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DESPITE initial global apathy towards diabetes and related non-communicable diseases, international action on diabetes is now gaining momentum, say Australian experts.
Writing in the MJA, Associate Professor Ruth Colagiuri, of the University of Sydney’s Menzies Centre for Health Policy, and coauthors said recent activity by the United Nations (UN), the WHO and the global public health community had alerted the world to the threat of non-communicable diseases (NCDS). (1)
“Although diabetes and related NCDs remain disproportionately underfunded, the UN now recognises them as a major challenge to human and economic development”, they wrote, pointing to action-oriented policy and monitoring requirements that were being driven by the UN and WHO.
“The UN, WHO and global public health community were slow to recognise the true magnitude of NCDs. Focused on eradicating infectious diseases and reducing perinatal mortality, they failed to appreciate both the size of the NCD problem and its implications”, they wrote, noting that in 2013 diabetes accounted for 5.1 million deaths.
The authors highlighted Australia’s role in negotiating the NCD global monitoring framework and its efforts in developing a National Diabetes Strategy, which is due for completion in mid 2015.
Professor Glen Maberly, senior medical advisor at the Innovation and Redesign Department, Executive Medical Services, Western Sydney Local Health District, Sydney, told MJA InSight global health organisations could quantify the size of the problem and advocate for change, and were “stepping up to the plate” in these areas. However, he said, the health sector lacked the necessary levers to out that change into effect.
“The tsunami of diabetes that is coming through has to be tackled largely through non-health interventions. We are getting [diabetes] because of our modern lifestyle— the change in food and the lack of physical activity — which are not altered in the health sector”, said Professor Maberly, who is also a senior staff specialist (endocrinology) at Blacktown Mt Druitt Hospital.
He said whole-of-government action was needed. “It’s got more to do with the fact that we’re using cars and we’re not using public transport — our physical activity levels have dropped off — and also the food that we eat”.
Professor Maberly is leading a project in western Sydney to create an alliance of councils, housing development companies and food suppliers to address the factors that have contributed to the area becoming a diabetes “hot-spot”, with twice the prevalence of diabetes as Sydney’s inner city and coastal fringe.
Inner city areas were increasingly becoming more walkable, liveable places that promoted healthier lifestyles, but these changes were yet to filter out to suburban areas.
“There is an equity issue. The greatest burden of diabetes is actually with the lower socioeconomic areas [and] is now emerging with the lower socioeconomic countries”, he said.
Dr Thomas Astell-Burt, senior lecturer in public health at the University of Western Sydney, and colleagues are working with the Chinese Center for Disease Control and Prevention to determine the prevalence and management of diabetes in China.
“What we’re finding is that there is considerable variation and it’s linked to urbanisation and changes in diet, which tend to be more progressively western, and more sedentary [lifestyles]. So what we’re seeing in China is a rapid change in circumstance which is promoting a rapid rise in diabetes”, he said. (2)
Dr Astell-Burt was the lead author on research published earlier this year finding that Australian neighbourhoods with more parks and green spaces that promoted physical activity were associated with a lower prevalence of type 2 diabetes than more built-up areas. (3)
“If we were able to change the types of environments that people were living in to something that we know is more healthy and liveable, that would be a good thing”, he told MJA InSight.
Professor Maberly said turning the diabetes epidemic around in Australia would be a “long haul” initiative, but not impossible.
“It took us more than 15 years to put on [an average of] 4 kg in weight in Australia, which is driving the epidemic”, Professor Maberly said. “So … it will take some time to change it, but the health sector by itself can only highlight the problem.”
1. MJA 2014; Online 10 November
2. Diabetes Care 2014; Online 28 October
3. Diabetes Care 2014; 37: 197-201
(Photo: Ollyy / Shutterstock)
The T2D epidemic is due to the combination of both excessive energy intake and altered physical activity patterns. Treatment must involve healthier dietary intake including drastic reduction in sugar intake AND targeted exercise to specifically address the structural and physiological imbalances in the patient. One of the key mechanisms for insulin resistance and lack of glycaemic control is that these patients have low muscle mass which is rarely activated. Specific exercise needs to be prescribed to increase muscle mass so that patients can regain the capacity of the largest organ system in the body to be more responsive to insulin and act as a “sink” for blood glucose. When physical activity is recommended to people with type II diabetes it is relatively ineffective from a physiological standpoint because it does not provide stimulus for muscle hypertrophy. Exercise is not a single medicine. We don’t prescribe statins for osteoporosis so why would we recommend walking to address muscle atrophy and T2D? Muscle is the largest endocrine organ in the body secreting a plethora of hormones and cytokines including leptin, IGF-1, IL-6 and Irisin (Pedersen and Febbraio, 2012). It is not as simple as just increasing physical activity or reducing sugar intake. We need an integrated and coordinated approach to patient management including the general practitioner, exercise physiologist, dietician, clinical psychologist and government support in terms of appropriate Medicare rebates commensurate with the cost of not addressing this issue correctly.
Guy Hibbins is right – obesity results from consumption of energy-dense foods AND inactivity. It is not as simple as saying ”it’s all sugar”, or some other simplistic message like ”fructose is poison” (it isn’t). Whether the inactivity if primary or secondary doesnt really matter, because increasing physical activity has all sorts of benefits, including to mental health, beyond simple weight loss. This Danish group has set up a successful and relatively simple regime for obese children and adolescents:
http://www.hvidovrehospital.dk/NR/rdonlyres/6FF4D2E1-D50F-43F6-B8EE-9E0F36EAADF5/0/HolmChroniccaretreatmentofobesechildren2011.pdf
The cause of the obesity epidemic is actually not so complex and mysterious. Regression analysis by the US National Institutes of Health in Washington has shown that the explosion of obesity since 1980 is mostly linked to the overconsumption of calorie dense processed foods, which are high in fat, sugar and salt and which are designed to maximise consumption and hence sales.
US per capita calorie consumption has increased by around 700kCal or 2900kJ per day since 1980 and exercise levels are largely unchanged. All this is explained in detail in the book The End of Overeating (2010) by former FDA head David Kessler.
In the book Salt, Sugar and Fat (2013) Pulitzer Prize winner Michael Moss explains how food companies know that calorie dense processed food is causing obesity but are locked into selling what is popular in order to keep their sales high and their shareholders happy. He argues that the only way around this is through greater regulation.
To be frank, I am rather disappointed that the message is being diluted by the lifestyle argument. It is equally arguable that inactivity is an association, or even a result, of obesity/metabolic syndrome/diabetes, rather than a significant cause.
The major problem is sugar. It is so ubiquitous as to be virtually unavoidable. Lower socioecomic groups are fatter and get more diabetes primarily because cheap, readily available food is full of sugar and carbohydrates.
Given the economic power of the sugar and food industries, our efforts must not be allowed to be undermined by shifting the blame to the people for being inactive. Food labelling must be front of package, and preferably a stop light system and unavoidably visible, hi-lighting sugar (and also carbs and calories). SSBs (sugar sweetened beverages), along with foods that are energy rich but nutrient poor, must be taxed.
WHO now advise that the maximum recommended intake of sugar is 5 tspn per day. Our government must act to give our population some slim chance of meeting such a target. There is twice that much in one can of soft drink.
Just as alcohol is a major social problem that needs a multi-pronged concerted effort, so does obesity, metabolic syndrome and diabetes. But let’s be clear. We have no chance so long as sugar is so ubiqitous, cheap, palatable, and not even clearly labelled. Let’s fight the problem at its source!