What is diabetes?

Diabetes is a chronic, potentially debilitating and often fatal disease. The disease occurs as a result of problems with the production and supply of insulin in the body. Either the body produces no or insufficient insulin (type 1 diabetes), or the body cannot use the insulin it produces effectively (type 2 diabetes). Insulin is a hormone made by the pancreas that helps ‘sugar’ (glucose) to leave the blood and enter the cells of the body to be used as ‘fuel’.

Two types of diabetes
There are two main types of diabetes:

Type 1 diabetes is sometimes called insulin-dependent, immune-mediated or juvenile-onset diabetes. It is caused by an auto-immune reaction where the body’s defence
system attacks the insulin-producing cells. The reason why this occurs is not fully understood. People with type 1 diabetes produce very little or no insulin. The disease can affect people of any age, but usually occurs in children or young adults. People with this form of diabetes need injections of insulin every day in order to control the levels of glucose in their blood. If people with type 1 diabetes do not have access to insulin, they die.

Type 2 diabetes is sometimes called non-insulin dependent diabetes or adult-onset diabetes. People with type 2 diabetes do not usually require injections of insulin. Usually, they can control the glucose in their blood by watching their diet, taking regular exercise, oral medication, and possibly insulin. Type 2 diabetes is most common in people older than 45 who are overweight. However, as a consequence of increased obesity among the young, it is becoming more common in children and young adults. Type 2 diabetes is the most common type of diabetes and accounts for 90-95% of all diabetes. If people with type 2 diabetes are not diagnosed and treated, they can develop serious complications, which can result in an early death. Worldwide, many millions of people have type 2 diabetes without even knowing it. Others do not have access to adequate medical care. The onset of type 2 diabetes is also linked to genetic factors but obesity, physical inactivity and unhealthy diet increase the risks.

Some women develop a third, usually temporary, type of diabetes called ‘gestational diabetes’ when they are pregnant. Gestational diabetes develops in 2-5% of all pregnancies, but usually disappears when the pregnancy is over. Women who have had gestational diabetes have an increased risk of developing type 2 diabetes later on.

Impaired Glucose Tolerance (IGT)

People with impaired glucose tolerance (IGT) have glucose levels that are above normal but below the level at which diabetes is diagnosed. People with IGT have a signifi cant risk of developing type 2 diabetes. They are thus an important target group for primary prevention. Changes in lifestyle, including diet and physical activity can greatly reduce the onset of diabetes.

The onset of type 1 diabetes is often sudden and dramatic and can include symptoms such as:

• Abnormal thirst and a dry mouth
• Frequent urination
• Extreme tiredness/lack of energy
• Constant hunger
• Sudden weight loss
• Slow-healing wounds
• Recurrent infections
• Blurred vision

The same symptoms that are listed above can also affect people with type 2 diabetes, but usually the symptoms are less obvious. The onset of type 2 diabetes is gradual and therefore hard to detect. Indeed, some people with type 2 diabetes show no obvious symptoms early on. These people are often diagnosed several years later, when various complications are already present.

Life-threatening complications

Without proper insulin production and action, glucose remains in the blood, leading to chronic hyperglycaemia (raised blood sugar). This can result in short and long-term complications, many of which, if not prevented and left untreated, can be fatal. All have the potential to reduce the quality of life of people with diabetes and their families. The most common long-term complications are: Diabetic nephropathy (kidney disease), which may result in total kidney failure and in the need for dialysis or kidney transplant. Diabetic eye disease (retinopathy and macular oedema), damage to the retina of the eye which can lead to vision loss. Diabetic neuropathy (nerve disease), which can ultimately lead to ulceration and amputation of the feet and lower limbs. Cardiovascular disease, which affects the heart and blood vessels and may cause fatal complications such as coronary heart disease (leading to a heart attack) and stroke. Diabetes is the fourth leading cause of death by disease globally. Every year, 3.8 million
people die from diabetes-related causes.

• Diabetes affects 246 million people worldwide and is expected to affect some 380 million by 2025.
• Each year another 7 million people develop diabetes.
• Each year, 3.8 million deaths are linked directly to diabetes-related causes including cardiovascular disease made worse by diabetes-related lipid disorders and hypertension.
• Every 10 seconds a person dies from diabetes-related causes.
• Every 10 seconds two people develop diabetes.
• In many countries in Asia, the Middle East, Oceania and the Caribbean, diabetes affects 12 to 20% of the adult population.
• Seven of the 10 countries with the highest number of people living with diabetes are in the developing world.
• In 2025, 80% of all diabetes cases will be in low and middle-income countries.
• Just under half of all people with diabetes are aged between 40 and 59. More than 70% of them live in developing countries.
• India has the largest diabetes population in the world with an estimated 41 million people, amounting to 6% of the adult population.
• In China, where 4.3% of the population is affected by diabetes, the number of people with this condition is expected to exceed 50 million within the next 20 years.
• Type 1 diabetes, which predominately affects youth, is rising alarmingly worldwide, at a rate of 3% per year.
• Some 70,000 children aged 14 and under develop type 1 diabetes annually.
• An increasing number of children are developing type 2 diabetes, in both developed and developing nations.
• Type 2 diabetes has been reported in children as young as eight.
• Reports reveal the existence of type 2 diabetes in child populations previously thought not to be at risk.
• In Japan, the prevalence of type 2 diabetes amongst junior high school children has doubled from 7.3 per 100,000 in 1976-80 to 13.9 per 100,000 in 1991-95, with type 2 diabetes now outnumbering type 1 diabetes in that country.

References:
All epidemiologic data are drawn from the Diabetes Atlas, third edition, International Diabetes Federation 2006

The global diabetes epidemic has devastating personal and social effects, far greater than most people imagine. Surprisingly, the highest costs of diabetes are not the hundreds of billions spent on complications that could have been prevented, although these expenditures are large, but the suffering imposed on families (death, disability and economic stress) and the resulting large annual losses in economic growth that harm everyone. Diabetes harms all people in society, not just those who live with diabetes. From an economic point of view, these effects are tragic because proven, low-cost treatments are available to prevent most of them. Even in the poorest countries, many of these treatments would actually save medical care expenditures.

Death and disability

Diabetes is expected to cause 3.8 million deaths worldwide in 2007, roughly 6% of total world mortality, about the same as HIV/AIDS and malaria combined. Using World Health Organization (WHO) fi gures on years of life lost per person dying of diabetes, this translates into more than 25 million years of lost life each year.
The International Diabetes Federation (IDF) estimates that the equivalent of an additional 23 million years of life are lost each year to the disability and reduced quality of life caused by diabetes complications. Losses to mortality and disability are particularly high in poor and middle-income countries, where people with diabetes are unlikely to get the treatments that are proven to prevent the disease’s killing and disabling complications. For example, in sub-Saharan Africa mortality from diabetes is four times higher than the world average. In these locations, children with type 1 diabetes often die because governments do not ensure that insulin is available and affordable. Instead, many governments tax insulin at their borders, and prevent low-cost generic insulin from being sold. A recent comparison of three otherwise similar African countries showed the consequences. In Zambia, which has a program for insulin management, a person requiring insulin for survival can expect to live an average of 11 years. In Mali, the same person can expect to live for only 30 months, while in Mozambique that person will be dead within a year. Needless deaths in children are tragic and affecting. Statistically, however, diabetes causes nearly all its death and disability in adults. As a result, many children’s lives are adversely affected by a diabetes-related death or disability in the family. This can mean that children must abandon education to supplement the household income or help care for an ailing relative. The economic impact of diabetes on the family can leave no money to pay for children’s medicine and schooling.

Family economic stress from diabetes

In the poorest countries, people living with diabetes and their families bear almost the entire cost of whatever medical care they can afford. In India, for example, the poorest people with diabetes spend an average of 25% of their income on private care. The most that they can pay for are treatments that keep them alive by blunting the highest, quickly fatal levels of blood sugar. Where average incomes are higher, as in Latin America and the Caribbean, families still pay 40-60% of diabetes care costs out of their own pockets, which strictly limits the amount of care that they can get. Blood sugar regulating drugs alone are reported to account for about half of all spending. Little or no money is available to pay for the aspirin, ACEI-inhibitors, statins, and other cheap generic drugs that could prevent renal failure, heart attacks, strokes, and amputations.
IDF’s new estimates of national diabetes-care spending for 2007 include USD 6 per person with diabetes in Burundi, USD 10 in Tajikistan, USD 78 in Guyana, and USD 48 in Haiti. These amounts cannot even cover the annual wholesale price of a generic oral agent capable of preventing acute, life-threatening high-blood sugar.

The devastating effects of diabetes on families translate into signifi cant losses for every individual in society. The mechanisms are many: loss of investments in trained labour; increased taxation (in all its forms) for medical care and support of the disabled; the economic failure of family units and small businesses; withdrawals of children from education (especially girls) to care for ailing relatives; AIDS, tuberculosis, crime and other adverse consequences of destitution; and the general loss of the hope and self-reliance that ultimately drive all economic growth. Considering mainly the effects of premature mortality, WHO estimates that (between 2005 and 2014) diabetes, heart disease and stroke combined will cost: $555.7 billion in lost national income in China, $303.2 billion in the Russian Federation; $336.6 billion in India; $49.2 billion in Brazil $2.5 billion even in a very poor country like Tanzania. Much of the heart disease and stroke in these estimates is linked to diabetes. If nothing is done, diabetes threatens to subvert the gains of economic advancement globally. Accounting for disability, the opportunity costs of care-giving and other factors might triple these WHO fi gures. Government budgets worldwide will face the immense strain of diabetes care on disability payments, pensions, social and medical service costs, and revenue. Furthermore, private health insurers and employers will face the spiralling costs of treating more and more people with diabetes. Because diabetes is increasing faster in the world’s developing economies than in its developed ones, it is the developing world that will bear the brunt of lost economic growth. The economic opportunities that the United Nations wants to create for developing countries with its Millennium Development Goals will be greatly undermined by diabetes if treatments to prevent its complications are not used.

Better treatment can save money everywhere

The costly and fatal effects of diabetes arise largely from its complications, especially heart disease, stroke, amputation and kidney failure. These can be prevented or long-delayed by inexpensive, off-patent pills to control blood sugar, blood pressure, and bad cholesterol (which together reduce risks by more than half); by low-dose aspirin to reduce heart disease risk by 20-25 percent; by stopping smoking (the most important ‘treatment’ of all), and by adopting a healthy diet and exercise. The most effective way to prevent diabetes is by losing weight and getting exercise, but some pills also delay diabetes. In 2006, the World Bank systematically assessed the cost-effectiveness and feasibility of diabetes interventions in developing countries. They identifi ed 14 life-saving treatments that would be cost-effective in every developing region of the world, including four that would actually save money for everyone. The four cost-saving treatments are simple, minimal control of high blood sugar and high blood pressure, foot care in people at high risk of ulcers, and preconception care for women with diabetes. Subsequent research would add a daily aspirin and possibly a daily statin drug to this list. These diabetes treatments are not only inexpensive and cost-saving, they are straightforward to distribute and easy for patients to take. Side-effects are rare at proposed dosages. Regular monitoring is not essential. The pills are almost too inexpensive to be worth the risk of counterfeiting. And treatments like these fl ow easily through a country’s existing, locally governed healthcare infrastructure, strengthening the core institutions on which every nation’s health ultimately depends.
Tragically, most of the cost-saving treatments recommended by the World Bank are rarely used outside the industrialized world, despite saving medical care costs. A major reason is that most of the health budgets of the poorest countries come from outside donors. These donors focus almost all their resources on infectious disease and diseases affecting children. However, because illness is the most important cause of destitution in the developing world, the death, disability and poverty of parents and grandparents resulting from diabetes and cardiovascular disease can have a devastating impact upon dependent children and grandchildren.

World expenditures for diabetes treatment are growing more quickly thanworld population. In 2007, the world is estimated to spend at least USD 232 billion to treat and prevent diabetes and its complications. By 2025, this lower-bound estimate will exceed USD 302.5 billion. In industrialized countries, about 25% of the medical expenditures for diabetes go to treating elevated blood sugar; 25% go to treating long-term complications, largely cardiovascular disease and 50% are consumed by the additional general medical care that accompanies diabetes.

For example, expenditures for a person with diabetes who has end-stage kidney disease are 3 to 4 times higher than expenditures for a person with diabetes and no complications. In the United States, acute hospitalization consumes 44% of diabetes-attributable costs; followed by:

• 22% for outpatient care;
• 19% for drugs and supplies; and
• 15% for nursing care.
  
  Similar proportions are reported for other high-income countries such as Finland. In middle-income countries, half of diabetes medical expenditures are used for blood sugar control, which is essential for the prevention of acute life-threatening hyperglycaemia. The remainder is split between general medical care and chronic complications.
  
  In Latin America and the Caribbean, drugs to reduce blood sugar levels are believed to account for about 50% of all spending.
  It is believed that in low-income countries almost all expenditure for diabetes is directed towards drugs to prevent death from high blood sugar.

Disparities in spending for medical care

• More than 80% of expenditures for medical care for diabetes are made in the world’s economically richest countries.
• Less than 20% of expenditures are made in the middle- and low-income countries where 80% of people with diabetes will soon live.
• One country, the United States of America, is home to about 8% of the world’s population living with diabetes and spends more than 50% of all global expenditures for diabetes care.
• Europe accounts for another quarter of diabetes-care spending.
• The remaining industrialized countries, such as Australia and Japan, account for most of the rest.
• In the world’s poorest countries, not enough is spent to provide even the least expensive life-saving diabetes drugs.
• If nothing changes, the disparity in spending for diabetes care between the industrialized countries and the rest of the world will increase.

Access to care

Although the medical care costs of diabetes are much higher in industrialized countries, nearly all of them have organized medical care insurance systems and/or governmental provisions for medical services. This allows families to survive fi nancially when diabetes strikes. However, costs in these countries are higher than they need to be because insuffi cient money is invested to prevent expensive complications such as heart disease, stroke, kidney disease and amputations. In developing countries, most people living with diabetes bear the brunt of the medical costs out of their own pocket, because the majority of such countries lack an adequate healthcare infrastructure. Health budgets are usually very low compared to military and other expenditures. Imported medicines are taxed for revenue, not subsidized. Doctors and nurses are poorly paid and often emigrate to richer countries or leave the core medical care system for the higher salaries paid by outside donors for infectious disease control. Kickbacks and
inappropriate incentives from drug manufacturers are not unknown. Drug distribution by governments is unreliable, forcing people to buy from private pharmacies, which charge high prices. Health insurance to spread risk is largely unknown. Source: All economic impact data are drawn from the Diabetes Atlas, third edition, International Diabetes Federation 2006.


http://www.worlddiabetesday.org/files/docs/DATASHEET_DM_IGT_in_adults.pdf

http://www.worlddiabetesday.org/files/docs/DATASHEET_Health_expenditures.pdf