- Evidence-based interventions are too often unavailable, leading to thousands of preventable deaths globally daily.
- The COVID-19 pandemic has highlighted the vulnerability of people with diabetes, and lack of action in tackling key risk factors.
Ahead of World Diabetes Day (14th November), The Lancet publishes a new report calling for action to close the gap in diabetes prevention and care. Worldwide, 463 million people have diabetes, with 80% from low-income and middle- income countries (LMICs). In 2019, 4.2 million people died as a result of the condition and its complications.
On average, diabetes reduces life expectancy in middle-aged people by 4-10 years and independently increases the risk of death from cardiovascular disease, kidney disease, and cancer by 1.3-3 times. Diabetes is among the leading causes of non-traumatic leg and foot amputations and blindness, especially among people of working age.
The COVID-19 pandemic has highlighted the vulnerability of people with diabetes. People with diabetes are at least 2 times increased risk of severe disease or death from the virus, especially in individuals with poorly controlled diabetes, or who have diabetes-related complications, but the risk is also exacerbated by social conditions in disadvantaged communities that lead to lower access to care and higher rates of comorbidities.
While effective treatments and prevention strategies exist, barriers to provision and access mean that, in most care settings, their use is scarce. The Lancet Commission on Diabetes brings together 44 leading experts who collaborated for four years to develop a multicomponent, integrated strategy involving the redesign of clinical workflows and training of non-physician personnel to form diabetes teams to support diabetes care with ongoing data collection to inform practices and policies.
Based on a comprehensive analysis of the available data on diabetes care, the Commission summarises the best evidence for effectively managing diabetes, which relies upon six components:
- 1) Sustained weight reduction in patients with obesity by 15kg or more can induce remission of type 2 diabetes for up to 2 years
2) Reducing blood sugar levels (HbA1c) by 0.9% (10 mmol/mol), systolic blood pressure by 10 mm Hg, LDL cholesterol concentration by 1 mmol/L (39 mg/dL), or a combination of all three, can independently reduce the risk of cardiovascular disease, all-cause death, or both, by 10-20% in patients with type 2 diabetes
3) Reducing multiple risk factors, including by use of statins and renin-angiotensin system (RAS) inhibitors, can prevent cardiovascular-renal events by 20-40% in individuals with or at risk of having diabetes
4) Use of SGLT2 inhibitors and GLP-1 receptor agonists can reduce cardiovascular-renal events and death rates by up to 40%, independent of their effect on lowering blood glucose concentration
5) Use of data-driven, team-based integrated care through the reorganisation of healthcare provision can reduce cardiovascular and all-cause death in patients with type 2 diabetes by 20-60%
6) Implementing a structured lifestyle intervention and use of metformin can each prevent or delay type 2 diabetes in individuals with impaired glucose tolerance by 30-50%
New modelling by the Commission estimates the impact of these strategies. For instance, the ten LMICs with the greatest burden of diabetes (China, India, Brazil, Mexico, Indonesia, Egypt, Pakistan, Bangladesh, Turkey, Thailand) account for 217 million cases of type 2 diabetes - representing nearly 50% of all diabetes cases. The Commission estimates that 3.2 million of these individuals would die in three years if not treated, with 1.3 million of these deaths due to cardiovascular disease. By reducing HbA1c, blood pressure and LDL cholesterol through achieving a diagnosis rate of 50%, ensuring access to essential medicines such as statins, which are available at extremely low cost even in LMICs, in at least 70% of patients, and with a support system to sustain reductions in these risk factors over three years, up to 800,000 premature deaths could be avoided.
In high income countries, quality care is generally provided to young individuals with type 1 diabetes. By contrast, most young individuals in LMICs countries receive minimal care. Globally, 1.61 million people have type 1 diabetes. The Commission estimates that 14,466 young individuals (aged under 25 years) with type 1 diabetes died in 2017 globally. The vast majority of these deaths are preventable and comprehensive care for type 1 diabetes could lead to over 12,092 fewer deaths each year in this age group.
Lead author Professor Juliana Chan, The Chinese University of Hong Kong, says: "By protecting our environment, changing our practice, and empowering our communities, we can reduce the burden of diabetes as a root cause of many noncommunicable diseases. The diabetes epidemic is a calling that concerns all of us, as everyone has contributed to the ecosystem in one way or another to fuel the epidemic. As such, we all have the collective responsibility to rise to this challenge to sustain our environment and to use our finite resources wisely to preserve humanity. The global challenge of diabetes transcends political, economic, social, and technological domains." 
Writing in a linked Comment, Katie Dain, NCD Alliance, Switzerland, says: "As the world seeks to create a more sustainable, fair, and equal future in the wake of COVID-19, the NCD community must become more effective advocates for change. In celebrating the centenary of insulin discovery, we can create valuable opportunities to do so, with lived experience as the engine to drive further progress. We must collectively call on political leaders and governments to make good on their UN commitments with decisive, inclusive, and accountable leadership and appropriate investment if we are to reach the 2025 NCD targets and 2030 SDGs. Irrespective of the challenging financial landscape, investment in tackling diabetes and other NCDs now will prevent substantial and unsustainable health-care costs in the future."
The Commission is published ahead of World Diabetes Day 2020, which will also see the announcement of the development of the WHO Global Diabetes Compact, to be launched in April 2021.
A Lancet editorial published alongside the report states: "The evidence-base for improving diabetes prevention and care is strong. The question now for diabetes advocates is how to achieve the comprehensive, systems-level change needed to translate this evidence into action? ... Through the [WHO Global Diabetes] Compact, WHO will work with partners to support countries to mobilise resources and accelerate structural transformations that together will enable the scale-up of access to essential diabetes medicines and technologies, the inclusion of diagnosis and treatment of diabetes in primary healthcare and universal health coverage packages, and the reduction of major population-level diabetes risk factors such as obesity. This initiative represents a valuable opportunity to build partnerships between governments, care providers, patient advocates, and non-governmental organisations to implement the Commission's recommendations through a renewed global diabetes movement. The case to act has never been more urgent."
Peer-reviewed / Review, modelling and opinion
NOTES TO EDITORS
This study was funded by The Chinese University of Hong Kong, the US Centers for Disease Control and Prevention, and The Croucher Foundation. A full list of authors and their institutes is available in the paper.
The report will be launched at a webinar on Friday 13 November 2020 (Friday) at 1400 UK time - to attend, please register: https://bit.ly/3lc0DF2
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