A Global Perspective on Diabetes
The United Nations passed a resolution on December 20, 2006 recognizing diabetes as a global threat. This was a momentous event because it was the first time the U.N. passed such a resolution for a non-infectious disease. The passage of this resolution is especially appropriate because it came shortly after the conclusion of the 19th World Diabetes Congress earlier this month in Cape Town, South Africa. The World Diabetes Congress is the largest international conference on diabetes, hosted by the International Diabetes Federation (IDF), and held once every three years. The U.N. resolution was much mentioned at the conference; the IDF has led the Unite for Diabetes campaign for the passage of this U.N. resolution in the past year with the support of both other non-profit organizations and industry.
At the World Diabetes Congress this year, we learned a great deal about international differences as well as similarities in diabetes care. Though new advances in pharmacotherapy seemed almost universally exciting to the attending clinicians, the extent to which new drugs are actually accessible to doctors and patients from different countries varies widely. The gap is even bigger for devices, which can be considerably more expensive than drugs. Among all the chatter about continuous glucose monitoring or incretin therapeutics here in the U.S., we sometimes forget that some countries are far, far behind in the state of diabetes care. The IDF Congress was therefore dichotomized between presentations on new therapeutics – exciting for those in developed countries – and sobering presentations on the dearth of care in under-developed countries. Type 1 diabetes patients in Mozambique can only get insulin shots at local hospitals, and even there the availability of insulin is not guaranteed. Most die within a year of diagnosis. Luckily, as reflected by the U.N. resolution, the world is changing. However, the message we came away with is that diabetes care looks different from a global perspective than it does from the American, Canadian, or European perspective we're more used to.
In many countries, actual care lags very, very far behind ideal care. The cutting edge of research, therefore, is just not relevant to many at this conference. While progress in insulin tends to be eclipsed by new drug classes and devices at U.S. meetings, at IDF there was quite a lot of interest in insulin and insulin analogs. The analogs in particular are seen as clinical advances in countries where even regular insulin may be in uncertain supply. Similarly, there was very little interest in devices; continuous glucose monitoring, which some patients and doctors in the U.S. are beginning to experiment with, was hardly mentioned. The technology is simply too expensive.
What was unsurprising was a heavy focus on obesity. It looks like obesity is becoming a problem almost everywhere. In particular, there is a rising prevalence of the "metabolic syndrome" throughout the world. This term signifies a group of characteristics related to obesity, diabetes, and cardiovascular disease that are associated with each other; when there's one, there's likely to be another. We learned at IDF of the many causes of the metabolic syndrome beyond the usual suspect, obesity. There's family history, the stress of modern lifestyles, and, particular to developing countries, rapid societal and environmental changes that affect the immune system and insulin resistance. What's worse is how hard the epidemic is hitting children. The IDF's theme in 2007 will be "diabetes in children." We heard some surprising statistics suggesting that obese children progress to diabetes much faster than adults: within two years from impaired glucose tolerance!
Drugs with unsurprising face time at IDF were incretins and TZDs. Incretins are an exciting new class of drugs for people with type 2 diabetes. Byetta and Januvia are examples that are approved. Both seem to be effective without the traditional side effects of anti-diabetes medication like weight gain, and some people lose a lot of weight on Byetta, though many don't like that it needs to be injected. There is a potential with these drugs for beta cell preservation and regeneration, which is exciting though still unproven. TZDs also basked in a spotlight regained at this conference. This class of oral drugs was introduced in the late 1990s and increase insulin sensitivity in people with type 2 diabetes. The results from two huge studies involving TZDs were presented at the meeting, which together showed that TZDs can both prevent diabetes and prevent the progression of diabetes more effectively than other drugs. We predict that members of this class (which includes Avandia and Actos) will continue to be great drugs for less wealthy areas of the globe, especially once the drugs become generic. Inexpensive TZDs would allow healthcare providers to prescribe more widely for both pre-diabetes and diabetes.
Now that we're back from IDF, we feel incredibly thankful for the state of the art in diabetes treatment options and our access to them. Diabetes is lethal without the right tools (and education!) to manage the disease. Though we have a long way to go in our own country in terms of diabetes care and much to think about in our own lives, it's important once in a while to be reminded of how much work still needs to be done to equalize care globally.
Kelly Close is Editor-in-Chief of diaTribe, an electronic newsletter that helps people learn about new ways to manage diabetes better. diaTribe focuses on new drugs, devices and research. diaTribe is free and available online at www.diatribe.us.
NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.
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I no longer wear an insulin pump. Nor do I wear a CGM. I wish the latter were different, as I think a CGM would be quite useful, but the welts that it leaves on my skin - in spite of multiple efforts to fight that welts - are just unacceptable. I am, however, still interested in when people remove their pumps and why. I've seen some recent discussion around folks being asked to remove their pump for mammogram procedure, so I figured I'd ask around the hospital I work to...