Diabetes Mellitus is a chronic metabolic disease characterized by elevated blood glucose (hyperglycemia). It is associated with an absolute or relative deficiency in the secretion and/or action of insulin.
There are three main forms of diabetes: type 1, type 2, and gestational diabetes. Type 2 diabetes is the most common, accounting for approximately 85% to 90% of all cases. It is related to modifiable risk factors such as obesity or overweight, physical inactivity, and high-calorie diets of low nutritional value.
Methabolic syndrome is characterized by the presence of prediabetes in conjunction with one other cardiovascular disease (CVD) risk factor (hypertension, upper body obesity or dyslipidemia).
- The World Health Organization (WHO) estimated that the number of people with Diabetes in the Americas was 62 million in 2012. According to the Diabetes Atlas, the number of people with diabetes will reach the 109 million mark by 2040.
- In 2015 Health Expenditures for diabetes in the Americas were estimated at $382.6 billion (or 12-14% of health budget) and this number will increase to $445.6 billion by 2040.
- Poorly controlled Diabetes increases the chances of premature mortality as well as chronic complications such as cardiovascular diseases, blindness, nephropathy, foot ulcers and amputations. In addition, people with diabetes are at higher risk of presenting tuberculosis, especially those with poor glycemic control.
- The risk of dying from cardiovascular disease (CVD) and all causes is between two and three times higher among people with diabetes than among their peers without diabetes.
- The cost of health care for people affected by diabetes is between two and three times higher than among peers without diabetes.
- While diabetes and its complications are largely preventable, lack of access to quality health care services and lack of knowledge of preventive measures are widespread.
- Studies have demonstrated that approximately one-third of people with type 2 diabetes are undiagnosed, and already present complications at the time of diagnosis.
- People at risk for diabetes should be recommended daily consumption of fruit and vegetables, 30-minute physical activity per day and maintaining a healthy weight.
- People with diabetes should adhere to a healthy lifestyle and medication, if indicated by health provider, to ensure an adequate control of blood glucose.
Women and diabetes:
- In many countries, obesity and diabetes affect women disproportionately. Gestational diabetes in particular has detrimental consequences for both mother and child, increasing the frequency of perinatal morbidity and mortality. In addition, maternal obesity and diabetes have been linked to increased susceptibility for the child to develop diabetes during their youth, creating a vicious circle.
- Diabetes also affects other health conditions; because it impairs immunity, for example, diabetes has been associated with tuberculosis. The relationship among diabetes, maternal and newborn morbidity and tuberculosis may have a negative impact on the achievement of the related Millennium Development Goals in many countries of the Region. Furthermore, low birth weight is associated with an increased risk for type 2 diabetes during adulthood. This may exacerbate the diabetes epidemic in low and middle income countries that are still struggling with a high frequency of low birth weight.
Obesity as a precursor to diabetes:
- The obesity epidemic, which is linked to the rise in diabetes, is largely driven by the twin trends of changing dietary patterns and decreasing physical activity. Most countries in the Americas are experiencing a shift in dietary patterns toward increased consumption of energy-dense foods, rich in saturated fat, sugars, and salt. This pattern, coupled with the fact that 30 to 60% of the population does not meet minimum recommended levels of physical activity (e.g., 30 minutes walking per day) contribute in large part to the high rates of overweight persons and obesity in the Region.
- Adults are considered overweight if they have a body mass index (BMI) between 25 kg/m2 and 29.9 Kg/m2 and considered obese if their BMI is above 30 Kg/m2. Research has demonstrated a strong and consistent link between obesity and diabetes; increases in BMI are associated with increased risk for diabetes and abdominal obesity has emerged as a strong predictor of diabetes.
- Environmental changes are the major contributors to the aforementioned changes in diet and physical activity patterns. A combination of government policies, regional and global market forces, inadequate response to changing demographic patterns, technological advances that precipitate behavior and lifestyle changes, and lack of awareness and action by civil society are key factors leading to the rising epidemics of obesity and diabetes. However, the strong social and environmental determinants of obesity and ill health provide an important area for intervention with strong evidence-based data to guide action.
Diabetes' international framework:
- The international community has recognized the problem of chronic disease and set the stage for its intervention with the WHO Global Strategy for the Prevention and Control of Chronic Diseases (WHA53.17, 2000), The Framework Convention for Tobacco Control (WHA56.1, 2003), the Global Strategy on Diet, Physical Activity and Health (WHA57.17, 2004) and most recently, the aforementioned Regional Strategy on Chronic Diseases (CD47/17, Rev.1).
- The United Nations General Assembly recognized the burden of diabetes by adopting a resolution in D Since then, PAHO has collaborated with Central America, the Caribbean, South America and the US-Mexico border in the area of obesity and diabetes, strengthening capacity for surveillance, conducting public awareness campaigns, facilitating quality improvement strategies for chronic care, and creating task forces for specific issues, among other activities.
- PAHO is also providing assistance and support to several Member States in the creation, implementation, and evaluation of evidence based clinical guidelines for the prevention and control of diabetes, the development and implementation of face to face and internet based diabetes education training programs for people with diabetes and health professionals, and the development of prevention programs as well as the analysis of policies related to diabetes and obesity.
- The current proposal prioritizes results-oriented actions that Member States can take, even in resource-constrained settings, to address the challenges of obesity and diabetes.
Interventions for the prevention and management of diabetes and obesity:
- Prevention and management strategies are crucial to turn back the tide regarding obesity and diabetes. Evidence demonstrates that risks of chronic disease begin in the uterus and continue into old age. Therefore, strategies to address the problem at all stages of the life cycle are important, including paying particular attention to obesity and diabetes in women of reproductive age.
- The frequency of medical care and health expenditures among those with diabetes increases as early as eight years before clinical onset of the disease. This means that persons at the highest risk for type 2 diabetes are often already in contact with the health system and can be easily identified. People with prediabetes have been shown to have increased risk for diabetes and cardiovascular diseases. Diabetes screening facilities are the opportune identification point for such at-risk individuals, or for those in the early stages of obesity and diabetes, when non-pharmacological treatment may still be a preferred option. Studies have demonstrated that approximately one-third of people with type 2 diabetes are undiagnosed, and already present complications at the time of diagnosis.
- Two approaches need to be used to implement prevention strategies: the population-based approach and the individual, high-risk approach. The individual approach focuses on high-risk or affected individuals through direct interventions.
- The population and individual approaches are complementary and function best when combined in an integrated manner.
- Promote universal access to care - Universal access to health care to ensure diabetes prevention and control programs reach all sectors of the population especially those with limited resources and increased risk of type 2 diabetes.
- Primary prevention of type 2 diabetes - Primary prevention at the population and individual level through activities such as health promotion, creation of healthy public policies focused on food, diet and physical activity, and creation of healthy environments. Make diabetes screening and prevention programs available at the first level of care so people at risk can be detected and provide guidance to prevention programs.
- Screening for type 2 diabetes and Impaired Fasting Glucose/Impaired Glucose Tolerance - Identification of people at risk for diabetes (with two or more risk factors for type 2 diabetes (such as a family history of diabetes, high blood pressure, a history of hyperglycemia or gestational diabetes, or overweight) where preventive services are available.
- Improving the management of diabetes - Standards for care and management of obesity and diabetes should be developed and implemented at the primary care level. The chronic care model is a framework to identify gaps in care with the aim of designing strategies for quality improvement. The creation of community programs within the civil society can provide additional support to people with obesity and diabetes.
- Secondary prevention of complications - Strategies include patient and provider education, efforts aimed at smoking cessation, increased physical activity, and healthy eating. A number of clinically proven strategies are available for the secondary prevention of complications such as CVD, nephropathy, retinopathy, blindness and amputations. The WHO package of Essential NCD Interventions in Primary Health Care (WHO — PEN) provides treatment protocols, referral criteria, an affordable list of essential medicines and technologies and templates for record keeping in primary health care.
- Surveillance and monitoring - Various sources of information can be used for the surveillance of diabetes and obesity in populations, including periodical population-based surveys using the WHO Steps method, health service statistics, school-based surveys and routinely collected vital statistics.
- Health policies - Use fiscal, regulatory and other government powers to create environments that make the healthy choice the easier choice to make. This includes, for example, increasing taxes to reduce consumption of sugar-sweetened soda; banning advertising of unhealthy foods to children along with the sale of these foods in schools; and promoting public transportation and recreational spaces to encourage urban residents to be more physically active.
PAHO is working with Member States and other partners to increase people's access to quality integrated diabetes care, including:
- PAHO's Health Technology Manual includes a series of actions that can be taken at the first level of care to prevent or better control diabetes.
- The Passport for Healthy Lifestyle is tool for the improvement of the management of diabetes and other chronic diseases and it is available in English, Spanish and Portuguese.
- Implementing diabetes education courses for health professionals and people with diabetes in the PAHO Virtual Campus (currently available only in Spanish).
- Providing training in the implementation of the integrated management of chronic diseases.
- Providing advice and training on the implementation of patient centered care by providing self-management support.
- Support the implementation of evidence based diabetes guidelines and protocols such as those from the Latin American Diabetes Association, and the American Diabetes Association.