 years.

I have no family history of type 1 di-abetes that I know of. My awareness of diabetes at that time could not be described as ‘high’ but it was probably above average for the general popula-tion. I had two grandparents with a simi-lar condition, type 2 diabetes, and I had learned basic diabetes knowledge in my biology classes at school. Indeed, during the months of ill health leading up to my diagnosis, I had even suggested to my grandmother that I thought I might have the disease.

Despite my in extremis diagnosis, I have been very lucky in terms of medical and family support – for me and my diabetes. My mother is a doctor, and although she had not herself cared for

people with diabetes, she had studied the disease. After I was diagnosed, she returned to her medical books and trawled the Internet to learn about daily diabetes management. She passed on her knowledge to me, and helped my father and sisters to help out with daily care routines.

Diabetes – one of many challengesNowadays, I am the proud, busy mother of Muhammad, who is nearly five years old, and Ibraheem, who at the time of writing is aged just three months. Having diabetes while giving birth to and raising kids presents a wide range of challenges to women everywhere. My fluctuating glucose levels were a con-stant concern during both pregnancies and I maintained strict control through-out. The period of breastfeeding can be even more of a challenge: my glucose levels tend to drop rapidly while the baby keeps me so busy that at times I do not pay enough attention to my self!



One of the challenges proved insur-mountable: it was difficult to find a gynaecologist with experience han-dling pregnancies in women with type 1 diabetes. Many simply refused to take my case on learning about my diabetes. Fortunately, the Internet offers access to informed blogs and websites of respected organizations. The Internet must be approached with extreme caution; it can be a mine-field of dangerous misinformation. Nonetheless, I was able to research my pregnancies thoroughly and share with my healthcare providers some of the recommendations and guidance on managing pregnancy with diabetes.

My eldest son was born with normal birth weight (3.2 kg) while the second boy was born a little prematurely and weighed (2.4 kg). Both boys are develop-ing well, growing at a normal rate and both are bright and physically fit.

Women and diabetes in PakistanIn general terms, in Pakistani society, the wealthier women tend not to work. Women with diabetes in that sector are able to dedicate time and money to their self-care. In the low-income group, which comprises the majority of the population, women with diabe-tes cannot afford to purchase essential medicines. Many women with type 1 diabetes die because they cannot access the insulin they need to survive.

Socioeconomic changes in Pakistan, like many other countries and regions, is driving up the number of people with diabetes and other chronic diseases. With more than 187 million residents, Pakistan has the sixth largest popula-tion in the world. While ours remains largely a rural society, the urban centres are growing: more than 11 million peo-ple live in Karachi and 6.5 million in Lahore; seven other cities have a popula-tion above 1 million. Between1950 and

2008, the urban populations expanded more than seven-fold, while the total population grew four-fold.1

Over the past 15 years or so, we have also seen a dramatic rise in the num-ber of people with diabetes – mostly type 2 diabetes. There were 7 million people known to be living with diabe-tes in Pakistan in 2010. According to IDF estimates, by 2030, Pakistan will be home to that many women with dia-betes; the depressing projection of 13.8 million people with diabetes will take us to fourth place in the table of countries with the largest diabetes population – behind China, India and the USA.2

Poverty and unmet needsEstimates of the number of people liv-ing in extreme poverty vary. Up to 60% of the population lives on less than USD 2 a day.3 For these people, who have to pay for essential medicines out of their family budget, a diagnosis of diabetes of any kind can push an entire family into absolute poverty.

Meanwhile, the changing socioeconomic environment appears to be exacerbating

it was difficult to find a gynaecologist with experience handling pregnancies in women with type 1 diabetes.

A diagnosis of diabetes of any kind can push an entire family into absolute poverty.


the spread of diabetes and its costly, disa-bling complications. Among the grow-ing middle classes, computers and video games are taking over as the free-time activity of choice for millions of children, transforming them into couch potatoes (and mouse potatoes!) with an increased risk for obesity and type 2 diabetes.

Many people are already in need of diabetes care and medication. Unless radical steps are taken to respond to the epidemic of chronic disease in the de-veloping world, countries like Pakistan will be hit very hard by socially and economically. Spiralling healthcare costs, lost productivity, families driven into poverty and lost educational op-portunities will conspire to undermine our very development.

Behind the figures, there are human stories of struggle against ‘health injus-tice’. I once met a woman crying by the roadside, who, she told me, had a son with type 1 diabetes. She was begging for money to pay for his insulin. According to the woman, if she bought the insulin out of her household budget, her other six children would go without food.

Focus on womenI would describe Pakistan as a moderate-ly conservative society in terms of gender issues. The indicators for our health and social development are poor compared with men – especially in the rural ar-eas. Most women never adopt a formal

profession, although this is changing rapidly. We have a long way to go be-fore discrimination against women with diabetes can be completely eliminated.

For many people, getting their daugh-ter married off to a suitable man is the most important aspect of their lives. Beyond satisfying the parents’ wishes for their daughter’s emotional wellbe-ing, marriage is a socioeconomic neces-sity. Lack of awareness and widespread entrenched belief in myths relating to the disease – that a woman with diabe-tes cannot have children, for instance – combine to perpetuate discrimina-tion against women with diabetes in Pakistan. Many poor women with the condition find themselves alone and without a profession.

Light of hopePools of hope shine through the dark-ness. There are people working hard and projects underway that strive to provide free healthcare services to the poor. (We Pakistanis are a philanthropic lot!) Projects like 'Insulin My Life', run by the Baqai Institute of Diabetology and Endocrinology (an IDF Centre of Education) and a similar project un-dertaken by the Diabetic Association of Pakistan (the IDF Member Association in Pakistan) are worthy initiatives. Both are providing free insulin, syringes and test strips to children with type 1 diabetes children whose parents cannot afford to pay for treatment. For my part, I am taking

sana AjmalSana Ajmal is a Vice-President of the International Diabetes Federation Young Leaders in Diabetes project.

references1 United Nations Development Programme. The

Human Development Report 2007-2008. UNDEP. New York, 2008. Available: http://hdr.undp.org/en/media/HDR_20072008_EN_Complete.pdf

2 International Diabetes Federation. IDF Diabetes Atlas, 5th ed. IDF. Brussels, 2011. Available: www.idf.org/diabetesatlas

3. World Bank. Pakistan: poverty assessment. World Bank. Washington DC, 2011. Available: www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/1999/04/28/000009265_3961008023932/Rendered/PDF/multi0page.pdf

part in a series of diabetes education and awareness seminars, which aim to inspire and break the myths around diabetes – especially those relating to women.

Call to actionAll sectors of Pakistani society must become engaged in addressing issues re-lating to awareness and the lack of it, dis-crimination at any level, and the lack of access to good-quality care. As diabetes advocates, we are tasked with involving all sectors of society in diabetes advo-cacy. Since its inception in 2011, the IDF Young Leaders in Diabetes project has set up a global network that will form the fabric of the diabetes community at the highest level. Our overarching goal is to unite the global diabetes community and the public worldwide to create a unified voice for diabetes that will speak loudly enough to improve daily life and future prospects for millions of people wherever they live.


Behind the figures, there are human stories of struggle against health injustice.


the gLobaL Campaign

Leonor Guariguata

Tracking the global epidemic – new estimates from the IDF Diabetes Atlas Update for 2012

There is no country in the world that does not bear some burden from diabetes. The IDF Diabetes Atlas Update for 2012 confirms that cases are increasing

everywhere and at an alarming pace. Today, there are an estimated 371 million adults living with diabetes. To put this number into perspective: if all the people

with diabetes formed a country, it would be third-largest in terms of population after China and India.

Four out of five of the people with diabetes live in low- and middle-income countries, where health systems

are struggling to keep pace with the growing burden of non-communicable disease. IDF biostatistician, leonor

Guariguata, provides this update for Diabetes Voice.

Not surprisingly, the countries with the highest numbers of people with diabetes are also those with the largest popula-tions: China, India, the USA, Brazil and the Russian Federation. The top 10 coun-tries for numbers of people with diabetes account for two-thirds of all cases in the world. All but two of those countries are in active economic development.

While large countries have many people with diabetes, the world’s smallest nations are by no means exempt. Western Pacific Islands dominate the list of countries with the highest percentage of the population living with diabetes. In such countries, diabetes is becoming the norm and not the exception, with more than one quarter of adults over 20 living with the disease.

It is not just cases of diabetes that are on the rise; deaths due to diabetes are also


the gLobaL Campaign

Tracking the global epidemic – new estimates from the IDF Diabetes Atlas Update for 2012

mOre THAN 371 mIllION peOple HAve DIABeTes

Top 10 counTries / TerriTories for people wiTh diabeTes (20-79 years)

China

India

USA

Brazil

Russian Federarion

Mexico

Indonesia

Egypt

Japan

Pakistan

0millions

10 20

92.3

63.0

24.1

13.4

12.7

10.6

7.6

7.5

7.1

6.6

40 60 8030 50 70 90 100

increasing. New evidence informs esti-mates that there were 4.8 million deaths in adults attributable to diabetes in 2012. That is the equivalent of one death every seven seconds. Most of those deaths occurred in middle-income countries, where the mortality rate due to diabe-tes is also higher than in high-income countries. The difference in rates can be explained partially by the fact that there is an overall higher death rate in low- and middle-income countries; but it may also reflect health systems that are not equipped to respond effectively to the diabetes epidemic.

The tip of the icebergThe new Atlas estimates also show a high proportion of undiagnosed diabetes. Up to half of all cases in the world have not been diagnosed, representing ap-proximately 187 million people. Type 2

the world estimates it spent usd 471 billion on diabetes but the true cost is higher.

the gLobaL Campaign

december 2012 • volume 57 • issue 414 DiabetesVoice


leonor guariguataLeonor Guariguata is a biostatistician at IDF.

diabetes can progress for many years without showing any symptoms, and often when symptoms do appear, they are not immediately recognized as being due to diabetes. During this time, high levels of blood glucose, blood pressure and cholesterol continue to damage the body unchecked, provoking complica-tions. Often, it is not until a complica-tion has already developed that diabe-tes is diagnosed. This delay is a serious problem for the individual who must deal with the disabling consequences. Moreover, diabetes that has progressed to complications is more difficult and more expensive to manage – placing a serious extra burden on health systems and economies – than diabetes that is detected early.

An estimated USD 471 billion was spent globally in 2012 on healthcare for the treatment and management of diabetes. Some of this spending represents an important investment in care that is essential to managing the disease. Much of it, however, results from unmanaged diabetes and the high costs involved in treating complications – spending that could have been prevented. So the true cost of diabetes is higher than USD 471 billion, which does not include money spent by people with diabetes on travel-ling to their care centre, lost wages from disability or the expenses the family incurs to support a person affected by the disease.

In low- and middle-income countries, a disproportionate amount of this cost is paid out-of-pocket by the person living with diabetes. With major complica-tions of diabetes, such as stroke, often

diabetes will kill 4.8 million adults this year – one person dead every seven seconds.

in some parts of the middle east, half of the adults over 45 have diabetes.

affecting the wage earners of the family, the wider economic impact of diabetes becomes even greater. The substan-tial expense diabetes can impose on a household means that in some situa-tions, having the disease can put people at risk of poverty.

Valuable resources under threatEvidence also indicates that type 2 dia-betes is affecting people at younger ages than ever before. The majority of people with diabetes are under the age of 60. Studies from countries in the rapidly developing Middle East show that half of adults over 45 in some regions have diabetes. New studies have shown that younger people who develop type 2 diabetes progress to complications at a faster pace and are at a higher risk of dying early from the disease than older people with diabetes. In parallel, up to half of all deaths due to diabetes are occurring in people under the age of 60. This evidence dispels the myth that diabetes is only a disease of the elderly.

Finding the figuresDescribing a disease and its impact starts with measuring its magnitude. The Atlas project routinely gathers in-formation published in medical journals and reports describing the prevalence of diabetes in countries, regions and cities. The evidence from those publications is then pulled together and systemati-cally reviewed to generate the estimates presented in the IDF Diabetes Atlas. These estimates are the keystone for diabetes advocacy and they can be a powerful tool to motivate change from governments. In order to maintain the urgency needed to drive that change,

the IDF Diabetes Atlas project will pro-duce a new Atlas every two years, and an update of the estimates in the years in between.

The rapid pace of the epidemic has ob-vious implications for the individuals and families affected on a daily basis. But it is also affecting health systems and economies. The evidence for ur-gent action on diabetes continues to be overwhelming. The chronic and pro-gressive nature of the disease ensures that unless prevention happens early and effectively – without the necessary prevention, treatment and attention – the epidemic is set to overwhelm at an ever-increasing pace all countries that have not yet committed to meeting dia-betes head-on.

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Awareness in action: a look back at World Diabetes Day 2012Lorenzo Piemonte and Isabella Platon

From Chennai to Copenhagen, delhi to doha, mumbai to

melbourne the world once again came together on 14 november 2012 to raise awareness of the

ever-increasing threat posed by the diabetes epidemic in every

part of the world, and help to bring about improvements to the lives

of the 371 million people currently affected by diabetes. in the more

than 160 countries represented by the international diabetes

Federation (idF), national diabetes associations, health professionals, people with diabetes and dedicated

individuals from all sections of civil society put diabetes firmly in the public spotlight by organizing

a wide variety of activities on the day itself and throughout

the month of november.

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Awareness in action: a look back at World Diabetes Day 2012

World Diabetes Day 2012 marked the fourth year of IDF's five-year focus on diabetes education and prevention, and rallied the global diabetes community around the slogan Diabetes: protect our future – underscoring the link between the urgent need for action against the current diabetes epidemic and our collective duty to protect the health of future generations. The focus was on young people. Children and adolescents were the driving force behind the pro-motion and dissemination of educa-tional messages promoting awareness of the threat from diabetes. Three key messages informed World Diabetes Day activities worldwide:■ Access to essential education for everyone■ The way we live is putting our health

at risk■ People with diabetes face stigma and

discrimination

An animated video was produced to promote these messages and a selection of physical and online materials was de-veloped and shared throughout the IDF network for use in local World Diabetes Day awareness activities.

Special focus was placed on getting the blue circle – the global symbol of diabetes and logo of World Diabetes Day – recognized among a mainstream audience through the launch of the Pin a Personality campaign. The diabetes community was encouraged to identify local personalities, ask them to wear the blue circle pin to show their support for the diabetes cause, take a picture and send it for display on the IDF website. The initiative proved very popular with our member associations, who com-mented that the pin allowed them to share information about diabetes in

a positive way. Several special events were organized at the national level to present local personalities with the blue circle pin.Notable public figures that have been pinned include former UN Secretary General Kofi Annan, his Royal Highness Prince Joachim of Denmark, the Vice-President of Tanzania Dr Mohamed Gharib Bilal (see photo) and five-time Tour de France winner Miguel Indurain. There are over 400 pinned personalities featured on the IDF website. They include local, na-tional and international leaders and ce-lebrities from the worlds of art, music, health, broadcasting, religion, politics and sport.

India flying the flagIn recent years, IDF has chosen a country on the frontline of the diabe-tes epidemic as the venue for its World

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Diabetes Day celebrations. Following on from China, we took the blue-circle campaign to India, home to the world’s second-largest diabetes population. IDF partnered with local organizations in a nationwide campaign that involved major events in the cities of Ahmedabad, Cochin, Chennai, Hyderabad, New Delhi, Kolkata and Mumbai.

Throughout the month leading up to World Diabetes Day, local and national diabetes organizations led a series of activities targeting health professionals and the general public, resulting in the country's largest-ever diabetes aware-ness campaign. The campaign united the medical community, diabetes or-ganizations, the media, government, the

private sector and the general public on a single platform with an overarching objective: to facilitate the exchange and growth of knowledge around diabetes.

In several cities, diabetes screening drives in hospitals and clinics, govern-ment and corporate offices, community centres and other venues reached hun-dreds of thousands of people with the 2012 campaign messages, and promoted life-saving early detection and treatment for diabetes.

The people’s movementIn a powerful of display of unity around a shared cause, millions of people worldwide went blue for diabetes throughout the month of November.

Here are just a few of the literally thou-sands of initiatives and activities that put diabetes in the headlines of the newspapers and on the televisions and computer screens of millions of people around the globe.

In Nigeria, the Diabetes Association of Nigeria mobilized its 37 chapters with celebrations in all of the country's state capitals on 14 November, featuring ac-tivities for children and adolescents and mass screenings.

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the Brazilian campaign reached 1,000 cities and engaged more than 1 million people.

DiabetesVoice 19december 2012 • volume 57 • issue 4

lorenzo piemonte and isabella platonLorenzo Piemonte is IDF Communications Coordinator.Isabella Platon is IDF Head of Communications.

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with increased unity and commitment, a healthy future is possible.

In Jordan, the national chapter of the International Federation of Medical Students' Associations held a series of celebrations in Amman, which included screen-ings, blue lightings, a human blue circle, posters and leaflets, and awareness through newspapers and magazines.

The Mexican Fundación Chespirito, a World Diabetes Day Champion, held

its annual 'Danos Una Mano' (Give us a Hand) event on 14 November. Grants of MXN 200,000 (EUR 12,000) were awarded to two programmes that fo-cus on diabetes care and prevention, and research into diabetes and obesity in children.

The Federation of National Diabetes Associations in Brazil held their 15th annual nationwide campaign aimed at promoting diabetes awareness and the prevention of diabetes and its com-plications. Covering 1,000 cities, the campaign engaged more than 1 mil-lion people in activities that included free screenings and tests for diabetes complications, walks, competitions for school children involving drawing, po-

etry and storytelling, and exhibitions promoting healthy nutrition.

In Australia, Diabetes Australia Victoria held events for people with diabetes and stakeholders and partners. These included lighting up Hamer Hall, Victoria’s premier concert venue; a sum-mit for bloggers; and the presentation of the Diabetes Australia Research Trust’s Millennium Grant and 20 seeding grants to diabetes researchers for their projects for the coming year.

"Rock for a Cure" in Denmark was or-ganized by the national chapter of JDRF. This special gala and reception provided an update on diabetes in the country and looked at what can be done about it.

Turning the world blueWorld Diabetes Day would not be the same without the Blue Monument Challenge and this year proved no exception. In fact, the Challenge has been taken up with such enthusiasm that we witnessed an increase in the number of countries that went blue for diabetes. According to our latest figures, some 600 monuments and buildings in more than 60 countries went blue

for diabetes in November. The CN Tower in Toronto, the London Eye and the Obelisk in Buenos Aires were among the world landmarks to show their support and bring diabe-tes to light.

14 November is also about turning awareness into ac-tion. IDF once again marked the day by releasing the lat-est figures on the worldwide prevalence, mortality and cost of diabetes. The numbers throw into stark relief the real

dimensions of the epidemic. The first annual update of the IDF Diabetes Atlas showed that the total number of people with diabetes has risen to 371 million and continues to grow in every country.

Our task, to identify and promote for workable solutions to the diabetes epi-demic, remains immense. But the mil-lions who went blue for diabetes on 14 November showed the world that unity and commitment is growing and a healthy future is possible.

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diabetes advocacy in 2012 – highlights, achievements and progressKatie Dain

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Inspiring a new level of political leadership2012 has seen a new level of seriousness for diabetes and NCDs within both the UN system and national governments. One of the cornerstones of the UN Political Declaration on NCDs is that diabetes and NCDs are multi-sectoral issues that require global solutions. In just one year, this sentiment has inspired leadership and action across the world’s guiding authority – the United Nations. Previously an issue reserved for the World Health Organization (WHO) and the health sector, now diabetes and NCDs are being included in the leading UN agency and funds programmes, meeting and discussions. The UN Development Programme (UNDP), UNAIDS and UNICEF are among the leaders, and the new vision and cooperation within the inter-national community must be encouraged and supported.

Governments around the world have also acknowledged responsibility for diabetes and NCDs in a way not seen be-fore. The bold step taken in China – where 15 government

When world leaders met at the 2011 uN High-level summit on Non-Communicable Diseases (NCDs) and adopted the uN political Declaration on NCD prevention and Control, the global health and de-velopment landscape changed forever. Diabetes and related NCDs were recognized as a ‘major 21st cen-tury challenge’ and national governments signed up to a set of commitments for action covering the spectrum of prevention, treatment and care. As one of the earliest voices to call for the summit and an instrumental player during preparations, IDF is proud to have been at the heart of this sea change. But now over a year on from this watershed event, what has changed for people with diabetes? Where has IDF focused its advocacy efforts in 2012 and what have been the major achievements for diabe-tes and NCDs in this post-summit year? And look-ing ahead, what are the next political milestones to continue the momentum of the summit? Katie Dain offers some highlights, achievements and an overview of IDF’s new advocacy programme – the Diabetes Roadmap to the Future Development Agenda.

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there are already signs of the ‘summit effect’ that idF has fought hard for.

december 2012 • volume 57 • issue 4


ministries will drive a major new strategy to reduce death and disability from NCDs – is just one example of the new level of national leadership emerging. Action on prevention and treat-ment for people with diabetes and those at risk is unfolding from Fiji to Finland, and across the en-tire region of the Americas. The Pan American Health O r g a n i z a t i o n (PAHO) signalled leadership on the issue of access to essential medicines by expanding their Strategic Fund for Public Health Supplies to include diabetes and NCDs in September. These are early signs of the ‘Summit effect’ that IDF has fought hard for.

Foundations for global action and accountabilityIn the aftermath of the UN Summit, WHO has led a se-ries of consultations to define the foundations of the global architecture for NCDs. Many of these consultations were mandated in the UN Political Declaration, and IDF and the NCD Alliance have led the civil society response to ensure strong outcomes for diabetes and NCDs. These consultations are shaping the first set of global NCD targets to inspire and monitor progress; the next Global NCD Plan 2013-2020, which will set the agenda for all sectors over the coming years; and a global multi-sectoral partnership to mobilize action and resources. All are interconnected and could result for the first time in a coordinated and accelerated global response to diabetes and NCDs.

After nearly two years of consultations, negotiations and sustained advocacy, governments agreed the first set of global NCD targets and a global monitoring framework in November 2012. This was a major breakthrough for diabetes and NCD advocacy, signalling a new era of action and accountability. By agreeing an ambitious set of nine global voluntary tar-gets and 25 indicators, governments for the first time will have to report on progress to the UN on regular basis and be encouraged to improve data collection, surveillance and monitoring of the epidemic.

It has been a long and hard-fought battle to secure this am-bitious set of targets. Back in May 2011, IDF and the NCD Alliance first proposed targets to governments in the lead up to the UN High-Level Summit on NCDs. A year later, at the World

Health Assembly, we secured the first global target “to reduce preventable death from NCDs by 25% by 2025” – known as the '25 by 25' vision. And as 2012 comes to an end, eight more global targets and 25 indicators were approved to drive progress

towards the vision.

Critically, the targets agreed balance both prevention and treat-ment. Every step of the way, our calls for an ambitious and comprehensive set of targets were coun-

tered by the voices of some governments wanting a smaller set that solely focus on primary prevention, not treatment. The result – targets covering the four major NCD risk factors (physical inactivity, diet, tobacco and alcohol); blood pres-sure; diabetes/obesity; essential medicines and technologies; and multidrug therapy for people at risk of stroke and heart attack, including people with diabetes – is testament to the power of IDF and the NCD Alliance’s coordinated advocacy from global to national levels.

Many targets are important for diabetes but three are critical for our community - the targets to “halt the rise in diabetes and obesity”, achieve “80% availability of affordable basic technolo-gies and essential medicines in public and private facilities” and ensure “50% of people at risk of heart and stroke (including people with diabetes) receive drug therapy and counseling”. Diabetes is the only one of the four major NCDs that now has its own global target, and the other two targets have the potential drive change in health systems that will improve access to essential life-saving treatment for hundreds of millions of people with diabetes worldwide. IDF worked hard to ensure diabetes did not get buried in a generality of NCDs, and we have succeeded.

Together with the specific targets above, the other building blocks of the Global NCD Framework are taking shape. As WHO develops the next Global NCD Action Plan for 2013-2020, IDF has been working to ensure priorities and actions for diabetes – aligned to our Global Diabetes Plan 2011-2021 – are fully integrated. The next Global NCD Plan must truly be a roadmap of action for everyone, which will achieve the global targets and commitments in the UN Political Declaration by harnessing the expertise and skills of all sectors, particularly civil society. The epidemic of diabetes and other NCDs is too big for one sector to solve alone, and both the opportunity

The first ever global targets adopted by all governments on diabetes and NCDs was a major advocacy victory.

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our movement is gaining momentum, and idF will continue to work to translate political commitments into real change for millions.

katie dainKatie Dain is IDF Global Advocacy Manager.

of the next Global NCD Plan and the global multi-sectoral partnerships for NCDs must be developed to accommodate a truly multi-sectoral response to diabetes and NCDs.

Positioning diabetes post-2015 In addition to shaping the global architecture for NCDs, IDF has also been gearing up for our next major political milestone – the expiry date of the Millennium Development Goals (MDGs) in 2015. The exclusion of diabetes from the current MDGs has been a significant barrier to generating political priority and resources for the epidemic, particularly in low- and middle-income countries, which shoulder the brunt of the burden. This time round, we cannot afford to allow diabetes and NCDs be sidelined from the global development agenda. The political mandate for their inclu-sion is strong, reinforced at the UN MDG Review in 2010, in the UN Political Declaration on NCDs in 2011, and more recently at the UN Conference on Sustainable Development (Rio+20) in June 2012.

IDF and the NCD Alliance have contributed to the strength-ening of this political mandate over the years, working hard to reframe diabetes and NCDs as a development and poverty issue, and an issue of human rights and social injustice. And now, as the UN official process to scope the post-2015 de-velopment agenda has begun, we are using that hard-fought political mandate. 2015 may seem a long way off, but con-sultations and important feeder meetings got underway this year – and IDF and the NCD Alliance have been tracking and influencing events every step of the way, successfully keeping diabetes and NCDs at the heart of discussions.

Highlights in 2012 include guaranteeing diabetes and NCDs are included in key health consultations for post-2015, par-ticularly the UN global thematic consultation on health to be held in March 2013; influencing the UN Task Team on post-2015 by being invited to submit ‘think pieces’ on positioning health and NCDs post-2015; and keeping diabetes and NCDs central to the parallel process on Sustainable Development Goals (SDGs) which was launched at Rio+20 in June. IDF is widely recognized as a thought leader on diabetes, NCDs and development, and this reputation will be of great benefit as negotiations step up a gear in 2013.

The diabetes movement is gaining momentumAfter the fervour of the UN Summit, we have seen progress on diabetes and NCDs on all fronts. But undoubtedly unfin-ished business remains. Where is the money for combating a disease that governments affirm as one of biggest threats to development in the 21st century? And where is the people’s movement and public outrage for a disease that kills over 4 million people every year, mostly in poor countries?

The UN Summit was just the beginning and we have to be in this fight for the long haul. Encouragingly, our movement is gaining momentum and, guided by our Roadmap programme, IDF will continue to work to translate political commitments and global targets into real change for the millions of people with diabetes and those at risk.

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the genetics behind type 2 diabetes – lessons from gwAsTimothy M Frayling

Obesity is one of the main driv-ers of type 2 diabetes, and the

increased prevalence of obesity underpins the increase in type 2

diabetes around the world. Nevertheless, there are many overweight and obese people

who do not develop diabetes, and many leaner people who do. One of the reasons for this apparent

discrepancy is varying genetic predisposition. scientists have

spent many years attempting to identify the DNA sequence vari-ations and genes involved. They hoped that this work to discover

genes would help them pin-point the molecular defects that influence insulin resistance and

insulin secretion, leading to new therapies, and help predict the

risk for the disease. Tim Frayling provides this timely update.

Deoxyribonucleic acid (DNA), popularly referred to as the building block of life, contains the genetic code that influences who we are. The human genome is the complete set of genetic information stored in DNA sequences in 23 pairs of chromosomes. We know that our DNA code provides the formula for making the molecules and proteins that mediate the chemical reactions in our body and are central to its functioning.

Genome-wide associations studies (GWAS) examine common genetic variants in different people in order to determine whether any variant is associated with a trait or condition, such

as type 2 diabetes. It is only in the last five years that real progress has been made in identifying the DNA sequence variations and genes involved in the development of type 2 diabetes. This has been as a result of technological advances that allow us to test hundreds of thousands of DNA variants in one go.

Further advances in sequencing technology have allowed us to read the entire 3.2 billion base-pair code of thousands of people with diabetes – and people without the disease who constitute ‘controls’ – giving us an almost complete catalogue of human genetic variation. Thanks to these advances, we know of 65 regions of the human genome that are associated with type 2 diabetes,1 compared to the three regions we knew of five years ago.

Lessons from GWASFirst, the bad news: the effects of the genetic variants identified to date are too subtle to have any meaningful

real progress has been made in identifying the dnA sequence variations involved in the development of type 2 diabetes.


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timothy m FraylingTim Frayling is Professor of Human Genetics at the University of Exeter, UK ([email protected]).

references1 Morris AP, et al. Large-scale association analysis

provides insights into the genetic architecture and pathophysiology of type 2 diabetes. Nat Genet 2012; 44, 981-90.

2 Church C, et al. A mouse model for the metabolic effects of the human fat mass and obesity associated FTO gene. PLoS Genet 2006; 5: e1000599.

3. Church, C. et al. Overexpression of Fto leads to increased food intake and results in obesity. Nat Genet 2012; 42: 1086-92.

4. Teslovich TM, et al. Biological, clinical and population relevance of 95 loci for blood lipids. Nature 466, 707-13.

5. Ding EL, et al. Sex hormone-binding globulin and risk of type 2 diabetes in women and men. N Engl J Med 2009; 361: 1152-63.

6. Perry JR, et al. Genetic evidence that raised sex hormone binding globulin (SHBG) levels reduce the risk of type 2 diabetes. Hum Mol Genet 2012; 19: 535-44.

association is approximately equivalent to what was expected. We do not know yet whether targeting SHBG could offer a therapeutic option for diabetes but the pharmaceutical industry will note the finding with interest.

The way aheadAdvances in human genetics are leading to a relatively new type of study aimed at understanding the disease mechanisms behind diabetes. It is now possible to recruit research volunteers based on an interesting genetic variant that they carry, and perform in-depth physiological studies on the volunteers to understand how the gene variant functions.

In summary, human genetic discoveries will greatly inform diabetes research for many years to come, even if we cannot use DNA to predict disease.

human genetic discoveries will greatly inform diabetes research for many years to come.

predictive value over and above traditional risk factors, such as increased body mass index. This situation may improve as we use larger and larger studies to identify more genetic risk factors. However, it seems unlikely that DNA profiling will help us to predict the risk of type 2 diabetes. Nonetheless, the identification of so many DNA sequence variations associated with type 2 diabetes in such a short space of time provides the diabetes research community with an unprecedented opportunity to advance understanding of the disease mechanisms.

Most importantly, researchers who are trying to understand how beta cells and insulin-responsive tissues develop and function normally now have a much-refined list of candidate mechanisms. Moreover, those focusing on animal models and cellular models can now identify the most likely genes. An example is the FTO gene, the DNA variations that confer the strongest risk of obesity in the general population. This gene had no known role in diabetes or metabolism until the human genetic association with obesity was revealed. Now, several types of rodent models point to a new mechanism that affects appetite and metabolism.2,3 Further research on the FTO gene and protein could yield vital advances in understanding of how our appetite and metabolism are affected in today’s obesogenic environment.

The second major lesson from GWAS has been that using human genetics in clever ways can help dissect compli-cated metabolic associations. Several research groups are using the genetic equivalent of a randomized controlled trail to test causal directions between associated human traits. This approach, termed Mendelian randomization, uses

the principle that genes are randomly sorted at meiosis (cell division for sexual reproduction) and can be used to under-stand causal directions between traits. A proof-of-principle example is the strong association between variants that alter levels of LDL cholesterol and cardio-vascular disease: genetic variants that have the greatest effect on LDL levels have the greatest effect on risk for car-diovascular disease – a result consistent with statin trials, in which statin drug therapy, which lowers LDL cholesterol, lowers also cardiovascular risk.4

Increasingly, researchers are using Mendelian randomization to tease apart the hugely complicated networks of metabolic associations that occur before the onset of diabetes. For example, we have known for many years that type 2 diabetes is associated with reduced levels of sex hormone-binding globulin (SHBG). This binding protein is produced in the liver and circulates in the blood stream to transport testosterone, and to a lesser extent oestrogens, to target tissues. It has always been assumed that insulin resistance lowers SHBG levels. But genetic studies have shown that the opposite may also be true: reduced SHBG levels are likely to influence diabetes risk causally.

Two large studies used genetic variants near to the gene that encodes the SHBG protein.5,6 These variants are strongly associated with levels of circulating SHBG and risk for type 2 diabetes. Furthermore, given the association between the genetic variants and SHBG and the association between SHBG and type 2 diabetes, the


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lessons from the hadza: poor diets wreck efforts to prevent obesity and diabetesHerman Pontzer

we are all familiar with the unsettling statistics on obesity. the world health organization projects that within the next three years, one in three people worldwide will be overweight, and one in 10 will be obese. the global obesity pandemic brings with it a host of health concerns, including an increased in-cidence of type 2 diabetes. the root cause of weight gain is energy imbalance – taking in more calories than you expend. But the societal causes of obesity, and the reasons behind the sudden increase in unhealthy weight gain worldwide, remain a matter of intense debate: are we eating too much, exercising too little, or both? in this report, herman pontzer shines a light on the complexities of energy expenditure and reveals some surprising yet crucial issues.

One way to address the debate is by asking what life was like in the distant past. Many public-health issues in the developed world are thought to arise because our modern lifestyles are so radically different from those in which we evolved. For most of our species’ 200,000-year history, we have been living as hunter-gatherers, foraging for wild foods using simple hand-made tools and covering long distances each day on foot.1 Millennia spent hunting and gathering have shaped our biology; it is the lifestyle to which our bodies are adapted. By comparison, our modern, industrialized lifestyle so very recent that our biology has not had time to adjust.

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If obesity is on the rise because modern lifestyles burn fewer

calories, the Hadza should expend more energy than populations

in the USA or Europe.

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Learning from the HadzaMy colleagues and I recently measured daily energy expenditure – calories burned each day – among the Hadza of northern Tanzania, one of the last remaining populations of traditional hunter-gatherers on the planet.2 While no population living today is a perfect model for our distant past, people like the Hadza allow us to compare modern lifestyles with those more similar to the lifestyle of our hunter-gatherer ancestors. If obesity is on the rise because modern, sedentary lifestyles burn fewer calories, populations like the Hadza should expend more energy each day than populations in the USA or Europe.

To measure daily energy expenditure, we used a technique known as the double-labelled water method. Participants drank a small dose of ‘labelled’ water, containing uncommon isotopes of hydrogen and oxygen. We then measured the concentration of those isotopes in urine samples taken over the next 11 days. By comparing the concentrations of the uncommon hydrogen and oxygen isotopes in each participant’s urine samples, we were able to calculate the rate at which their body produced carbon dioxide. This in turn gave us an accurate, direct measure of energy expenditure for each participant. Double-labelled water is the gold standard for measuring daily energy expenditures because it is much more accurate than other methods, such as activity monitoring or self-reported food intake. It is also safe.

We lived with the Hadza as they went about their normal daily routines during the study. The Hadza live in grass huts on the dry East African savannah in small

camps of about four or five families. Each day, women leave camp in a group to forage for wild plant foods, usually berries, fruits, and tubers. Men head out alone to hunt with a bow and arrows, covering long distances in search of game; they also collect wild honey, chopping into hollow tree limbs with small, simple hatchets. Children too young to forage with their mother, and too old to be carried in a sling, spend the day around camp with the elders. When the men and women return to camp, food is shared widely. The Hadza have no crops, no vehicles or guns, no domesticated animals or machinery; they rely on one another to make a living in a difficult environment.

Unexpected findingsThe results were surprising: Hadza energy expenditures were no different from those of modern industrialized populations! We ran a number of statistical tests, accounting for body mass, body fat percentage, age, sex and other variables. In each, energy expenditures among the Hadza were indistinguishable from people living in the USA and Europe. When we compared the Hadza more broadly to a set of 98 populations worldwide, we

found their daily energy expenditures were right near the global average.

Were the Hadza in our study less active than typical hunter-gatherers? Not at all. We measured daily activity using wearable GPS units and found that Hadza men walked an average of 11 km each day, while women walked about 5 km each day. Moreover, all of their food during the study came from the wild, requiring intensive digging to harvest tubers, chopping to access honey, and carrying to get it all back to camp.

We also examined whether Hadza adults were somehow inherently more efficient, and found no evidence for this explanation. In separate tests of the energy cost of walking (calories per kilometre) and resting (calories per minute), we found the Hadza participants in our study were not different from other populations. Foraging requires a complex set of learned skills – hunting, tracking, digging, and chopping, to name a few

the hadza rely on each other to make a living in a difficult environment.

hadza men walked 11 km a day, while the women walked 5 km.

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– and there is little doubt that the Hadza learn to do carry out specialized tasks more efficiently and effectively than outsiders could, but their bodies do not appear to be inherently more efficient at using energy.

Our results suggest that daily energy expenditure is more complicated than we often envision. We have known for a long time that most of the energy our body burns each day is spent on the basic cellular activity that keeps us alive. Physical activity, even among active people, usually accounts for only a small portion of our daily energy expenditure. The similarity in total daily

energy expenditure across peoples of radically different lifestyles suggests that our bodies adapt to their environments, shifting energy expenditure between tasks to keep total expenditures in check. There is some supporting evidence for

this hypothesis from other studies of traditional populations but more work is needed to test the idea thoroughly.

It really is about dietThe surprising findings from the Hadza study suggest that decreased energy expenditure is not the primary cause of obesity in modern, industrialized populations – our average daily energy expenditures are probably similar to those of our hunter-gatherer ancestors. Instead, obesity is on the rise because people are eating too much. We are taking in more calories than we need, and the excess is being stored as fat. Unfortunately, overeating is easy to do

where food is plentiful and many of our choices are energy-dense, processed foods. Foods that are high in sugars and other carbohydrates may be particularly dangerous, as they depress energy expenditure and leave us feeling hungry.3

Exercise is still extremely important! We need to stay physically active to keep our heart, lungs, brain and immune system healthy, especially as we get older. The Hadza offer an important lesson here too: because they are so active, high-blood pressure and other chronic diseases common in developed countries are unheard of among the Hadza, and men and women are active and vital well into their 60s, 70s and 80s. However, when it comes to fighting the global increase in obesity, we need to start by changing our diets. Without a serious effort to change the way we eat, we will have an extremely hard time turning the rising tide of obesity worldwide.

When it comes to fighting the global increase in obesity, we need

to start by changing our diets.

herman pontzerHerman Pontzer is Assistant Professor of Anthropology at Hunter College, City University of New York, USA, and co-founder of HadzaFund.org.

Vists www.hadzafund.org to learn more about the Hadza and the projects involving their community.

references1 Conroy GC, Pontzer H. Reconstructing

Human Origins: A Modern Synthesis. 3rd ed. Norton. New York, 2012.

2 Pontzer H, Raichlen DA, Wood BM, et al. Hunter-gatherer energetics and modern human obesity. PLoS ONE 2012; 7,e40503.

3. Ebbeling CB, Swain JF, Feldman HA, et al. Effects of dietary composition on energy expenditure during weight-loss maintenance. JAMA 2012 307: 2627-34.

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environmental factors in metabolic diseases – the invisible threat of food contaminantsJérôme Ruzzin and Anders Goksøyr

Hazardous chemicals can enter the body in different ways: in the food we eat; in the air we breathe; and in the household and personal care prod-ucts that touch our skin. Exposure to environmental pollutants begins very early in life – when mothers-to-be eat contaminated food, they inadvertently expose their baby to contaminants by direct transfer across the placenta. Exposure to potentially hazardous chemicals continues through breast-feeding, and we go on to be exposed regularly through the food we eat. Figure 1 shows the dietary sources of two very harmful chemical compounds – PCB153, which was used in industrial insulators and lubricants, and is associ-ated with cancer and nervous system problems; and the pesticide, DDT.1 Curiously, little information is avail-able to consumers about the amount of pollutants that are present in our food and a large part of the population is entirely unaware of them.

Industrialization has been one of the most important advances in human history, resulting in improved survival

and quality of life for millions worldwide. However, a by-product of our modern-day human activities has been the

production of numerous potentially noxious chemicals. Nearly 150,000 are registered by the european Chemicals

Agency, and more than 70,000 were produced in the usA in 2009. some of these chemicals are very long lasting,

and environmental pollutants are now found everywhere on earth – even in remote areas, such as the Arctic. No-

one is completely unaffected by hazardous chemicals and contaminants. In contrast to those of of our ancestors,

the 21st century human body comprises several non-natural chemical cocktails that interact continuously

with our cells and organs. Here, the authors look at the links between chemicals in our food chain and the risk

for metabolic diseases, including type 2 diabetes.


Where are they coming from?Some chemicals, such as bisphenol A and phthalates, can leak into food from plastic packaging, containers and bot-tles, where they are used as additives. Others, like persistent organic pollutants (POPs), find their way into food due to their chemical properties. Highly resist-ant to degradation, POPs have accumu-lated in our food chain. If absorbed, they will remain in the body for many years, sometimes decades – even trace levels in food can build up into hazardous amounts over a period of years.

POPs are used in thousands of different compounds, including pesticides, fungi-cides and weed killers; polychlorinated

biphenyls (PCBs – previously used in coolants, hydraulic fluids, paints and other products); polybrominated diphe-nyl ethers (PBDEs – used in electrical goods and textiles, and as flame retard-ants in coatings that inhibit or resist the spread of fire) and many others.

Contributing to riskIn 2006, a breakthrough study revealed that the risk of diabetes was consider-ably higher in people with high levels of POPs compared to those with lower levels.2 Later investigations conducted around the world, including in the USA, Europe and Asia, reported simi-lar links between POPs and diabetes. For example, there was an increased incidence of type 2 diabetes among Finnish people born between 1934 and 1944 who had accumulated large amounts of certain POPs during their lifespan.3 The most important source of POPs in Finland is fatty fish, such as herring and salmon from the Baltic

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pCB153

FIGure 1: esTImATeD DIeTAry CONTrIBuTIONs TO THe INTAKe OF pCB153 AND pesTICIDe (DDTsum) IN ADulTs1

dairy products

cheese

poultry

eggs

fats

fish

Meat

DDTsum

ChEESE

MEAt

PoUltRyEggS

FAtS

FISh

dAIRy PRodUCtS

Sea. In the USA, the production of chemicals has been found to parallel the prevalence of diabetes.4

A possible link between POPs and cardi-ac complications has also been reported, while other, shorter-lived chemicals – such as bisphenol A, organotins and phthalates – have been associated with metabolic disorders. Indeed, there is much evidence to suggest that long-term exposure to environmental pollutants is playing an important role in the current epidemic of diabetes.

Findings from animal and cell studies point to the same conclusion. At a cellular

very little information is available to consumers about the amount of pollutants present in our food.

long-term exposure to environmental pollutants may be playing an important role in the current epidemic of diabetes.


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between environmental pollutants and metabolic diseases, and their findings highlight the urgent need to tackle this important global issue.

Legislation and regulationA number of different national and international agreements, which were established to prohibit or reduce the production of certain chemicals, and set maximum permitted levels and a tolerable daily intake for a range of

level, hazardous substances can disrupt the action of insulin and interfere with glucose metabolism. Other chemicals have been shown to act as obesogens – stimulating the synthesis and accumula-tion of lipids within the cell – and may even predispose certain cells to differenti-ate into adipocytes (fat cells).

Fatty fish confirms the linkThe effects of eating fatty fish were in-vestigated recently in an effort to gain

more insight into the role of the POPs in our food. Remarkably, POPs present in farmed Atlantic salmon were able not only to induce disorders linked to dia-betes and obesity; they were also able to counteract the potential benefits of omega-3. These original findings could have important implications for nutri-tional guidelines, and might explain why people who consume fatty fish may be at increased risk for type 2 diabetes.5 Both animal and cell studies confirm the link

the removal of environmental contaminants should be a requirement for food producers.


are calculated based on body weight, and regulatory policies usually do not distinguish between children and adults. But children may become over-exposed to contaminants because the food intake per kilogram of body weight they need to grow properly is very high; and since the metabolic defence system at this stage of life is not entirely developed, environmental pollutants can be espe-cially harmful.

The way aheadThe number of people suffering from type 2 diabetes and other metabolic

diseases continues to rise at alarm-ing rates worldwide, and young peo-ple are increasingly affected. Much of the blame has, probably rightly, been laid at the door of excess caloric intake and obesity, but recognition by doc-tors, nutritionists and clinicians of the potential threat from environmental pollutants might reveal new directions and opportunities for diabetes care and prevention. Clearly, better-harmonized regulation across foodstuffs is needed. Moreover, the removal of environmental contaminants from food should be a re-quirement for food producers. A recent study showed that it is possible to reduce contaminant levels in farmed Atlantic salmon by reducing levels in the fish feed, thereby reducing potential health risk.7 A stronger focus on contaminant levels in foodstuff is obviously and ur-gently needed.

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Jérôme ruzzin and Anders goksøyrJérôme Ruzzin is a postdoctoral fellow in the Environmental Toxicology Research Group, Department of Biology, University of Bergen, Norway.Anders Goksøyr is Professor of Environmental Toxicology and Head of the Department of Biology, University of Bergen, Norway.

references1 Fromberg A, Granby K, Hojgard A, et al.

Estimation of dietary intake of PCB and organochlorine pesticides for children and adults. Food Chem 2011; 125: 1179-87.

2 Lee DH, Lee IK, Song K, et al. A strong dose-response relation between serum concentrations of persistent organic pollutants and diabetes: results from the National Health and Examination Survey 1999-2002. Diabetes Care 2006; 29: 1638-44.

3. Airaksinen R, Rantakokko P, Eriksson JG, et al. Association between type 2 diabetes and exposure to persistent organic pollutants. Diabetes Care 2011; 34: 1972-9.

4. Neel BA, Sargis RM. The paradox of progress: environmental disruption of metabolism and the diabetes epidemic. Diabetes 2011; 60: 1838-48.

5. Ruzzin J, Jacobs Jr DR. The secret story of fish: decreasing nutritional value due to pollution? Br J Nutr 2012; 108: 397-9.

6. Ruzzin J. Public health concern behind the exposure to persistent organic pollutants and the risk of metabolic diseases. BMC Public Health 2012; 12: 298-302.

7. Ibrahim MM, Fjaere E, Lock EJ, et al. Chronic consumption of farmed salmon containing persistent organic pollutants causes insulin resistance and obesity in mice. PLOS One 2011; 6: e25170.

foodstuffs. Meanwhile, however, new chemical compounds are being devel-oped to replace older substances, creat-ing a new range of emerging potential threats to health.In the European Union, the European Food Safety Authority regulates risk assessments of food and feed safety. The implementation of the Rapid Alert System for Food and Feed allows the early detection of potential health threats in the foodstuffs that are on the market. There are, nonetheless, major limita-tions to current legislation.6 Firstly, the legislation assumes that in terms of ex-

posure to harmful chemicals, the higher the dose, the greater the detrimental effects. However, some chemicals have the capacity to cause serious metabolic dysfunction even in very low doses. Secondly, the toxicity of chemicals has been assessed chemical by chemical, whereas in the real world we are exposed to a constellation of hazardous chemi-cals simultaneously. When hundreds of chemicals are mixed together, their individual harmful impact can occur at concentrations far below those described in the current regulations.

A third caveat relates to the homogene-ity, or lack of it, in the legislation. If a chemical represents a potential human health risk, it ought to be regulated in the same way in all types of food. Oddly enough, however, this is not the case. Pesticides, PBDEs, and certain PCBs, for instance, are regulated in many food products but not in seafood. Moreover, levels of tolerable intake of pollutants

Some chemicals have the capacity to cause serious metabolic

dysfunction even in very low doses.


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prescribing physical exercise – focus on a combined approachCésar Oliveira

Despite our efforts to the contrary, many of those at high risk for diabetes go on to develop the disease. Numbers of peo-ple with diabetes worldwide continue to spiral beyond even the most pessimistic projections – 371 million currently, the world diabetes population is set to rise to more than half a billion worldwide by 2030, according to the International Diabetes Federation’s latest figures. Huge numbers of people struggle every day to control their blood glucose levels.

Fortunately, a number of interventions are able to improve significantly a per-son’s long-term blood glucose control. Research has demonstrated that by fol-lowing specific diets, combining exer-

Factors relating to the environment and lifestyle are central to the development of type 2 diabetes. In recent decades, research has focused on a variety of approaches – pharmacological, dietary and physical – to preventing and treating this disease, with generally encouraging results. With lower cost and fewer side effects, lifestyle modifications have been proven to be as effective as drug therapies, cutting by half the risk of diabetes in people who are at high risk. These results unmistakably indicate that people can stay healthier for a longer period of time, delaying or even preventing the onset of type 2 diabetes by being physically active and eating well. In some studies, exercise alone or exercise plus diet produced better effects than interventions based on diet alone, which confers on exercise a vital role in the prevention of diabetes. Here, César Oliveira makes the case for prescribing physical exercise to combat type 2 diabetes.

physical activity promotes a wide range of benefits, as well as improving blood glucose control.

December 2012 • Volume 57 • Issue 4

prescribing physical exercise – focus on a combined approach

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cise and diet, or restricting the intake of calories, many people can achieve and maintain normal glucose levels without the aid of drug therapies.1-4

Because of its ability to regulate blood glucose concentrations, exercise is rec-ognized as a cornerstone for diabetes prevention and treatment. Exercise promotes a wide range of benefits, as well as improving blood glucose, such as improvements in aerobic capac-ity, muscular strength, body composition and endothe-lial function – not to mention emotional wellbeing – with has a strong impact on quality-of-life and life expectancy. Indeed, capacity for physical exercise has been found to predict risk of death among

35DiabetesVoice


people with diabetes, independently of body mass index.5

We know that unfit people with diabetes who lead a sedentary life are at signifi-cantly increased risk for cardiovascular disease. However, the dose-response ratio for physical activity/fitness is such that when these people undertake high levels of physical activity or become very physically fit, their level of risk drops dramatically to a level similar to that of their peers with normal body weight or peers without diabetes.6

Given that diabetes can shorten life ex-pectancy by 15 years even in optimum circumstances in terms of ac-cess to essential care, the ben-eficial effects of physical e xe rc i s e look, atthe very least, extremely sig-nificant. Yetexercise is the most underused

strategy for the prevention and man-agement of this disease, and we found people with diabetes to be even more inactive than their counterparts without the disease.7

Prescribing physical activityThanks to the efforts of investigators around the world, robust guidelines are available on physical activity and exer-cise for people with diabetes. In order

to provide additional information as a practical, easy-to-apply adjunct to inter-national recommendations, we recently reviewed various features of combined (aerobic plus resistance) exercise inter-ventions for people with type 2 diabe-tes, and discussed the ways these might affect blood glucose control.8 Having analyzed 28 interventions, we have high-lighted a number of key findings.

Take a combination approachExercise is able to enhance insulin sen-sitivity, improve blood glucose uptake and increase muscle mass and the ex-pression of GLUT-4 glucose transport-ers on the muscle cell surfaces.9 These mechanisms appear to be synergis-tic. This reinforces the message that everybody – with or without diabetes – should engage in both aerobic ex-ercise (walking, running, swimming, dancing) and resistance activities (free weights, multi-gym machines, resist-ance bands).

Structured adviceStructured recommendations are the most effective. This means that a pre-scription of exercise should include fun-damental characteristics, such as the mode, intensity, duration, frequency, sets, repetitions and rest intervals, among others. Vague guidelines like ‘be more active’ may not generate the desired effects.

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physical exercise is the most underused strategy for the prevention and management of diabetes.

36 DiabetesVoice


Seek a specialistIn research studies, best results were achieved when exercise was prescribed and supervised by specialists in physi-cal exercise. When one is not acces-sible or available, people’s ability to follow recommendations, as well as the glucose-lowering effects of the intervention, are weaker generally. People with diabetes should, where possible, seek professional advice in order to improve these factors and in order to minimize the risk of injury or overtraining.

More is bestThe current minimum recommendation for frequency and volume exercise is as follows: 150 minutes of aerobic exercise, distributed in three sessions per week; and 10 sets of resistance training in two weekly sessions. Evidence suggests that beneficial effects might occur at lower weekly frequencies but better outcomes are expected with higher frequencies.

Regulate intensityPeople should exercise as a minimum at around 55% of their maximum heart rate, roughly the equivalent in adults of walking briskly. Regulating the intensity of resistance exercise can be trickier – especially for people who are generally more sedentary. The weight a person moves as part of the exercise must be light enough to be able to complete at least eight consecutive repetitions but heavy enough that he or she cannot per-form more than 15 consecutive repeti-tions. Good technique here is essential to minimize the risk of injury.

Use large muscle groupsThe most effective modes of aerobic exercise seem to be those which require a person to use larger groups of mus-cles, such as walking, jogging or run-ning. These are more likely to generate

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higher rates of energy expenditure than other modes of exercise that use smaller muscle groups. In people with diabe-tes who have developed, or who are at high risk for, lower-limb complications, an impact-free elliptical trainer would be the ideal choice in order to avoid microvascular foot injuries. But un-dertaking a variety of aerobic activities is also encouraged. In terms of choice and intensity, the same principles apply to resistance training because modes of resistance training that use a high percentage of total muscle mass are es-timated to be more beneficial. A few examples would be lunges, squats, leg presses, chest presses, push-ups and lat pull-downs and chin-ups.

DiscussionOur review raised some other techni-cal issues that should be addressed in future studies. While it seems likely that everyone may benefit from a combined-exercise intervention, some people might achieve extra results by emphasizing the aerobic component, while others would benefit most from more resistance exercises. Our review also suggests that splitting aerobic and resistance training on different days might be of special relevance for op-timal glycaemic control. We believe that a better understanding of these topics will drive the development of individualized, tailor-made exercise prescriptions, leading to enhanced health benefits.

The health-related effects of physical activity are so powerful that exercise is often referred to as medicine. But exercise is unique, and valuable in many other ways: it can be a fun, socially in-clusive and gratifying experience that makes people happier, prettier and more confident. And that in itself is not a bad start!

César oliveiraCésar Oliveira is an assistant teacher at the Escola Superior de Desporto e Lazer, Melgaço, Portugal.

references1 Lindeberg S, Jönsson T, Granfeldt Y, et

al. A Palaeolithic diet improves glucose tolerance more than a Mediterranean-like diet in individuals with ischaemic heart disease. Diabetologia 2007; 50: 1795-807.

2 Williams KV, Mullen ML, Kelley DE, Wing RR. The Effect of Short Periods of Caloric Restriction on Weight Loss and Glycemic Control in Type 2 Diabetes. Diabetes Care 1998; 21: 2-8.

3. Roberts CK, Won D, Pruthi S, et al. Effect of a short-term diet and exercise intervention on oxidative stress, inflammation, MMP-9, and monocyte chemotactic activity in men with metabolic syndrome factors. J App Physiol 2006; 100: 1657-65.

4. Lim EL, Hollingsworth KG, Aribisala BS, et al. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 2011; 54: 2506-14.

5. Church TS, Cheng YJ, Earnest CP, et al. Exercise Capacity and Body Composition as Predictors of Mortality Among Men With Diabetes. Diabetes Care. 2004; 27: 83-8.

6. Gill JMR, Malkova D. Physical activity, fitness and cardiovascular disease risk in adults: interactions with insulin resistance and obesity. J Clin Sci 2006: 409-25.

7. Egede Le ZD. Modifiable cardiovascular risk factors in adults with diabetes: Prevalence and missed opportunities for physician counseling. Arch Intern Med 2002; 162: 427-33.

8. Oliveira C, Simões M, Carvalho J, Ribeiro J. Combined exercise for people with type 2 diabetes mellitus: A systematic review. Diabetes Res Clin Pract 2012; doi:pii: S0168-8227(12)00302-6. 10.1016/j.diabres.2012.08.004.

9. Roden M. Exercise in type 2 diabetes: to resist or to endure? Diabetologia 2012; 55:1235-9.

december 2012 • volume 57 • issue 4DiabetesVoice38

depression and diabetes – a significant challenge for people with diabetes and healthcare providersNia Coupe, Charlotte Garrett, Linda Gask

A diagnosis of diabetes is always stressful. people are suddenly faced with having to manage a complex treat-ment regimen, including amended diet, regular monitoring and pharmacological therapies, often leading to a variety of new fears and responsibilities about their health. problems with emotional adjustment to the condition can have negative effects on diabetes self-management – which in turn can impact on emotional wellbeing, in a classical vicious cycle. Here, the authors report on the relationships between diabetes and depression, and suggest a model of collaborative care for people with diabetes and mental health problems.

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Rates of depression in people with diabetes have been found to be twice those in the general population.1 Furthermore, when present alongside long-term conditions such as diabetes, depression is significantly associated with greater reduction in health status than is the case for depression alone, or for single or other multiple long-term conditions alone.2

Mental and physical health in diabetesThe experience of diabetes can lead to distress, anxiety and depression through the burden of the condition and its impact on function and quality of life. Mood problems may lead to poorer outcomes, perhaps by reducing a person’s ability to self-manage his or her condition, or by disrupting doctor-patient

communication. In order to understand better the relationship between depression and diabetes, our research group carried out a meta-synthesis of 22 studies on the topic.3 This review high-lighted the wide variety of psychological reactions experienced, and confirmed that the impact of diabetes on functioning and conflict with healthcare professionals, as well as with family, can be a significant source of stress for people with diabetes.

Whether an individual sees himself or herself as ‘a person with diabetes’ or as ‘a diabetic patient’ may be important in terms of emotional consequences and their impact on self-care. How much labels matter has been hotly argued but the concept is real – people who see themselves as still primarily


CLiniCaL Care

as ‘a person who has diabetes’ may feel more control over their condition and self-manage more effectively, while those who see themselves as a ‘diabetic patient’, implying that the diabetes has made them someone no longer well, may feel less in control, have higher levels of psychological distress, and self-manage less well.

Our study also highlighted variability in responses to the ex-perience of psychological distress among people with diabetes, including sometimes potentially unhelpful responses, such as defensiveness and denial of vulnerability, to an extent that interfered with their ability to engage with health services and to self-manage. The wide variety of strategies used by people with diabetes for coping with psychological distress was also highlighted.

Recognition and diagnosis of depressionResearch, including that conducted by our group,4 has high-lighted several important reasons why depression goes un-detected. Firstly, only a minority of people with long-term conditions, such as diabetes, present to primary care with psychological problems,5 with the majority more likely to present with physical symptoms alone.6 Secondly, people with diabetes and healthcare providers may ‘normalize’ depres-sion in people with long-term conditions, such as diabetes –considering it as a common and understandable response to the losses associated with these conditions.4

The increasingly performance-managed disease management approach to primary care consultations in some high-income countries, such as the UK, may also be problematic as it may narrow opportunities for discussing depression.4 Although the UK does encourage screening for depression in people with long-term conditions, there is little evidence for outcomes from this, perhaps because resources may be lacking to act upon the screening result. Meanwhile, negotiating accept-able labels for depression may be a particular challenge and people with long-term conditions may be unlikely to see their problems as a separate disorder in need of specific treatment.4 Labels of ‘psychiatric’ ill-health still carry undeserved stigma and may be resisted.

Efficacy of currently available treatments Currently available treatments for depression, such as anti-depressants and psychological interventions, are effective in improving depressive symptoms in people with diabetes.7 In the UK, such treatments are recommended by the National Institute for Health and Clinical Excellence (NICE) for people with depression and a long-term condition, to be delivered according to a stepped model of care.5

However, less evidence exists for treatment that achieves si-multaneous improvements in both mental and physical health outcomes – which presents a far greater challenge.8 Indeed, a recent review of psychosocial interventions in people with co-morbid depression and diabetes was unable to identify one particular type of intervention which consistently provided benefits for the symptoms and outcomes of both the physical and the mental health conditions.9

Collaborative care Collaborative care, a way of organizing care for people with chronic conditions, is intended to deliver integrated care for people with diabetes and co-morbid affective disorders and may be able to deliver better outcomes. Collaborative care typically involves:■ a multi-professional approach to care, including the intro-

duction of the role of case manager■ a structured management plan■ scheduled follow-up contacts■ enhanced inter-professional communication.10

The role of the case manager is integral, to help the person with diabetes to co-ordinate all aspects of care. The role can be taken on by any appropriately trained professional with a background in primary care, although results from a meta-analysis of trials to date looking at collaborative care for depression suggested that results may be better for those trained in mental health.11 Case managers communicate with all of the professionals involved in the patient’s care, and ideally should be equipped to deliver brief psychological therapy and provide motivational support to people under the regular supervision of a mental health specialist.11

Evidence from the USA suggests that this model of collabo-rative care can indeed improve outcomes for people with depression and diabetes in primary care. A recent trial of collaborative care versus usual care for people with depression and co-morbid diabetes and/or coronary heart disease, led to significant improvements in both physical and psychological

people with long-term conditions and their health care professional advisors may not see their depression as a separate disorder in need of specific treatment

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Whether people see themselves as

‘a person with diabetes’ or ‘a diabetic patient’

may be important emotionally – and

impact on self-care.

december 2012 • volume 57 • issue 4DiabetesVoice40


health.12 In the UK a trial is underway to test whether col-laborative care can produce similar outcomes in primary care in people with depression and diabetes and/or heart disease (see web link below).

Future directionsMental health problems, such as depression, remain under-recognized and under-treated in people with diabetes. Limited success in achieving both psychological and physical health gains from interventions suggests the way forward may lie in the delivery of integrated interventions for de-pression and diabetes through a collaborative approach. However, despite the potential benefits of this model in offering a more holistic approach to care, many challenges exist to its implementation.

Challenges to collaborative careEnsuring an integrated, collaborative approach to care rep-resents one such challenge. As commonly occurs with the introduction of any new way of working, there is a tendency over time to default back to old modes of practice. Sustained commitment, strong leadership and regular scheduled meet-ings between staff to review progress and solve problems are likely to be necessary in order to maintain the collaborative care model in practice.

Even after the introduction of collaborative care, many of the barriers to recognition and diagnosis will remain. Professional education and skills training are needed to address some of these problems. The training given should concentrate on ways in which mood can be explored within the time constraints of the primary care environment.

Engagement of people with diabetes as well as their health-care professionals with collaborative care interventions is also likely be a challenge. Low expectations of psychological wellbeing are likely to mean that significant work needs to be done before and after referral in order to encourage a person to view their low mood as problem for which they can and should receive some help, support and treatment.

Towards better understandingMore research is required to understand the full range of emotional problems associated with diabetes. More work is needed in particular to improve understanding of how depression and anxiety relate to and can be easily distin-guished from diabetes-related distress, and how the onset of emotional problems can be prevented.

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nia Coupe, Charlotte garrett, linda gaskNia Coupe is Research Assistant with an interest in depression and collaborative care.Charlotte Garrett is Research Associate with an interest in psychological interventions for depression long-term conditions and access to mental health care for ethnic minority groups.Linda Gask co-leads the COINCIDE study and is Professor of Primary Care Psychiatry. ([email protected]).All are based at the Greater Manchester CLAHRC and the Centre for Primary Care, Institute of Population Health, Manchester Academic Health Science Centre, University of Manchester, UK.

Further readingMore information about the authors’ research into collaborative care can be found at: http://clahrc-gm.nihr.ac.uk/what-we-do/innovating-through-research/health-care-practitioners/coincide-trial/

references1 Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of

comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2004; 24: 1069-78.

2 Moussavi S, Chatterji S, Verdes E, et al. Depression, chronic diseases and decrements in health: results from the World Health Surveys. Lancet 2007; 370: 851-8.

3. Gask L, Macdonald W, Bower P. What is the relationship between diabetes and depression? A qualitative meta-synthesis of patient experience of co-morbidity. Chronic Illn 2011; 7: 239-52.

4. Coventry PA, Hays R, Dickens C, et al. Talking about depression: a qualitative study of barriers to managing depression in people with long term conditions in primary care. BMC Fam Pract 2011; 12: 10.

5. National Collaborating Centre for Mental Health. Depression in adults with chronic physical health problems, full guideline. National Clinical Practice Guideline 91. 2009 available from www.nccmh.org.uk/guidelines_dchp.html

6. Tylee A, Ghandi P. The importance of somatic symptoms in depression in primary care. Prim Care Companion J Clin Psychiatry 2005; 7: 167-76.

7. van der Feltz-Cornelis CM, Nuyen J, Stoop C, et al. Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis. Gen Hosp Psychiatry 2010; 32: 380-95.

8. Detweiler-Bedell JB, Friedman MA, Leventhal H, et al. Integrating co-morbid depression and chronic physical disease management: identifying and resolving failures in self-regulation. Clin Psychology Rev 2008; 28: 1426-46.

9. Harkness E, Coventry P, Macdonald W, Gask L, et al. Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes: A systematic review and meta-analysis. Diabetes Care 2010; 33: 926-30.

10. Gunn J, Diggens J, Hegarty K, Blashki GA. Systematic review of complex system interventions designed to increase recovery from depression in primary care BMC Health Serv. Res. 2006 6, 88.

11. Bower P, Gilbody S, Fletcher J, Sutton A. Collaborative care for depression in primary care: Making sense of a complex intervention: systematic review and meta-regression. Br J Psychiatry 2006; 189: 484-93.

12. Katon W, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2011; 363: 2611-2620.

managing diabetes during fasting – a focus on Buddhist lentTint Swe Latt and Sanjay Kalra

ritual fasting is an essential part of many major faiths. lent in Christianity, ramadan in islam, yom kippur in Judaism, or the navratras in hinduism –

fasts vary in duration and in degree. some ritual fasts pose challenges to the physical health and fitness

of those following the ritual, which are significant in people with diabetes, who have metabolic disorders

and use treatments that impair their capacity to fast for long periods of time. with growing numbers

of people affected by diabetes worldwide – and as that population grows older, enjoying greater life

expectancy with ever-improving diabetes management – the number of people with diabetes wishing to

observe religious fasts also looks set to increase. tint swe latt and sanjay kalra look at special management

issues in the context of Buddhist ritual fasting.


With some 500 million devotees world-wide, Buddhism is a major world faith. It is the principal religion in many Asian countries, including Myanmar, Sri Lanka, Thailand, Laos, Cambodia, Vietnam, Taiwan, Mongolia and Bhutan. Many people in India and China also follow Buddhism. All these countries are report-ing substantial increases in the number of people with diabetes. Buddhism, then, like the other major world religions, has been unable to escape the impact of the diabetes pandemic.

Buddhism’s rainy retreatDevout Theravada Buddhists observe a fast lasting three lunar months every year during the rainy season. This fast, known as Vassa ('rainy retreat'), is re-ferred to in English as ‘Buddhist Lent’ and in Myanmar as War Dwin. The fast is characterized by a 12-hour period (from noon to midnight) of fasting followed by a 12-hour period in which the fast is broken. The three-month duration of the fasting period, as well as these 12-hourly cycles of fasting and feasting, make observing Vassa a tricky task for the devout. It calls for physical and emo-tional strength, as well as sustained social support, to complete the fast successfully. This is especially true for people with diabetes, who face specific challenges related to blood glucose control.

Surprisingly, however, Buddhist Lent has not been the focus of research into diabetes-related health issues relating to the fast. Perhaps for this reason, many healthcare professionals are not aware of the particular needs and challenges facing people with diabetes who wish to observe Vassa.

Acute complications – hypoglycaemia provoked by delaying meals and hy-perglycaemia due to snacking and the intake of very calorie-rich foods – are likely to occur more frequently during fasts. Hypoglycaemia might be noticeable for the person fasting only with subtle symptoms, such as difficulties practis-ing meditation. This is a delicate issue for devout Buddhists, and must be ap-proached with care and sensitivity. With a fast period occupying a quarter of each year, it is likely that chronic complica-tions, both macro- and microvascular, are exacerbated by prolonged periods of fasting, as a consequence of poor blood glucose control.

Sensible, practical guidance is required for nutrition, physical activity, meditation practices and drug therapy throughout the fasting period. Following informed advice will help to ensure a positive expe-rience, safeguarding physical health and emotional and social wellbeing.

Preparing for VassaPeople who plan to follow the fast should receive counselling and educa-tion before Vassa begins. People must know about the potential side effects of fasting with diabetes, and the steps needed to prevent them – including the need for the intensive supervision of diabetes during the fasting period. This is where healthcare providers should be proactive, encouraging people to discuss the issues prior to fasting.

People should review their medical his-tory and undergo a full physical examina-tion with a view to ensuring a complica-tion-free fast. Elective procedures, such as cataract surgery, should be performed well before the fast or postponed for three months to avoid the increased risk of peri-operative complications secondary to poor blood glucose control.

Hypoglycaemia awarenessIt is crucial that people with diabetes who wish to observe Buddhist Lent be fully aware of the signs and symptoms of hypoglycaemia, and of how to pre-vent and manage it. Awareness training should focus on the subtle symptoms of hypoglycaemia in the brain (neurogly-copenia), such as difficulty in praying; adrenaline-related complaints, such as trembling; as well as general symptoms, like headaches.

NutritionWhile fasting, devout Buddhists are allowed to drink liquids, they cannot consume solids or alcohol during the 12 hours of fasting. People tend to drink high-calorie liquids, such as fruit juice, soya milk and soft drinks, as well as green tea and water. Many people in Asia add unrefined sugar (known widely as ‘jag-gery’). During the hours of feasting, people are allowed a small snack after midnight, a normal serving of breakfast and a large lunch before noon. People with diabetes should be encouraged to eat small frequent meals while feasting, and

clinical care

vassa has not been the focus of research into diabetes-related health issues.

It is crucial for people to be aware of the signs of hypoglycaemia and of its prevention and management.

DiabetesVoice 45December 2012 • Volume 57 • Issue 4

drink low- or medium-calorie liquids at short intervals during the hours of fasting.

The nutritional and pharmacologi-cal management of diabetes should be planned at the same time. Drug thera-py should be tailored to facilitate each person’s dietary plan, while nutritional and exercise habits should be reviewed regularly and modified where necessary. Low-calorie drinks, such as green tea, soya milk, and freshly squeezed fruit juices should be encouraged. People should avoid large portions of calorie-rich drinks, like sugar-sweetened soft drinks and processed juices, although small amounts may be used in specific situations. Certain low-calorie food sup-plements, which can be mixed with water or milk, may be an option.

Meals can be modified to reduce caloric content and glycaemic index. Boiled rather than fried noodles, for example, will contribute to improved blood glucose control. Whole grains and rices, complex carbohydrates with a reduced glycaemic index, are always the preferred option.

Physical activity and meditationVassa is an important time for medita-tion, which can be practised while walk-ing and/or sitting. Choosing walking meditation can help improve general health and use calories, may help avoid hyperglycaemia.

As mentioned earlier, hypoglycaemia can impair the quality of meditation, which can be distressing for devout Buddhists. Simple advice to drink a small glass of fresh juice before prayer can help to en-hance the experience.

Oral medicationsThe emphasis while choosing a phar-macological therapy for diabetes during Buddhist Lent must be on safety and

tolerability. Each case has to be consid-ered individually and a bespoke regimen agreed by the person with diabetes and his or her diabetes healthcare provider. While medicines that act only by improv-ing insulin sensitivity such as metformin should not cause problems with reduced caloric intake, all insulin secretagogues and exogenous insulin risk causing hy-poglycaemia. Regimens should be tai-lored to the food plan the fasting person with diabetes will undertake. In general terms, long-acting drugs, such as gliben-clamide, should be avoided during Vassa. Repaglinide, low-dose sulfonylureas with a reduced tendency for hypoglycaemia (glimepiride, gliclazide) and gliptins should be considered instead. Oral medi-cations prescribed as a once-daily dose can be taken in the morning. If a twice-daily dose is required, giving two-thirds of the dose in the morning may be considered. We have found using a sustained-release preparation of metformin taken before noon can be effective.

The relative advantages and disadvan-tages of various classes of drugs have been discussed in detail by international bodies recently, and new guidelines and clinical recommendations were pub-lished this year.1,2 These can be used to inform a selection of the appropriate drug therapy during Buddhist Lent.

InsulinIn order for people with type 1 diabetes to keep the fast, regular glucose monitoring is essential to ensure safety and general wellbeing. Insulin therapy might need to be modified during Vassa. Properly man-aged basal-bolus regimens where the basal

insulin is enough to control endogenous glucose production and fast acting insu-lin is taken just before any carbohydrate containing meal should work, but doses may need adjusting, especially if the usual doses of the basal regimen are not evenly divided. We have found using insulin analogues with their reported relatively reduced risk of hypoglycaemia, helpful. Insulin regimens should be tailored ac-cording to each person’s specific dietary pattern. We have found that using basal or premixed insulin, given once daily, before the main meal of the 24 hour period may be enough for many people with type 2 diabetes. Safety, convenience and tolerabil-ity should remain the goals throughout.

Final pointsGiven the large and growing numbers of people observing Vassa around the world, there is an increasing need for practical, culturally appropriate informa-tion on the precautions and specific man-agement strategies to be adopted while fasting. More attention and research needs to be focused on the interaction between diabetes, nutrition and religions. Guidelines that provide appropriate man-agement strategies for diabetes during Vassa will help countless people enjoy a fulfilling fasting experience.

clinical care

more attention needs to be focused on the interaction between diabetes, nutrition and religions.

tint swe latt and sanjay kalraTint Swe Latt is an endocrinologist. He is Rector of Medical University 2, Yangon, and President of the Myanmar Society of Endocrinology and Metabolism.Sanjay Kalra is an endocrinologist at Bharti Hospital, Karnal, Haryana, India.

references1 IDF Clinical Guidelines Taskforce. Global

guideline for Type 2 diabetes. IDF. Brussels, 2012.

2 Inzucchi S, Bergenstal R, Buse J, et al. Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012; 55: 1577-96.


diabetes in societY

A ‘parma campaign’ for Africa – a 42,000 km initiative against ketoacidosisMaurizio Vanelli and Cesare Beghi

In 2007, Diabetes Voice reported on a community awareness campaign to promote early recognition of the symptoms of type 1 diabetes in children and, above all, prevent the appearance of ketoacidosis. That initiative, based in parma, Italy, was success-ful and at a relatively low cost, which led other groups to repeat the experience in in europe, North America and Australia. But no-one had tried to set one up in a developing country – until the authors packed the necessary supplies into lorries and sent the campaign overland to 32 African countries. The arrival of the campaign caravan and activities sparked a great deal of interest and a degree surprise among the communities visited along the 42,000 km expedition. The experience reconfirms the authors’ conviction that every opportunity must be seized upon to raise awareness around the world of the simple steps that can be taken to prevent ketoacidosis – and that no child should die of diabetes, wherever he or she was born.

Left untreated, diabetes ketoacidosis has a 100% mortality. Even in the best centres, diabetic ketoacidosis carries a significant risk of death, and the more established (ie the later) the condition is discovered, the worse the metabolic derangement and the greater the risk of permanent disability and death. Such events are preventable, if the early signs of type 1 diabetes are detected early, before ketoacidosis has been able to establish itself. One of the warning signs of type 1 diabetes among children is unexpected and repeated bed-wetting. Although a lot of parents will recognize bed-wetting as a problem, especially in a child who is usually dry throughout the night, in many cases it is not identi-fied by paediatric healthcare providers as a sign of the onset of type 1 diabetes.


Diabetes in soCietY

world as the Parma campaign,1 resulted in an important drop in the frequency of ketoacidosis in the Parma area.2,3

Achieved at minimal cost, the success of the Parma campaign caught the at-tention of a number of groups, who have repeated the experience in their respective countries in Europe, North America and Australia. As far as we know, however, such a programme had never been attempted in a low-income developing country. We took the deci-sion to carry the Parma campaign’s pre-ventive message to Africa, where many children and adolescents with diabetes die due to ketoacidosis because they are diagnosed late or not at all.

Opportunity knocksCircumstances presented us with two opportunities to help get the campaign to Africa. The first came in the shape of

the parma campaign achieved an important reduction in ketoacidosis.

the Master’s degree course in Emergency and Essential Care in Developing Countries, organized at the University of Parma by the Centre for International Cooperation (in collaboration with the Italian Ministry of Foreign Affairs and the Geneva Foundation for Medical Education and Research). Every year, 20 young practitioners from Angola, Burkina Faso, Ghana, Guinea Bissau, Mozambique, Niger, Senegal, Sierra Leone and Sudan take up the one-year course. We seized the opportunity to integrate into their curriculum modules on the diagnosis and treatment of type 1 diabetes – emphasizing the tenets of the Parma programme.

The course was an ideal workshop to discuss, adapt and develop the neces-sary tools to reproduce the campaign in different regions of Africa. It was

Our group initiated an awareness cam-paign in paediatric clinics and hospital departments, pharmacies and schools throughout Parma, with its key focus on bed-wetting – the overarching aim being to promote the early diagnosis of diabetes before the appearance of ketoacidosis. Posters were displayed and numerous meetings were organ-ized to alert as wide an audience as possible to the threat of ketoacidosis. The campaign message comprised five simple questions and statements: Does your child drink and urinate more than usual? Has he/she started wetting the bed again? Make sure he/she does not have high blood sugar levels. Call your paediatrician today. Children can have diabetes too.

That community-centred initiative, which has become known around the


diabetes in societY

agreed unanimously that a poster-based campaign would be the best vehicle to broadcast three crucial messages: Children too can have diabetes; Excessive drinking and urinating are important signs of diabetes; a ‘dry’ child who starts to wet the bed is at risk of having high blood sugar.

We edited campaign posters in English and French. The only major difference between these and the posters used in Italy is advice to contact a ‘healthcare professional’ (meaning doctor, nurse, midwife) rather than ‘paediatrician’, because in many African regions it remains virtually impossible to find a paediatrician.

The doctors attending the Master’s course, upon returning to their respec-tive countries, displayed the posters in public places judged to have a large throughput of people with an interest in children’s health. The young medics were also instrumental in translating the posters into local languages.

In top gearThe second opportunity came via the 12th edition of the Italian-organized 2012 Overland World Truck Expedition, which travelled 42,000 km through 32 African countries, carrying, among other things, humanitarian supplies. Campaign posters were mounted on the side of the Overland trucks and the expedition doctors were tasked with presenting the campaign to the hospitals and mobile clinics, missions, villages and schools along the expedition route.

Several hundred (plastic-coated) post-ers were distributed and displayed in venues that are attended daily by preg-nant women, parents, children, teachers, nurses, doctors and midwives. Reports from Africa have been positive. One of the Overland doctors commented that the diabetes messages “attracted people’s attention and got people interested eve-rywhere we went.”

The road to hopeThanks to the expedition, which was filmed by Italian television, the African campaign was on the road for 162 days. We delivered life-saving messages to large numbers of people in 26 coun-tries from Morocco in the very north of the continent to Botswana and South

the African campaign was on the road for 162 days, delivering life-saving messages in 26 countries.

maurizio vanelli and Cesare BeghiMaurizio Vanelli is Professor of Paediatrics and Director of the Postgraduate School of Paediatrics at the University of Parma, Italy. He is also Dean of the School of Medicine at the same University.Cesare Beghi is Professor of Cardiac Surgery. He is President of the University Centre for International Cooperation at the University of Parma and Rector Delegate for International Cooperation. He led the medical team on the Overland expedition.

AcknowledgementsThe authors would like to extend their sincere thanks to the Overland team for their matchless support, to Novo Nordisk Italia for assistance with the posters, and to Rossana Di Marzio for editorial support.

references1 Vanelli M. Education and public information:

preventing diabetic ketoacidosis in Italy. Diabetes Voice 2007; 52: 39-41.

2 Vanelli M, Chiari G, Ghizzoni L, et al. Effectiveness of a Prevention Program for Diabetic Ketoacidosis in children. Diabetes Care 1999; 22: 7-9.

3 Vanelli M, Chiari G, Lacava S, et al. Campaign for diabetic ketoacidosis prevention still effective 8 year later. Diabetes Care 2007; 30: e12.

in many African regions it remains virtually impossible to find a paediatrician.

Africa in the south, and from Senegal and Gambia in the east all the way to Tanzania in the west.

This extraordinary experience has un-derlined our strong belief that every opportunity should be taken to spread the world that diabetes ketoacidosis can be prevented. No child should die of dia-betes. A passing truck could be enough to make all the difference.

overland trucks carried the campaign's life-saving messages


Diabetes in soCietY

the meteoric rise and rise of #gbdoc – a

personal experience of what social media can

do for peer supportPaul Buchanan

From tiny acorns mighty oaks grow. In paul Buchanan’s case, that acorn was the idea to create an online ‘agora’ for people with diabetes – a meeting place where ideas and experiences could be exchanged freely and responsibly, and a focal point for a nascent peer support network. paul’s vision is a network of online communities worldwide united by diabetes through social media. That is where the mighty oak analogy ends: a mighty oak takes many years to grow. every month, the uK’s diabetes online community that paul started grows dramatically, and the debates it generates reach extraordinary numbers of people – to the point that they recently became a globally ‘trending topic’ on Twitter. With the idea already being taken up in a number of other countries, including Australia, the usA and Germany, a global network is far from a distant hope. In this article, the community’s founder explains.

situation. Specifically, I looked into the US Diabetic Online Community (DOC).

The community gave me the opportunity to interact with hundreds of other people with diabetes. My confidence grew as my diabetes knowledge and skills devel-oped, and I began taking full control of the management my condition. Within three months, I had brought my HbA1c back down into the non-diabetic range.

24-karat peer support onlinePrior to my diagnosis, I was physically very fit and strong. The year before, I had been training for a marathon. Now I wanted to achieve that fitness again. So my next challenge was to go about developing a proper exercise regimen. I was unable to obtain clear medical guidance about the effects of physical activity on my diabetes. Once again,

The symptoms of my diabetes were ini-tially misdiagnosed. Unhappy with the information I had been given, I sought a second opinion. I was diagnosed with type 1 diabetes, and at the tender age of 44, I found myself taking my first insulin

injection. Perhaps unsurprisingly, I found that a great deal of the information of-fered to me about type 1 diabetes was directed at children and their parents. I decided to turn to the Internet in search of other people who might be in a similar


diabetes in societY

I turned to DOC and found that thou-sands of people with diabetes take part in sports and exercise every day, from family fun and local community sports to elite athlete cycling, competing at the highest level. I found two resources that were useful immediately.

In real timeThe first, the US-based Diabetes Social Media Advocacy network, was a revela-tion. Here was a group of people with diabetes, voluntarily meeting every week online to discuss a wide range of diabe-tes issues. Crucially, because they meet using Internet-based social media, I was able to follow the conversations and debates live. When I read these stories and experiences of real people with my condition who were all willing to share in real time, I felt I had struck gold.

Sport science and self-managementThe second of the invaluable resources that I found online with DOC was a link to a three-day event focusing on sports and exercise at the National Sports Academy at Loughborough University, UK (sponsored by Animas, a manufacturer of diabetes equipment). I joined the event and attended practical sessions in a swimming pool, in the gym and even on a football field, running, cycling, and essentially doing a whole range of things I really wanted to do. That weekend marked another turning point for me: an atmosphere of energy and empowerment filled the confer-ence room. I was one of 50 people with diabetes, all wanting to learn from each other, from the healthcare professionals and indeed from industry how better to self-manage our condition.

I returned home from the weekend feeling uplifted and increasingly con-fident. The following Monday morn-ing, I re-started my own training pro-gramme; on 15 September I completed my first triathlon.

All the people in that inspirational group in Loughborough wanted to keep in touch, so I decided to use social media. I started a Facebook group called Sporty Type1 Diabetics and started to build up a small number of contacts at first. I then created a Twitter identity, @theGBDOC, and started to tweet and blog about what I had learnt that weekend. When I offered to ‘host’ an online meeting, a group of people turned up and we chatted online. All of us had an interest in exercise and diabetes; all of us were motivated to take responsibility for our wellbeing.

Reaching out around the globeFor those who are unaware, Twitter enables people to send and read mes-sages (‘tweets’) of up to 140 characters. Its numbers are extraordinary. In 2012, there were an estimated 500-plus mil-lion active users, generating over 340 million tweets a day, and handling over 1.6 billion search queries every day. Twitter is currently one of the top 10 most visited websites on the Internet.

At 9 pm on 15 August 2012, #gbdoc held its first tweet chat. The first topic for discussion was UK National Hypo Awareness Week campaign, and the de-bate posed a series of questions about our own understanding of hypoglycae-mia, the remedies we use, and how we communicate about this and related issues to others.

This is where the numbers started to get very interesting for #gbdoc. The debate involved 62 people for approximately an hour. It reached a global audience of 483,637 people via Twitter. By week six, #gbdoc had grown from 62 to 319 par-ticipants from 10 countries. Amazingly, the group was creating so many tweets that the hash tag was ‘trending globally’. That means, bearing in mind that half a billion people use Twitter actively, that #gbdoc found itself among the most talked-about topics on the planet.

A world of possibilitiesSocial media form a tool that uniquely can provide a forum for people with diabetes to share knowledge and experi-ences to empower and support each oth-er. Platforms like Twitter and Facebook represent a huge opportunity for the global diabetes community, including healthcare professionals and industry, to help shape the future of our care, therapy and management.

At #gbdoc, our vision is of an online diabetes community (#doc) for every country – and in every language – where there are people with diabetes. That sounds ambitious, but the way things are going, we may be nearer to realizing that vision than we think!

paul BuchananPaul Buchanan is founder of #gbdoc ([email protected]).Visit www.gbdoc.co.uk for more information.

the us-based diabetes social media Advocacy network, was a revelation.

we found ourselves among the most talked-about topics on the planet.

we may be nearer to realizing our vision than we think!

Why A1cClinical studies show that in-office A1c results improve decision-making,2 patient compliance,3 and outcomes. “The immediate feedback of HbA1c results at the time of patient encounters resulted in a significant improvement of glycemic control at 6-month follow-up and persisted for the 12-month study.”4

Outcomes improve when healthcare providers are able to discuss A1c results with patients in real-time.

In-office A1c testing is reimbursedIn-office A1c testing helps you more efficiently manage your patient. It may also reduce the effort and time needed to sort, send, receive, and collate lab samples and reports.

Choose your system for accuracy and more An in-office A1c system should give you highly accurate results.

In addition, look for:

• Simplified test procedure with no reagent preparation.

• Simple and flexible specimen collection.

• NGSPa certification and results that are aligned with DCCTb.

• A system that can also report out IFCC units if required.

• A robust, easily tailored data management system that supports the way your office works.

• Ability to enter patient and operator ID.

• Ability to utilize QC reminders and QC lockout.

• Minimal maintenance.

DCA® analyzers are used by three out of four physicians who perform HbA1c testing in the office5

• NGSP certified and aligned with DCCT results.

• Comparable accuracy to lab A1c tests.

• Simplicity: no reagent preparation, 6 minutes to results, and self-prompting screens.

• Flexible specimen collection: only requires 1 µL of capillary or venous blood sample.

• Decision support: immediate results allow convenient treatment plan adjustments. Additional features include A1c trend graphs and early detection/monitoring of kidney disease (with the optional urine microalbumin/creatinine test).

• Robust, flexible data management: enter patient and operator ID, print or transfer records to EMR/LIS, flash drive, PC, etc.— all through the easy-to-use touch-screen display. Stores up to 4,000 records.

• QC reminder and lockout options: allows the user to easily and conveniently validate system and test result accuracy.

• Excellent track record and low maintenance.

DCA Vantage Analyzer Control Sample Precision Data6

Assigned Value

% HbA1c Mean Value

mmol/mol HbA1c Mean Value

%CV SD

5.0% 5.3 34.4 1.76 0.09

6.5% 6.7 49.7 1.73 0.11

8.0% 8.1 65.0 2.02 0.16

DCA Vantage Analyzer in-office results align closely with laboratory results.

Siemens DCA® HbA1c test kit7 is CE marked and intended for use as an aid to diagnose diabetes and identify patients at risk for developing the disease. Learn more at www.siemens.com/dcanews

Order No. A91DX-9122-A4-4A00 | 11-2012 | All rights reserved | © 2012 Siemens Healthcare Diagnostics Inc.

For additional information visit www.siemens.com/dcanews

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a National Glycohemoglobin Standardization Programb Diabetes Control and Complications Trial

References1. International Expert Committee Report on the Roles of the A1C Assay in the Diagnosis of Diabetes.

Diabetes Care. 2009;32:7:1327-1334.2. Thaler LM, Ziemer DC, Gallina DL, et al. Diabetes in urban African-Americans. XVII. Availability of

rapid HbA1c measurements enhances clinical decision-making. Diabetes Care. 1999;22:1415-1421.3. Miller CD, Barned CS, Phillips LS, et al. Rapid A1c availability improves clinical decision-making in an

urban primary care clinic. Diabetes Care. 2003;26:1158-1163.4. Cagliero E, Levina DV, Nathan DM. Immediate feedback of HbA1c levels improves glycemic control in

Type 1 and insulin-treated Type 2 diabetic patients. Diabetes Care. 1999;22:1785-1789.5. GHX Market Intelligence, market data report. Q3 2009 Raw Data File.6. Siemens DCA Systems HbA1c Addendum to Instructions for Use Internal Study 10698776

Rev. A, 2012-05.7. Not all product offerings are available in all countries. Not available for sale in the U.S. Kit

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In-office A1c Results Improve Diabetes Decision-Making, Patient Compliance, and Outcomes

A1c is the “test of choice” says the International Expert Committee

Summary: According to the July 2009 International Expert Committee Report, “The A1c assay is the test of choice for the chronic management of diabetes.” 1 Other studies show in-office A1c results improve

diabetes decision-making, patient compliance, and outcomes.

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