We had better wake up fast to address this multifactorial problem.
What in the world, literally, are we going to do about the diabetes pandemic? This multifactorial problem requires multifaceted solutions targeting myriad etiological factors.
Though focused lifestyle interventions like the Diabetes Prevention Program (150 minutes of walking per week with the goal of losing five to seven percent of body weight) have been shown to delay the onset of diabetes significantly in high-risk patients, most of these subjects ultimately developed diabetes within 15 years of this intervention.1
Moreover, there is only limited evidence for implementing these strategies and changing bad outcomes in real-world settings.2
Although some medications decrease the risk of diabetes (e.g. metformin, pioglitazone, and weight-loss drugs), they can have significant side effects and may not be effective long-term.3
In fact, some evidence suggests population rates of diabetes and death from diabetes decline when economic downturns have forced people to eat less food (due to both scarcity and higher costs).4,5
There is no single magic bullet.
Short of major global recession (God forbid), there are several possibilities that make sense:
• Laser-focused community education about healthy lifestyle choices beginning at an early age
• Meaningful economic incentives to exercise and to design our communities, schools and workplaces to promote physical activity
• Massive economic incentives to produce and eat a variety of genuinely nutritious foods and in moderation (following Michael Pollan’s great advice-that is, eat real food, not too much, mostly plants)
• Significant, collaborative, and cooperative multinational and multidisciplinary environmental change (both “carrots” and “sticks”) to reduce factors determined to be reasonably contributory by the body of scientific evidence.
To this end, we need public advocates, we need leadership, and we need to wake up-the sooner the better.
The Lancet estimates that 422 million people worldwide had diabetes in 2012.6 Data were extrapolated from more than 751 population-based studies of diabetes prevalence from 146 different countries.
This shocking prevalence has grown nearly four times over 32 years (from 108 million cases in 1980), and evidence suggests that new cases of diabetes are now predominantly affecting middle- to poorer-income countries, contrary to previous assertions that diabetes was a disease affecting primarily affluent, developed nations.
China and India have the largest numbers of people living with diabetes (100 million and 70 million, respectively), figures that are being attributed to a growing middle class that is more likely to be sedentary and consume excess calories (both increasingly Westernized diets and increased intake of habitual foods).
Moreover, evidence suggests that Asian people are more likely to develop diabetes at lower body weight than those of European ancestry.7
Diabetes incorporates many risk factors into the disease.
Additional factors linked to the diabetes epidemic include:
• Reduced availability of diverse plant foods and the panoply of nutrients they contain8 (three crops account for the majority of food energy globally-wheat, rice and corn9)
• Depletion of phytonutrients from soil resulting from industrialized agricultural practices10
• Prenatal and childhood malnourishment11
• Chemical exposure11
• Antibiotic use12 that decreases beneficial diversity of the intestinal microbiome and increases the risk of diabetes and obesity in adolescence and adulthood (increased prevalence of Caesarian section births and use of nonnutritive sweeteners like aspartame and sucralose are also linked to this phenomenon13)
• Rising costs of fruits and vegetables14
• Reduced time spent outdoors due to climate change14
• Insufficient sun exposure and widespread vitamin D deficiency and insufficiency
See Figure 1.15
Other important risk factors may include:
• Warmer ambient indoor air temperatures linked to depletion of thermogenic brown adipose tissue16
• Increased levels of particulate air pollution that contribute to the pathobiology of insulin resistance17
• Decreased sleep18 and increased exposure to light at night,19 both of which have been shown to cause metabolic disturbances linked to diabetes
• Increased dietary consumption of added sugars20 (a phenomenon linked to diabetes more tightly than is obesity-at the population level, each 150 Kcal increase in added sugars per day [the equivalent of a 12-ounce can of sugar-sweetened soda] increases population prevalence of diabetes 1.1 percent, which in the U.S. means about 3.9 million additional cases of diabetes)
• Increased marketing of injurious foodstuffs, especially in the relative absence of dollars spent advertising healthy foods and portion sizes21
Diabetes care (office visits, hospitalizations, medical tests, medications) cost the world economy about $825 billion international dollars in 2014 for treatment and management (the U.S. accounted for $105 billion of this figure, which did not include indirect costs such as lost economic productivity-a number that is significantly higher in the U.S.,22 where every new case increases lifetime medical expenses $283,000 on average).
Diabetes remains a leading cause of blindness, end-stage renal disease, nontraumatic amputation, and cardiovascular disease. It causes 1.5 million premature deaths per year globally.6 Diabetes is also linked to a two-fold increased risk of Alzheimer’s and non-Alzheimer’s dementia.23
Equally troubling is strong evidence showing genetic and epigenetic predispositions toward type 2 diabetes from both injurious childhood exposures and changes in maternal mitochondrial DNA that guarantee transmission of type 2 diabetes to future generations.24
Even though good metabolic control reduces the risk of complications, it does not eliminate them or the risk of death and disability, particularly in poorer nations.
In fact, the global number of cases of diabetic eye disease is already at a level with which healthcare professionals cannot keep pace.25
Conservative estimates are that 46 percent of people who now have diabetes have not yet been diagnosed26 (28 percent in the U.S.), a number directly extrapolated from the prevalence of retinopathy at diagnosis. Obviously, the most effective way to reduce the human and financial cost of diabetes, including vision loss, is to prevent people from developing diabetes in the first place.
1. Diabetes Prevention Program Research Group. Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study. Lancet Diabetes Endocrinol. 2015 Nov;3(11):866-75.
2. Kahn R, Davidson MB. The reality of type 2 diabetes prevention.Diabetes Care. 2014 Apr;37(4):943-9.
5. Franco M, OrduÃ±ez P, Caballero B, Tapia, et al. Impact of energy intake, physical activity, and population-wide weight loss on cardiovascular disease and diabetes mortality in Cuba, 1980-2005.Am J Epidemiol. 2007 Dec 15;166(12):1374-80.
6. NCD Risk Factor Collaboration, (World Health Organization). Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participants. Lancet. 2016; 387(10027):1513-1530.
7. Cooper AJ, Sharp SJ, et al. A prospective study of the association between quantity and variety of fruit and vegetable intake and incident type 2 diabetes. Diabetes Care. 2012 Jun; 35(6): 1293-300.
8. Facts and Figures on Food and Biodiversity. International Development Research Center. Available at: http://www.idrc.ca/EN/Resources/Publications/Pages/ArticleDetails.aspx?PublicationID=565. Accessed April 8, 2016.
9. Horrigan L, Lawrence RS, Walker P. How sustainable agriculture can address the environmental and human health harms of industrial agriculture. Environ Health Perspect. 2002 May;110(5):445-56.
10. Jiang X, Ma H, Wang Y, Liu Y. Early life factors and type 2 diabetes mellitus.J Diabetes Res. 2013;2013:485082.
11. Mueller NT, Whyatt R, Hoepner L. Prenatal exposure to antibiotics, cesarean section and risk of childhood obesity. Int J Obes (Lond). 2015 Apr;39(4):665-70.
15. McDonnell SL, Baggerly LL, French CB, et al. Incidence rate of type 2 diabetes is >50% lower in GrassrootsHealth cohort with median serum 25-hydroxyvitamin D of 41 ng/ml than in NHANES cohort with median of 22 ng/ml. J Steroid Biochem Mol Biol. 2016 Jan;155(Pt B):239-44.
17. Weinmayr G, Hennig F, Fuks, K, et al. Long-term exposure to fine particulate matter and incidence of type 2 diabetes mellitus in a cohort study: effects of total and traffic-specific air pollution. Environ Health. 2015 Jun 19;14:53.
19. Morris CJ, Purvis TE, Mistretta J, Scheer FA. Effects of the Internal Circadian System and Circadian Misalignment on Glucose Tolerance in Chronic Shift Workers. J Clin Endocrinol Metab. 2016 Mar;101(3):1066-74.
21. Hawkes C. Regulating food marketing to young people worldwide: trends and policy drivers. American Journal of Public Health. 2007;97(11):1962-73.
23. Umegaki H. Type 2 diabetes as a risk factor for cognitive impairment: current insights.Clin Interv Aging. 2014 Jun 28;9:1011-9.
24. Drong AW, Lindgren CM, McCarthy MI. The genetic and epigenetic basis of type 2 diabetes and obesity.Clin Pharmacol Ther. 2012 Dec;92(6):707-15