FULL 63 PAGE PDF – The Lancet Commission on Diabetes: using data to transform diabetes care and patient lives
Dr David Ludwig on Twitter https://twitter.com/davidludwigmd/status/1328346729284964352
The Lancet CommissionsThe Lancet Commission on diabetes: using data to transform diabetes care and patient lives
2020 will go down in history as the year when the global community was awakened to the fragility of human health and the interdependence of the ecosystem, economy, and humanity. Amid the COVID-19 pandemic, the vulnerability of people with diabetes during a public health emergency became evident by their at least 2 times increased risk of severe disease or death, especially in individuals with poorly controlled diabetes, comorbidities, or both. The disease burden caused by COVID-19, exacerbated by chronic conditions like diabetes, has inflicted a heavy toll on health-care systems and the global economy.
In this Lancet Commission on diabetes, which embodies 4 years of extensive work on data curation, synthesis, and modelling, we urge policy makers, payers, and planners to collectively change the ecosystem, build capacity, and improve the clinical practice environment. Such actions will enable practitioners to systematically collect data during routine practice and to use these data effectively to diagnose early, stratify risks, define needs, improve care, evaluate solutions, and drive changes at patient, system, and policy levels to prevent and control diabetes and other non-communicable diseases. Emerging evidence regarding the possible damaging effects of severe acute respiratory syndrome coronavirus 2 on pancreatic islets implies the potential worsening of the COVID-19 pandemic and the diabetes epidemic, adding to the urgency of these collective actions.
Prevention, early detection, prompt diagnosis, and continuing care with regular monitoring and ongoing evaluation are key elements in reducing the growing burden of diabetes. Given the silent and progressive nature of diabetes, it is epidemiological analyses that have provided a framework for identifying populations and subgroups at risk of diabetes and its complications. Although the total prevalence of diabetes reflects disease burden, incidence rates might reflect the effects of interventions among determinant factors that include, but are not limited to, political, socioeconomical, and technological changes within a population, area, or both.
In 2019, 463 million people had diabetes worldwide, with 80% from low-income and middle-income countries. Over 70% of global deaths are due to non-communicable diseases, including diabetes, cardiovascular disease, cancer, and respiratory disease. On average, diabetes reduces life expectancy in people aged 40–60 years by 4–10 years and independently increases the risk of death
• Ensuring access to insulin, patient education, and tools for monitoring blood glucose concentration can prevent premature deaths and emergencies in young patients with type 1 diabetes, especially in disadvantaged communities
• The effects of maternal hyperglycaemia on childhood obesity require a multicomponent life-course strategy to prevent young-onset diabetes, which might benefit the next generation
• Complex causes, notably psychosocial needs, especially in patients with young-onset diabetes, call for structured assessment to personalise care for reducing premature development of non-communicable diseases and death
• The diverse environmental, behavioural, and socioeconomic causes of type 2 diabetes require a multitiered societal and population-based prevention strategy • The marked differences in diabetes diagnosis, treatment, and outcomes in low-income and middle-income countries versus those in high-income countries are likely to be due to differences in investment, capacity, health-care systems, and care organisation
• Sustained reduction of common cardiometabolic risk factors, including smoking cessation and use of statins, renin–angiotensin system inhibitors, SGLT2 inhibitors, and GLP-1 receptor agonist therapies can reduce cardiovascular–renal diseases and all-cause death in patients with type 2 diabetes
• The delivery of team-based care can enable systematic collection of data during routine clinical practice to improve the quality of electronic medical records and to establish registers for surveillance, prevention, and treatment
• The strengthening of existing infrastructures to provide continuing integrated care and the creation of career paths for physicians with knowledge and skills to reorganise diabetes care, train non-physician personnel, and use technology effectively can improve the accessibility, sustainability, and affordability of diabetes prevention and care.
Most experts recommend a screening strategy targeted at individuals at high risk who present with risk factors and risk markers for the disease, such as obesity and high blood pressure, which can be self-assessed. These data can be used to compute risk scores to detect individuals at high risk, followed by confirmatory laboratory tests including 75 g oral glucose tolerance test, HbA1c, or both.369 Regarding the best lifestyle intervention strategy, systematic reviews (including economic analyses) suggest that promoting healthy diet and physical activity, especially if delivered in groups or in primary care settings, and targeting individuals at high risk can be cost-effective in LMICs and HICs.348,349,384
The cost-effectiveness of some of these population-level interventions have been evaluated, including sugar-sweetened beverage taxes,402 restrictions on unhealthy food advertising,403 mass media campaigns to promote healthy lifestyle,404 and economic incentives to increase fruit and vegetable consumption.405,406 Because the effectiveness of such interventions cannot be determined from randomised controlled trials, simulation modelling is often used to estimate their costeffectiveness. Evidence from the few studies available suggests that these interventions are generally cost saving or cost-effective.407 Studies of the cost-effectiveness of fruit and vegetable subsidies were inconclusive.
The increased production of goods and free trade agreements have led to changes in leisure and non-leisure activity; excessive screen time; qualitative changes in diet, favouring sugar-sweetened beverages and sodium, and reducing intake of grains, fruits, and vegetables; increased portion sizes; and change in work schedules, which all in turn alter dietary patterns and sleep schedules. In LMICs, food insecurity, poor affordability of healthy foods (eg, fresh fruits, vegetables, whole grains), undernutrition, and high consumption of low-quality calories are not uncommon, and are often made worse by poverty.113,125 Similarly, in HICs, underserved communities often have few choices in leisure activities, are likely to consume more energy-dense food, and often cannot afford healthy foods that tend to be expensive.126,127 In the latest GBD 2017 analysis, dietary factors explained as much as 20% of the attributable risk of NCD.128