Diabetes Voice - April 2017 by International Diabetes Federation

Diabetes Voice GLOBAL PERSPECTIVES ON DIABETES

Volume 63 -Issue 1 - April 2017

ADVANCING THE URGENCY FOR ACTION

Shape the future of diabetes Learn. Discover. Connect. congress@idf.org / www.idf.org/congress / #IDF2017

The IDF Congress brings together healthcare professionals, diabetes associations, policy-makers and companies to share the latest findings in diabetes research and best practice.

Learn 160h of scientific sessions • 1000 ePosters •

Discover • 9 programme streams • 70 international exhibitors

Connect • 200 speakers • 12 000 delegates • 230 IDF members

When & Where • 4-8 December 2017 • Abu Dhabi National Exhibition Centre (ADNEC), United Arab Emirates Registration • 2 January 2017 - Online registration opens • 18 August 2017 - Early-rate deadline • 13 November 2017 - Online registration closes

Abstracts & Grants • 1 February 2017 - Abstract submission and grant application open • 21 April 2017 - Abstract submission closes • 28 April 2017 - Grant application closes

The International Diabetes Federation (IDF) represents the interests of the growing number of people with diabetes and those at risk.

CONTENT

15 4

GLOBAL CAMPAIGN Extensive Global Network Prepares To Assemble Elizabeth Snouffer

DIABETES VIEWS Urgent need for better interventions

Douglas Villarroel

6 11

NEWS IN BRIEF GLOBAL CAMPAIGN The Berlin Declaration: Strengthening early action for diabetes prevention and care

IDF launches Clinical Practice Recommendation on the Diabetic Foot: A Guide For Healthcare Professionals Ammar Ibrahim

DIABETES IN SOCIETY

New IDF network represents the global voice of diabetes Lorenzo Piemonte

Sanjay Kalra And Ashok Kumar Das

IDF Advocacy: New energy for the Young Leaders in Diabetes (YLD) Program

CLINICAL CARE

Interview with Oren Liebermann: The Insulin Express

Beatriz Yáñez Jimenez and Elizabeth Snouffer International Diabetes Federation Promoting diabetes care, prevention and a cure worldwide Editor-in-Chief: Douglas Villarroel Editor: Elizabeth Snouffer Editorial Coordinator: Lorenzo Piemonte All correspondence should be addressed to: Elizabeth Snouffer, Editor International Diabetes Federation Chaussée de La Hulpe 166, 1170 Brussels, Belgium Tel: +32-2-538 55 11 | Fax: +32-2-538 51 14 diabetesvoice@idf.org Diabetes Voice is available online at www.diabetesvoice.org

© International Diabetes Federation, 2016 - All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permission of the International Diabetes Federation (IDF). Requests to reproduce or translate IDF publications should be addressed to communications@idf.org. The material in this document is for information purposes only. IDF makes no representation or warrantires about the accuracy and reliability of any content in the document. Any opinions expressed are those of their authors, and do not necessarily represent the views of IDF. IDF shall not be liable for any loss or damage in connection with your use of this document. Through this document, you may link to third-party websites, which are not under IDF’s control. The inclusion of such links does not imply a recommendation or endorsement by IDF of any material, information, products and services advertised on third-party websites, and IDF disclaims any liability with regard to your access of such linked websites and use of any products or services advertised there. While some information in Diabetes Voice is about medical issues, it is not medical advice and should not be construed as such.

DIABETES VIEWS

URGENT NEED

FOR BETTER

INTERVENTIONS Douglas Villarroel Editor-in-Chief of Diabetes Voice.

t present there is cause for grave concern. There is an urgency for greater action to improve diabetes outcomes and reduce the global burden of diabetes now affecting more than 415 million lives worldwide. Diabetes, most predominantly type 2, is a leading cause and contributor to premature mortality and morbidity in developing and developed nations alike, and directly linked to the dramatic rise in obesity. Overall, people with diabetes are at twice the risk for premature death due to microvascular and macrovascular complications; diabetes is the leading cause of blindness due to retinopathy, a major cause of chronic renal failure and the leading cause of end-stage renal failure requiring dialysis. Macrovascular complications of diabetes include stroke and heart failure, as well as other major morbid conditions including lower limb amputation. Diabetes, if ignored or inadequately treated, destroys lives. What will it take for governments to recognize the urgency to take action?

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DIABETES VIEWS

Timely and appropriate interventions for both diabetes prevention and care are vital to the public health of every country worldwide. Based on firm evidence, IDF and its partners developed the four pillars of the Early Action in Diabetes initiative (2015) to establish targets and drive meaningful policies. The four pillars are: Prevention, Early Detection, Early Control and Early Access to the Right Interventions. The original initiative was followed by a forum composed of diabetes experts and political leaders from 11 countries resulting in the Berlin Declaration, written in 2016. This international proclamation represents the extreme urgency for global diabetes action today, and is discussed in greater detail in this issue (The Berlin Declaration: Strengthening Early Action for Diabetes Prevention and Care, page 11). By making lifestyle changes, such as improving diet and exercise, the risk of developing diabetes can be reduced. Type 2 diabetes starts long before symptoms present. However, once diabetes has developed, identifying and treating the disease early and appropriately may reduce serious and costly complications. Ammar Ibrahim, one of the expert authors of IDF’s new Clinical Practice Recommendation on the Diabetic Foot, writes about the new guide for healthcare professionals in this issue (page 23). IDF’s Recommendation is a much needed intervention developed to help HCPs better manage diabetic foot disease thereby eliminating the threat of amputation. Of the one million amputations per year, experts believe about 85% are preventable. Collectively, IDF, diabetes stakeholders, and policy makers can make a significant contribution in reducing the destructive impact of diabetes,

stopping the rise in diabetes and improving the lives of those living with the disease. People living with diabetes are also valuable advocates whose voices are essential to improving access and care and ending discrimination. IDF’s Blue Circle Voices (BCV) initiative is a virtual network drawing on the experiences of people living with diabetes from IDF Members and introduced in this issue (page 27). BCV members will participate in specific surveys and consultations covering topics from discrimination to access making a more transparent, solid call-to-action for improvements in care and greater understanding of people with diabetes everywhere. Gaps in diabetes awareness and education exist everywhere but information and care are weakest in developing countries where type 1 diabetes is misunderstood or not recognized at all. Oren Liebermann, CNN correspondent for Israel, developed type 1 diabetes in 2014 while travelling in Nepal. He has written a memoir about his experience in The Insulin Express and we are grateful for his interview (page 30). Our April issue of Diabetes Voice presents information specific to the IDF Congress 2017, where thousands of global experts in diabetes will gather in Abu Dhabi from the 4th to the 8th December. (Page 15) IDF’s Congress, the most significant global diabetes event worldwide, will share the latest achievements in diabetes research as well as explore new developments and technologies in care. It will be there that we will report not just on advances in treatment or focus on data, but also on progress for Early Action in Diabetes.

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NEWS IN BRIEF

WORLD DIABETES DAY 2017

FOCUS ON

WOMEN AND DIABETES The International Diabetes Federation (IDF) recently announced that World Diabetes Day 2017 will focus on women and diabetes, with the slogan â&#x20AC;&#x153;Our right to a healthy future.â&#x20AC;? There are currently over 199 million women living with diabetes and this total is projected to increase to 313 million by 2040. Gender roles and power dynamics influence vulnerability to diabetes, affect access to health services and health seeking behaviour for women, and amplify the impact of diabetes on women. Diabetes is the ninth leading cause of death in women globally, causing 2.1 million deaths each year. As a result of socioeconomic conditions, girls and women with diabetes experience barriers in accessing cost-effective diabetes prevention, early detection, diagnosis, treatment and care, particularly in developing countries. Socioeconomic inequalities expose women to the main risk factors of diabetes, including poor diet and nutrition, physical inactivity, tobacco consumption and harmful use of alcohol. Two out of every five women with diabetes are of reproductive age, accounting for over 60 million women worldwide. Women with diabetes have more difficulty conceiving and may have poor pregnancy outcomes. Without pre-conception planning, type 1 and type 2 diabetes can result in a significantly higher risk of maternal and child mortality and morbidity.

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Approximately one in seven births is affected by gestational diabetes (GDM), a severe and neglected threat to maternal and child health. Many women with GDM experience pregnancy related complications including high blood pressure, large birth weight babies and obstructed labour. A significant number of women with GDM also go on to develop type 2 diabetes resulting in further healthcare complications and costs. Stigmatisation and discrimination faced by people with diabetes are particularly pronounced for girls and women, who carry a double burden of discrimination because of their health status and the inequalities perpetrated in maledominated societies. These inequalities can discourage girls and women from seeking diagnosis and treatment, preventing them from achieving positive health outcomes. The World Diabetes Day 2017 campaign will promote the importance of affordable and equitable access for all women at risk for or living with diabetes to the essential diabetes medicines and technologies, self-management education and information they require to achieve optimal diabetes outcomes and strengthen their capacity to prevent type 2 diabetes. IDF will release campaign materials from May through to September to help the diabetes and wider WDD stakeholder community prepare for World Diabetes Day on 14 November.

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NEWSINBRIEF

PEOPLE INFECTED WITH HIV MORE SUSCEPTIBLE TO TYPE 2 DIABETES

TYPE 1 DIABETES PROGRESSES MORE RAPIDLY IN CHILDREN WITH HIGH BMI

People infected with HIV may be more susceptible to developing type 2 diabetes, suggests research published in the online journal BMJ Open Diabetes Research & Care.

According to a new study, published in Diabetes Care, children predisposed to type 1 diabetes who have a high body mass index (BMI) are at risk of more rapid disease progression, but the effect varies by sex and age.

The research found that type 2 diabetes prevalence among HIV-infected adults in the USA was 10.3% (95% CI 9.2% to 11.5%). Type 2 diabetes prevalence was 3.8% (CI 1.8% to 5.8%) higher in HIV-infected adults compared with general population adults after adjusting for age, sex, race/ethnicity, education, poverty-level, obesity, and Hepatitis C virus infection. Research analysis also showed that prevalence among HIV-infected adults may be likely to occur at a younger age and in the absence of obesity, a key risk factor for type 2 diabetes. Due to the higher prevalence of type 2 diabetes among HIV-infected adults, HIV-care providers should follow existing screening guidelines for diabetes, which recommend Fasting Blood Glucose (FBG) and HbA1c be obtained prior to and after starting antiretroviral therapy. The study concludes that additional research would help to determine whether type 2 diabetes screening guidelines should be modified to include HIV infection as a risk factor and to identify optimal management strategies in this population.

Researchers from the University of California studied 1,117 autoantibody-positive children from the TrialNet Pathway to Prevention trial. The research team observed a number of trends related to BMI data and type 1 diabetes risk: • Autoantibody-positive children with a BMI in excess of the 85th percentile were at greater risk of progressing to type 1 diabetes. • BMI-related influence on type 1 diabetes risk progression was more elevated among children under the age of 12. • Risk of diabetes progression from higherthan-average BMI values seemed to be more pronounced in girls than boys. Study findings suggest that elevated BMI throughout early childhood correlates with type 1 diabetes after autoantibodies are detected although the study did not ascertain whether lowering BMI can slow down progression to type 1 diabetes. The study authors emphasize the need for children to keep active and follow a balanced diet from an early age to maintain a healthy weight and improve health outcomes.

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NEWS IN BRIEF IN MEXICO, EVIDENCE OF SUCCESS TWO YEARS AFTER IMPOSING SUGAR-SWEETENED BEVERAGE TAX According to a study published in the journal Health Affairs, Mexico’s 2014 tax on sugar-sweetened beverages led to an average 7.6 percent reduction in the purchase of sugary beverages during the tax’s first two years. The current study, which is based on store-purchase data for 6,645 Mexican households from January 2012 through December 2015, provides evidence of sustained consumer response. Households at the lowest socioeconomic level, a group at high risk of obesity-related diseases, had the most significant decreases in purchases of taxed beverages in both years. Recognizing an urgent need to discourage people from drinking sugar-sweetened beverages due to its contribution to the country’s high burden of obesity and diabetes, the Mexican government implemented an excise tax of 1 peso per liter on all non-alcoholic beverages with added sugar on January 1, 2014. Mexico’s strategy represents the best evidence to date of how sizable taxes on sugary drinks may influence consumer behavior. Study authors concluded how their findings from Mexico may encourage other countries to use fiscal policies to reduce consumption of unhealthy beverages along with other interventions to reduce the burden of diabetes.

EXPERTS CALL FOR PAN-INDIA DIABETES POLICY At the four-day Diabetes India 2017 Seventh World Congress conference (February 23-26), Diabetes India Chairman, Banshi Saboo, called for more “Effective policy actions as early as possible [ ] to address the growing burden of diabetes in our country. We are bringing diverse stakeholders together to exchange innovative thoughts and ideas on how we can do this.” More than 3,000 diabetes experts and a variety of diabetes stakeholders attended the conference in New Delhi, the capital of India. Conference key focus areas were prevention, detection, control and access for the right interventions endorsing the four pillars of the Early Action in Diabetes initiative. Dr. Sanjay Kalra, an endocrinologist at Bharti Research Institute of Diabetes and Endocrinology, describes the plight in India and goals for decreasing the rise in both diabetes and complications, “The Indian Asian phenotype is marked by a propensity towards insulin resistance, central obesity, and the early development of complications. Our pragmatic vision is to achieve a 10% per annum rise in the number of people who are tested and achieve their glycemic goals.” Approximately, 69.1 million people in India live with type 2 diabetes and it is estimated that one million deaths per year in the country are attributable to diabetes. The Research trust of Diabetes India holds its international conference every two years in different cities of India.

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NEWSINBRIEF COMPLICATIONS HIGHER AMONG TEENS AND YOUNG ADULTS WITH TYPE 2 DIABETES The latest findings of the SEARCH for Diabetes in Youth study, published February 28 in the Journal of the American Medical Association found that teens and young adults with type 2 diabetes develop kidney, nerve, and eye diseases – as well as some risk factors for heart disease – more often than their peers with type 1 diabetes in the years shortly after diagnosis. Study researchers are also clear to point out that complications are “frequent in both groups.” SEARCH analyzed data from a nationally representative registry of young patients who had diabetes for a mean of 7.9 years. The observational study examined 1,746 youth with type 1 diabetes (averaging about 18 years) and 272 youth with type 2 diabetes (averaging about 22 years) between 2002-2015. All were diagnosed before age 20. By age 21 years, researchers estimated one in three youth living with type 1 diabetes and nearly three in four youth living with type 2 diabetes have at least one of the following complications or comorbidities: diabetic kidney disease, retinopathy, peripheral neuropathy, arterial stiffness, or hypertension. When asked why youth with both types of diabetes are suffering preventable complications, study author, Professor Dana Dabelea of the Department of Epidemiology, Colorado School of

Public Health in Aurora, Colorado (USA) indicates that many challenges are at stake, “Certainly lower than optimal glycemic control is a major risk factor for complications in both diabetes types. Of note, over half of SEARCH participants (with either type 1 or type 2 diabetes) had HbA1c levels above those recommended. Other mechanisms may be involved that we need to carefully study in the future. Also relevant is that these are young adults that are transitioning from pediatric to adult care. This is a period when glucose control worsens in both types of diabetes, and some of these young adults lose their healthcare coverage.” With regard to the crisis facing the care of youth with type 2 diabetes and the alarmingly higher rate of complications in this group, Professor Dabelea explains how several factors may be at work, “Type 2 diabetes with onset in adolescence may be a more aggressive disease than if presenting later in life; youth with type 2 diabetes have several comorbidities (dyslipidemia, hypertension), including a lifetime burden of obesity and likely

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NEWS IN BRIEF

poorer lifestyles that may contribute; also, they are more likely to be of minority origin, coming from disadvantaged families with lower access to care and maybe lower compliance. All such factors may contribute to the higher rates of complications seen in type 2 diabetes youth versus type 1 diabetes youth.â&#x20AC;? SEARCH findings emphasize the importance of early monitoring of youth with type 1 and type 2 diabetes for the development of complications. SIGNIFICANT INCREASED RISK OF MORTALITY FOR CHINESE WITH TYPE 2 DIABETES People in China living with type 2 diabetes can expect a lower life expectancy by an average of nine years according to study findings published in JAMA. In a seven-year nationwide prospective study of more than 500,000 adults in China, diabetes was more common in urban than rural areas (8.1% vs 4.1%, respectively), and individuals with diabetes had a significant increased risk of mortality from all causes, including a range of cardiovascular and noncardiovascular diseases. Compared with adults without diabetes, individuals with diabetes had a significantly increased risk of all-cause mortality (1373 vs. 646 deaths per 100,000). Diabetes was associated with increased mortality from ischemic heart disease, stroke, chronic kidney disease, chronic liver disease, infection, and cancer of the liver, pancreas and female breast. Approximately 10 percent of all deaths were from diabetic ketoacidosis (DKA) or coma and the risk of dying from acute complications was a much greater risk in rural areas than in urban areas. The study provides much needed current evidence of the specific diseases and complications that account for the increased mortality associated with diabetes in the Chinese population.

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ADA ISSUES UPDATED RECOMMENDATIONS FOR DIABETIC RETINOPATHY The American Diabetes Association (ADA) has issued updated guidelines on diabetic retinopathy (DR) in the March 2017 issue of Diabetes Care. The last ADA position statement on DR was published in 2002. DR is the most common cause of new cases of blindness in adults ages 20-74 in developed countries. The guidelines specify that screening strategies depend on the appearance and progression of DR and on risk factors that alter these rates. For adults with type 1 diabetes, ADA guidelines recommend a comprehensive eye exam within five years of onset. For people with type 2 diabetes, the guidelines recommend an eye exam at the time of diagnosis. Additionally, ADA advocates educating women with preexisting diabetes who are pregnant or planning to become pregnant on the risks of developing DR. More specific treatment guidelines are outlined including a strong recommendation for annual exams if any level of DR is detected in people with type 1 or type 2 diabetes. Advancements in DR assessment and treatment methods are reviewed and include widespread adoption of optical coherence tomography to assess retinal thickness and intraretinal pathology; widefield fundus photography to reveal microvascular lesions; and intravitreous injection of antiâ&#x20AC;&#x201C;vascular endothelial growth factor agents for treatment of proliferative DR. DR is a highly specific neurovascular complication of type 1 and type 2 diabetes, and its prevalence strongly correlates to both the duration of diabetes and level of glycemic management and control. Other factors that increase the risk of DR include chronic hyperglycemia, nephropathy, hypertension and dyslipidemia. The updated guidelines offer evidence-based information to providers giving people with diabetes the opportunity to improve glucose management and potentially avoid or delay the progression of DR.

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THE GLOBAL CAMPAIGN

THE BERLIN DECLARATION:

STRENGTHENING EARLY ACTION FOR DIABETES PREVENTION AND CARE Sanjay Kalra and Ashok Kumar Das

Globally, one in 11 adults currently has diabetes (415 million people), costing health systems 12 percent of their total expenditure. By 2040, the global number of people living with diabetes is expected to rise by 227 million or 10.4 percent of the population, increasing health system costs by $129 billion.1 The effects of diabetes are well known. The condition, both directly and indirectly, is responsible for a major proportion of diabetes-related morbidity and mortality. Type 2 diabetes is one of the leading causes of cardiovascular disease, blindness, kidney failure, and lower limb amputation in many countries.2 World leaders, politicians and policy leaders can no longer afford to ignore the evidence. Our world is facing a health crisis so pervasive that it has become responsible for devastating national healthcare systems, economies, and personal lives from communities in the Northern Territories of Australia to the manic streets of Mumbai as well as the wealthy avenues of Manhattan and across the globe in cities and villages in sub-Saharan Africa where diabetes is significantly on the rise. No country or state is immune from the public health disaster of diabetes. Almost half of the total diabetes population are not aware they have it and nearly 75 percent of all people with diagnosed and undiagnosed diabetes live in low- and middle-income countries.1 It is also well established that the implementation of effective policies and strategies are required immediately to stem the tide of the diabetes catastrophe.

The Berlin Declaration In December 2016, best practice policy recommendations across four pillars for diabetes prevention, early detection, early control and early access were presented at the Global Diabetes Policy Forum in Berlin, Germany. The Forum, organised and funded by AstraZeneca in collaboration with the International Diabetes Federation (IDF), Primary Care Diabetes Europe (PCDE) and the World Heart Federation (WHF) and supported by German Diabetes Aid (GDA) followed the work begun under

the banner of â&#x20AC;&#x2DC;Early Action in Diabetesâ&#x20AC;&#x2122; at the first Global Diabetes Policy Summit held in November 2015. Participants in the 2016 Forum included leading clinical experts in diabetes, as well as patient group representatives, policy makers, and political leaders from 11 countries. Their task was to debate and identify key diabetes issues for early actionable targets and consolidate these findings into a single document calling it the Berlin Declaration. The Declaration was ratified by experts from 38 countries and launched to stimulate meaningful policies at the national level and drive action for local platforms.

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THE GLOBAL CAMPAIGN

The Berlin Declaration A collective ambition for policy change to drive early action in type 2 diabetes

In partnership with:

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Supported by:

Volume 63 - Issue 1- April 2017

Disclaimer This document has been funded by AstraZeneca, and written in collaboration with other partner organisations.

THE GLOBAL CAMPAIGN

Four Pillars of Action The four pillars of the Early Action initiative are based upon firm evidence and were established to drive tangible, local action to implement policies that focus on: • • • •

Prevention Early detection Early control Early access to the right interventions3

The Berlin Declaration highlights the urgency to make early action for diabetes prevention and care a political priority. Written by experts from multiple nations, professions and disciplines, the Declaration has a relevance which extends far beyond clinical diabetology. It serves as an international catalyst for change that seeks to truly transform people’s lives. Levels of Prevention This taxonomic structure covers the entire spectrum of proactive approach to diabetes from primary, through secondary, to tertiary prevention. Primary prevention includes actions designed to prevent progression of risk factors such as unhealthy eating habits and physical inactivity. Secondary prevention encompasses the actions listed in early detection and control (early diagnosis and management). Tertiary prevention is concordant with early control which also includes timely care of complications of diabetes.4 Early access to the right interventions conveys the need to ensure translation of thoughts and words into action and results. National Policy The Berlin Declaration envisages a national diabetes control plan for each country which should focus on prevention of diabetes in both adults and children. The national screening program should also include systemic and proactive assessment of high risk individuals; foster alignment between relevant healthcare specialties; allow for collection

of data; and plan for capacity building. Early control can be promoted by creating national guidelines on the management of type 2 diabetes, establishing monitoring systems and offering financial incentives to healthcare professionals for optimal care. The national diabetes plan should also identify clear cut recommendations, strategies, goals, and timelines for achieving the same. A national formulary of drugs should be put in place and a ten-year plan prepared for ensuring better access to diabetes healthcare. Such plans should cover policies promoting preventive measures such as taxation of sugar-sweetened beverages, restricted advertisement of unhealthy foods, modification of urban environments and better access to healthy consumer foods and markets in order to encourage healthy living.

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THE GLOBAL CAMPAIGN

Challenges

Our Declaration

The importance of these strategies cannot be overemphasized. Yet it is challenging to implement them on the ground. The reasons for failure to meet targets fall under two factors: first, poor sensitization about the adverse effects of uncontrolled diabetes, and second, other priorities which prevent adequate focus on diabetes prevention and care.

The Berlin Declaration is meant to help us challenge the current status quo in diabetes prevention and care and improve efforts towards better management of diabetes. By working together and learning from each other, we will become more efficient and effective in our progress. The Berlin Declaration will improve the current state of diabetes to a significant degree enhancing the lives of individuals and improving diabetes prevention and care around the world.

These two issues need to be addressed by all stakeholders defined as the five Ps (patient, physician, public (community), policymaker/politician and payer (insurance).5 Concerted and sustained efforts should be made to inform, influence and empower stakeholders to the unwanted effects of uncontrolled diabetes and the evidence-proven improvement in outcomes that are possible with metabolic control. Apart from the health impact, the economic burden of diabetes and its complications should be mentioned. While no attempt should be made to denigrate the significance of other health and non-health related priorities, the role of diabetes in these conditions can be highlighted. Thus, diabetes can be positioned as a complementary rather than conflicting priority with tuberculosis, HIV, hepatitis, pregnancy, road traffic accidents, mental illness and cancers.6 Our Responsibility The South Asian physician occupies a significant place of pride and respect in his or her community. The primary care physician is community-based, community-oriented, community-responsive and community-relevant. As a result, any health related message coming from a healthcare professional is heard, accepted and often implemented by the community. Physicians should ensure that they all speak the same language in a manner their community can understand to promote prevention, early detection, early control and early access. Planning should involve religious, cultural and government leaders in diabetes related activities. Campaigns to create diabetes friendly physical and social environments can be spearheaded and supported, as can movements for healthy cooking and eating.

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Physicians form the backbone of the healthcare system and provide care to the vast majority of people with diabetes. The Berlin Declaration should be adopted by every country worldwide where diabetes efforts will be prioritized ensuring prevention, early detection, early control, and early access to the right interventions. This will achieve a global victory over diabetes and its complications. Sanjay Kalra is Vice President of South Asian Federation of Endocrine Societies (SAFES) and an endocrinologist at Bharti Hospital, Karnal in Haryana, India. Ashok Kumar Das is Professor & Head of Medicine PIMS, Pondicherry, India, and Patron for the Research Society for Study of Diabetes in India. References 1. International Diabetes Federation, IDF Diabetes Atlas, Seventh Edition, 2015. 2. Complications of diabetes. http://www.idf. org/complications-diabetes Accessed on 19 December 2016. 3. The Berlin Declaration. October 2016. 4. Kalra S, Sreedevi A, Unnikrishnan AG. Quaternary prevention and diabetes. J Pak Med Assoc 2014; 64:1324-6. 5. Kalra S, Unnikrishnan A G, Das A K. Improving adherence to insulin: Hope with degludec. J Soc Health Diabetes 2014; 2: 1-2. 6. Sharma R, Kumar KH, Kalra S. The ominous octet of â&#x20AC;&#x153;Sâ&#x20AC;? in noncommunicable disease. J Soc Health Diabetes 2017; 5: 12-15.

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THE GLOBAL CAMPAIGN

EXTENSIVE GLOBAL NETWORK PREPARES TO ASSEMBLE IDF CONGRESS 2017 Abu Dhabi, United Arab Emirates (UAE)

Elizabeth Snouffer

In 2017, the International Diabetes Federation (IDF) is bringing the 24th IDF Congress to Abu Dhabi, the capital city of the United Arab Emirates and home to 1.6 million residents. From the 4th to the 8th December, the global diabetes community—including scientific experts, prestigious medical faculty, leading advocates, public health specialists and more—will convene to share the latest achievements in diabetes research as well as explore new developments and technologies in care. Approximately 12,000 participants are expected to attend IDF’s biennial congress, the most significant global diabetes event, at the Abu Dhabi National Exhibition Centre, the largest exhibition centre in the Middle East. More than 250 speakers will be presenting the most important diabetes research findings and issues related to the global burden of diabetes. The international conference will host 230 national diabetes associations from 170 countries in partnership with the Emirates Diabetes Society and with support from the Abu Dhabi Tourism & Culture Authority, the Health Authority Abu Dhabi (HAAD) and other health organizations, providing a comprehensive global perspective. “With the number of people with diabetes in the MENA region expected to more than double within the next twenty years, Abu Dhabi is the perfect location to bring together the extensive global network that IDF represents,” says IDF President, Dr. Shaukat Sadikot.

IDF 2017 Program IDF 2017 will host a world class scientific program comprised of nine streams, introducing new areas such as Diabetes and Disasters; Diabetes in Women and Children; and Diabetes in Society and Culture. With the leadership of Professor Nam Cho, President-Elect of IDF, and in an effort to continually build on the success of past congresses, IDF 2017 will feature more e-poster presentations,

shorter session formats, and maximize congress access and efficiency for all participants. The following Congress program streams will assist in advancing strategies for national, regional and global efforts for diabetes prevention, improved treatment and access, and for the promotion of rights for all people living with diabetes.

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THE GLOBAL CAMPAIGN

Basic and Clinical Science

Diabetes in Society and Culture

Kyong Soo Park, a professor of Internal Medicine in the Division of Endocrinology and Metabolism at Seoul National University College of Medicine in Korea, is overseeing this stream dedicated to basic and clinical diabetes research progress and current advances in clinical practice and their application in diabetes care.

Massimo Massi Benedetti, former Associate Professor of Endocrinology at the University of Perugia, Italy, is leading this newly created stream which focuses on all aspects of the diabetes epidemic in different societies and how diabetes prevention and management can be enhanced with stakeholder involvement. Special attention will be placed on defining how environmental and cultural factors influence diabetes management.

Science of Diabetic Complications Isaac Sinay, an advisor at the diabetes unit at the Cardiovascular Institute of Buenos Aires in Buenos Aires, Argentina, is lead for this program that will cover the most advanced research on diabetes complications and current prevention strategies i n c l u d i n g e p i d e m i o l o g y, physiopathology, diagnosis and treatment. Diabetes and Disasters

Hak Chul Jang from the Department of Internal Medicine at Seoul National University Bundang Hospital and Seoul National University College of Medicine in Korea is leading the Diabetes in Women and Children stream. Special emphasis will be placed on the topic of hyperglycaemia in pregnancy including gestational diabetes and pregnancy in women living with diabetes. Diabetes 4-8 December in childrenâ&#x20AC;&#x201D;from type 1 diabetes to the emerging issue Abu Dhabi of type 2 diabetes in youth will also be a key focus.

Congress

A new program stream led by Nizar Al Bache from Syria, Chair of the Middle East and North Africa (MENA) Region of the IDF, will present experiences dealing with diabetes and disasters, both natural and man-made and provide practical information on how to be prepared to help people with diabetes before and during disasters. Diabetic Foot

Lawrence Harkless, founding Dean of the College of Podiatric Medicine and Professor of Podiatric Medicine, Surgery and Biomechanics at the Western University of Health Sciences in Pomona California, USA, is leading basic and clinical science of the diabetic foot including public health challenges presented by the condition.

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Diabetes in Women and Children

Education and Integrated Care This stream, overseen by Edwin Fisher, a public health professional, noted researcher and clinical psychologist, reviews the latest developments in diabetes education and care and their application and integration through healthcare professionals, families and communities. The significance of healthcare professional support; training for multidisciplinary healthcare providers; and tools and intervention approaches for enhancement of self-management will be examined.

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THE GLOBAL CAMPAIGN

Epidemiology and Public Health Professor Jaakko Tuomilehto, Professor Emeritus of Public Health, University of Helsinki, Finland, has developed a rigorous program which includes epidemiological studies concerning rise of type 1 diabetes and type 2 diabetes; diabetes prevention trials; and healthcare cost and reimbursement issues.

According to estimates from the latest IDF Diabetes Atlas (2015), more than 35 million people in MENA live with diabetes and this number is expected to rise dramatically if nothing is done. Approximately 40 percent of people with type 2 diabetes do not know it and nearly eight percent of the population has impaired glucose tolerance (20-79 years) or pre diabetes. By 2040, it is estimated that the prevalence of diabetes will rise to 11.4 percent which is equivalent to 72 million people living with diabetes in the region.

Living with Diabetes Manny Hernandez, a leading diabetes advocate from the US who has lived with diabetes since 2002, has developed an exceptional program on all aspects of living with diabetes. Included in the stream line-up are the following topics: peer-to-peer support and education; diabetes technology—digital health and mobile tools; and diabetes and mental health. Congress attendees will have the opportunity to participate in over 160 hours of scientific sessions, 1000 poster presentations and earn CME credits all to advance knowledge about one of the most significant health crisis in the world today. UNDERSTANDING THE BURDEN OF DIABETES IN MENA United Arab Emirates (UAE) is one of the 19 countries and territories of the IDF Middle East and North Africa (MENA) region. MENA is in transition encompassing rapid urbanization and wealth in many countries—such as UAE; and economic and geographic upheaval due to war and political changes in other less fortunate zones—like Syria. These two realities share a public health challenge; MENA has one of the highest rates of diabetes prevalence in the world. Reporting estimates for the region are also challenging because a large proportion of the resident population in many countries consists of migrants and refugees.

Many healthcare practitioners and researchers argue that incidence of type 1 diabetes is also rising sharply in the Middle East. Approximately ten thousand children (0-14) are diagnosed with type 1 diabetes in the region each year. Multiple risk factors are responsible for the region’s diabetes burden some of which are predominantly lifestyle issues, including increased prevalence of obesity, physical inactivity, and change in dietary patterns. In addition, there are factors unique to MENA that contribute to the high prevalence of the diabetes epidemic. These include an underlying genetic predisposition to diabetes, lack of diabetes public awareness, preventative care, and primary treatment of risk factors such as obesity. There may be no better place for worldwide experts to meet than MENA to take on diabetes and its challenges, which continue to confound and confront our world today. Dr Shaukat Sadikot, IDF President sums it up best, “The IDF Congress addresses issues facing what has become one of the most challenging health problems in the 21st century, namely the rapidly increasing number of people with diabetes worldwide, the number of adults with undiagnosed diabetes and the lack of optimal management leading to an increase in morbidity and early mortality.” Elizabeth Snouffer is Editor of Diabetes Voice.

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Vital information • For registration details, please click here. Benefit from discounted rates by registering before August 18, 2017. • Deadline for abstract submission is April 21, 2017. For more information, please click here.

• IDF provides 100 young researchers from around the world with the unique opportunity to attend the Congress and present their work. Submission for IDF grants closes on 28 April 2017. Click here for more information.

THE GLOBAL CAMPAIGN

IDF ADVOCACY: NEW ENERGY FOR THE YOUNG LEADERS IN DIABETES (YLD) PROGRAM Beatriz Yáñez Jimenez and Elizabeth Snouffer

Dario Rahelic, Secretary of the International Diabetes Federation (IDF) European Region Board was invited by the IDF Board to become Chair of the IDF Young Leaders in Diabetes (YLD) Program in February 2016 and it is easy to see why he is ideal for the volunteer position. As President of the Croatian Society for Diabetes and Metabolic Disorders, he has played a key role in efforts to help the Ministry of Health of the Republic of Croatia, national insurance companies and other authorities understand the need for better, stronger diabetes care in Croatia. His participation helped to achieve reimbursement of insulin pumps for people with type 1 diabetes; support of modern basal insulin analogues for people with type 2 diabetes and increased number of test strips allotted to children with diabetes. On becoming the YLD program Chair, Dr. Rahelic says, “I am very honored to lead such an important core program for IDF. What’s so key in the restructuring of the YLD program and its governance is to ensure it is integrated into all IDF programs and that all the YLD members receive full support from IDF. This includes aiding their growth and development in a variety of leadership roles as future IDF advocates.” The establishment of the YLD program as a key initiative whose objective is to empower young people living with diabetes as advocates for themselves and others living with diabetes worldwide remains unchanged with the IDF Board’s recommendation. In January 2017, Dr. Rahelic and the YLD Interim Committee including Gavin Griffiths as Program Coordinator, met in Brussels for their first face-to-face meeting.

The Committee determined many aims, objectives and strategic regional plans for YLD including: • Importance of YLD recruitment and development. • Importance of integrating all IDF Members into YLD representation and initiatives. • Development of a preliminary training summit program for the IDF Congress 2017 in Abu Dhabi. “Many of our new YLD plans will be shared at the IDF Congress 2017 in Abu Dhabi. We have also decided to hold a YLD Satellite Symposium – open to the public – which will clarify the significance of YLD activities and bring greater awareness to all IDF Members and Congress attendees about YLD,” says Dr. Rahelic.

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THE GLOBAL CAMPAIGN

YLD INTERIM COMMITTEE Dario Rahelic

Chair, IDF YLD Program Dario Rahelic, physician, internal medicine specialist, endocrinologist and diabetologist has been engaged in clinical practice for 14 years in his home country of Croatia. He is Assistant Professor and Head of the Department of Endocrinology, Diabetes and Metabolic Disorders at Dubrava University Hospital, Zagreb, Croatia; President of the Croatian Society for Diabetes and Metabolic Disorders of the Croatian Medical Association; Executive Committee Member of the Diabetes and Nutrition Study Group of EASD, the Croatian Endocrine Society, the Croatian Society for Obesity and the Croatian Society for Endocrine Oncology. He is Secretary of the IDF Europe Region Board.

Gavin Griffiths

YLD Programme Coordinator 26 years old, living with type 1 diabetes since 2000. Gavin is from the UK and has accomplished over 70 ultra-endurance challenges, including once running 30 marathons in 30 days across the UK. The experiences and research gathered through these events enabled him to start up Diathlete, a social enterprise providing education and encouragement for young people living with type 1 diabetes keen on physical activity and endurance. Since his first YLD training in Vancouver in December 2015, he has partnered with many young leaders to make positive projects happen across five IDF regions.

Lamin Dibba

Regional Representative, Africa 29 years old, living with type 1 diabetes since 2003. Lamin is from The Gambia and graduated from the University of The Gambia, with a BSc in Development Studies. He currently leads a group of over fifty young people with type 1 diabetes in his community and serves as an advocate for their needs. He firmly believes that diabetes challenges can be overcome through self-empowerment and diabetes education. 20 Diabetes Voice

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YLD INTERIM COMMITTEE Dániel Végh

Regional Representative, Europe 27 years old, living with type 1 diabetes since 2009. Dániel currently works as a dentist at the Semmelweis University of Budapest in Hungary. He is an active volunteer for the Hungarian Diabetes Association and a passionate advocate for oral health and diabetes. Daniel has shared his expertise at workshops and lectures during national and international conferences such as the European Federation of Periodontology (EFP) workshop and the IDF Congress.

Mohammed Khalid Ahmed Ali Al-Saadi

Regional Representative, Middle East and North Africa 31 years old, living with type 1 diabetes since 1990. Mohammed Khalid Al-Saadi is from Qatar and currently works as a Special Care Program Assistant for the Qatar Diabetes Association. His responsibilities include organizing diabetes camps for youth and representing his country at many conferences and events outside of Qatar.

Danielle McVicar

Regional Representative, North America and Caribbean 27 years old, living with type 1 diabetes since 2000. Danielle, who lives in Canada, works for Diabetes Canada running camp and youth activities. She is passionate about the need for increasing access to diabetes education, medicine and other required tools for people living with the condition. She has a bachelor’s degree in Finance and Marketing and in her spare time you’ll find her climbing mountains with her skis.

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THE GLOBAL CAMPAIGN

YLD INTERIM COMMITTEE Franco Giraudo

Regional Representative, South and Central America 30 years old, living with type 1 diabetes since 1995. Franco, currently living in Chile, is a medical doctor working in a pediatric hospital. He also creates educational programs and helps with camps for children and adolescents for the Juvenile Diabetes Foundation of Chile. He loves his work with the diabetes camps having attended 38 diabetes camps in his lifetime. Franco is earning his PhD with a focus on diabetes and oral contraception. In his free time, he enjoys travelling and learning about dinosaurs and history.

Tai Lin (Irene), Lee

Regional Representative, Western Pacific 24 years old, living with type 1 diabetes since 2003. Irene is a medical student at National Taiwan University in Taiwan. She has been working for medical human rights advocacy and scientific research since college. In 2013, she was elected Chair of the Western Pacific region and helped the Chinese Taipei Diabetes Association organize the YLD-WPR Congress for the IDF-WPR Congress in 2016. Additionally, Irene and new WP Young Leaders are currently running a yearlong video campaign covering multiple aspects of life with diabetes in IDF Western Pacific countries. These videos are launched on the 14th of every month.

For more information about the YLD, visit:

www.idf.org/youngleaders

22 Diabetes Voice

Beatriz YĂĄĂąez Jimenez is Advocacy Coordinator at IDF. Elizabeth Snouffer is Editor of Diabetes Voice.

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CLINICAL CARE

IDF Launches Clinical Practice Recommendation on the Diabetic Foot: a guide for healthcare professionals

Ammar Ibrahim

The IDF, represented by the Diabetic Foot Stream Committee, a group of diabetes experts dedicated to the care of people with diabetes and especially the prevention and treatment of the diabetic foot (DF), has produced a new guide entitled Clinical Practice Recommendation on the Diabetic Foot. The guide, available in April 2017, has been created to help diabetes healthcare professionals better manage the threat of DF in diabetes patient populations. It has been estimated that up to 85 percent of the one million amputations occurring per year are preventable. Diabetes is a systemic disease affecting nearly every part of the body, and often feet are the first to be impacted. Key to diabetes treatment is getting ahead of risks and complications to reduce and manage progression of the disease. As the diabetes pandemic progresses so do foot complications and ulcers which precede the majority of lower extremity amputations. The objective of the Clinical Practice Recommendation is to inform healthcare professionals of the crisis related to diabetic foot disease worldwide, persuade them that action is both possible and affordable, and to warn them of the consequences of not taking action. Due to lack of training and other factors, it has been estimated that less than one third of physicians recognize the symptoms of diabetic peripheral neuropathy, the leading cause of DF, even when it is symptomatic. The new guide will help educate healthcare professionals who may in turn help the millions of people worldwide who live with diabetic foot disease or who are at risk.

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CLINICAL CARE The number of adults with diabetes is estimated to be 415 million people worldwide, and low- and middle-income countries have experienced the fastest increases. Diabetes complications lead to heart attack, stroke, blindness, kidney failure and lower limb amputation. The rate of death from diabetes and its complications increased more than 15 percent between 2011 and 2015 despite medical advances, more practitioners working in the medical field and increased diabetes education, including national, regional and global conferences on diabetes at basic and advanced levels. Diabetes and its complications are rapidly becoming the world’s most significant cause of morbidity and mortality. According to data from IDF’s Diabetes Atlas (2015), it is predicted that by 2040 there will be over 642 million people with diabetes in the world. DF is one of the most common and debilitating complications of diabetes caused in part by poorly controlled diabetes or undiagnosed diabetes. With the lifetime incidence of foot ulcers occurring in up to 25% of all people living with the condition, currently it can be estimated that millions of people are or will be affected by DF. Consequently, DF contributes to the majority of diabetes-related hospitalizations and, therefore, accounts for a high percentage of the cost of diabetes worldwide. DF is considered the most common cause of nontraumatic lower limb amputation. The final result of delay in DF diagnosis and inadequately treated DF often leads to one form or another of amputation. DF’s impact on the life of an individual, once amputation surgery is required as a lifesaving measure, is economically and socially

Diabetic Foot is one of the most common and debilitating complications of diabetes.

24 Diabetes Voice

devastating. If the amputation takes place as a complication of diabetes, morbidity and mortality rates are staggeringly high, and the 5-year mortality rate after an amputation is more than 45 percent. However, the majority of DF problems can be prevented through early detection of risk factors and early intervention of a skilled multidisciplinary foot care team. As a result of this preventable complication, all diabetes healthcare providers need to unite efforts and exercise greater vigilance in examining the diabetic foot and complications that lead to DF, including neuropathy. Most critical to progress is shifting the treatment focus from acute care to prevention. It is essential that all healthcare practitioners treat people earlier in that ‘window of presentation’ between the moment when neuropathy presents but before an ulcer develops. More than 85% of amputations start with ulcers. If preventive measures are integrated into the treatment approach, DF and DF amputations will decrease. According to the Clinical Practice Recommendation, it is essential for healthcare professionals to concentrate efforts on the following: 1. Educate all persons with diabetes and their relatives to prevent DF: extensive awareness and education can achieve a very significant

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CLINICAL CARE reduction with early detection appropriate timing approach.

and

2. Once a person with diabetes presents with DF or has any manifestation of DF, it is critical to work intensively with the person with diabetes and family to prevent any type of amputation.

Etiology and Prevention The etiologies of DF include Peripheral Neuropathy (PN), Peripheral arterial disease (PAD) and infection. Additional to any of these three factors, trauma could be added. The most common cause of trauma is the use of inappropriate shoes and/or insoles. According to the etiology and natural history of DF, prevention must include the following: Appropriate Shoes and Insoles One of the first and most important preventive measures is to educate people with diabetes to use appropriate shoes which is a significant challenge to practitioners. It is not easy to define â&#x20AC;&#x2DC;appropriateâ&#x20AC;&#x2122; for a diverse worldwide population. However, as a consensus, the following types of shoe protection should be discussed, and usually enforced: 1. High and low temperature prevention. 2. Friction and attrition prevention. 3. Reduce plantar pressure. 4. Provide stability. 5. No foot compression. 6. Easy adjustment. 7. Must help on injury alert. 8. Light weight. 9. Orthotic friendly. 10. Impact absorption. Early Peripheral Neuropathy (PN) detection The second preventive measure is the early detection of PN. Neuropathy is the most frequently encountered complication of diabetes. Diabetic peripheral neuropathy is an impairment of the nerves throughout the body and can alter autonomic, motor and sensory functions. The reported prevalence of diabetic peripheral neuropathy ranges from 16

percent to as high as 66 percent. The most important result of the motor PN is the denervation of the foot intrinsic muscles (as a consequent of PN) which interrupts the normal balance between the toes flexors and extensors, resulting in the common diabetic foot deformity.

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CLINICAL CARE This deformity will increase the pressure in some points, leading to subcutaneous hematomas, calluses and if not detected and treated, will produce ulcers. In the sensitive PN, there are two types: Positive and Negative PN. In the first one the patient will feel specific symptoms including pain, cramp, and/or numbness and a need for specific drug treatment. The negative PN is the absence of the protective feeling against pain, pressure, temperature and also the absence of the ability to recognize the foot position. In other words, the negative PN will block any protective effect in the feet, and therefore, the person does not feel any foreign body in footwear, lacerations, wounds, improper positioning of the feet or very narrow shoes. As a result of any of the above, lesions in people with negative PN are discovered at a late stage. The importance of early detection of the PN is to classify people by risk category, and to organize a follow up strategy according to the category. This may change from a monthly visit in a very high risk category to a yearly visit in a low risk category. Educating patients on how to prevent injuries through very specific advice and recommendations is key for prevention. For example, educating a patient on: the correct way to cut toenails; the adequate temperature to wash feet; the application of humectant creams between toes; the threat of walking in bare feet (not even a home environment is safe); the adequate inspection of shoes before daily use; searching for the possibility of a foreign body inside footwear; and the use of noncompressive, clear color, cotton socks.

specific characteristics: 1. Affects the proximal part of the aorta, femoral vein 10-15 years earlier compared with people without diabetes. 2. The specific arterial lesion in persons with diabetes is the involvement of the distal midsize arteries (below the knee), resulting in some type of arterial stenosis or obstruction. The adequate regular peripheral vascular evaluation for all people with diabetes is essential and mandatory to achieve early detection of possible PAD, and this evaluation must include at least: pulse palpation, Ankle-Brachial Index (ABI), and Doppler. One of the important measures to be assumed as prevention and/or treatment of PAD is exercise. It is clearly demonstrated that daily activity of 30 minutes walking, at least 5 times/week can increase the distal tissue oxygenation up to 30 percent (more than the usual use of any drug for the same purpose). The key message to be able to treat diabetes and to prevent any possible complication, including DF, aside from adequately controlling blood glucose, is to inform and motivate multidisciplinary teams attending to DF to make prevention a priority and after that, to take earlier treatment action for better outcomes and fewer amputations. Ammar Ibrahim is Director General, Instituto Nacional de Diabetes (INDEN) and Chair of the IDF South and Central America (SACA) Region. He lives in Santo Domingo, Dominican Republic.

Classification in risk category gives guidelines for professionals on follow-up timing. 3. Peripheral arterial disease (PAD) Up to half of all patients with diabetic ulcers have PAD. In people with diabetes, PAD has two 26 Diabetes Voice

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DIABETES IN SOCIETY

NEW IDF NETWORK REPRESENTS

THE GLOBAL VOICE OF DIABETES Lorenzo Piemonte

Blue Circle Voices (BCV) is a new IDF initiative, which will represent the interests of people living with, or affected by, diabetes, through a worldwide network of members and other stakeholders. BCV will act as the global voice of people living with diabetes and will draw upon the experiences of people living with diabetes from countries represented by IDF Members. The virtual network will focus on a variety of issues and challenges that people with diabetes encounter in our world today. Seeking to understand and clarify limitations within diabetes communities, BCV consultations will result in the development of strategies for resolution, strengthening the varying needs of people with diabetes worldwide. Consultations, utilising surveys as one format, will be conducted online, supported by a dedicated closed portal on the IDF website and co-ordinated by IDF staff at the Executive Office. BCV will strengthen IDF’s presence in global forums and bring both better awareness and credibility to diabetes prevention, care, access and rights issues. Composed of adults living with diabetes of all ages and from all IDF regions, BCV accommodates representation from the following groups. • • • • •

People with type 1 diabetes People with type 2 diabetes. People with less common types of diabetes. Women with a history of gestational diabetes People connected to diabetes through the care of a child, close relative or loved one with diabetes.

BCV Membership BCV members are obligated to represent and share IDF’s mission—promote access to diabetes care, fight discrimination against people with diabetes and promote prevention of type 2 diabetes. The role of a BCV member is hinged upon engaging actively on the BCV portal, campaigning and speaking out for diabetes causes and promoting IDF activities at the national and global level. Key Objectives of BCV • Provide national and regional perspectives to issues of concern for IDF. • Provide input to important IDF initiatives, including global consultation on topics of interest such as access to diabetes care, discrimination and more. • Provide personal experiences for the IDF website and specific projects. • Support advocacy and other activities of IDF national members or regional offices.

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We asked newly designated BCV members from around the world to discuss what types of issues are specific to their country and what they hope BCV will achieve in the months ahead. Their commentary, representing a variety of cultures, is compiled below.

NIGERIA

and also provide medicine including insulin and blood glucose test kits. What are you most excited about in participating in the BCV? I am excited about BCV because I believe my community will benefit from our fight against the disease. Also, my participation will enable me to interact with other people and learn new information about diabetes management helping me become a stronger advocate.

SINGAPORE

Rakiya Garba Kilgori, 52 years, Inspector of Education, living with type 2 diabetes. What gaps do you think exist today in your local diabetes community and what do you hope the BCV network will achieve? In my community, there are many barriers that make fighting diabetes and getting adequate care difficult. Many people are unaware of the existence of diabetes. People who live with diabetes donâ&#x20AC;&#x2122;t prioritize medical care, do not visit their doctor or the clinics and resort to traditional medicine. Women are not allowed to go out to seek medical assistance due to cultural beliefs that women should be in purdah and are not supposed to be seen or heard. Additionally, the cost of insulin and diabetes supplies makes it difficult to fight the disease. I hope that the Blue Circle Voices network will assist to reach out to people to be aware of the disease through the media and other appropriate channels 28 Diabetes Voice

Julie Seow, 60 years, Diabetes Life Coach, living with type 1 diabetes. What types of issues do you think are specific to Singapore? Singapore has the second highest proportion of people with diabetes among developed nations. The diabetes prevalence for people 18-69 years is one in nine. Rising obesity among the young is contributing to the increase in type 2 diabetes. Affluence and a nation known as being a food paradise makes it difficult to stay on a healthy eating path. Singapore is also a very fast paced society and stress in schools and workplaces often contribute to the person with diabetes who may neglect or compromise diabetes care. The Singapore government declared war on diabetes in April 2016. The focus is on raising awareness of diabetes, educating the public on early screening and prevention, and promoting healthy lifestyles

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through healthy eating and physical activity. What do you think BCV can do for the global voice of diabetes? The organization that I work for, TOUCH Diabetes Support, has as its mission to build a community of support for persons and families living with insulin treated diabetes. Over the years, we have seen how caring relationships in the community can benefit people with diabetes and their families. Participating in the BCV network will link this network of support to the global diabetes community. We can learn from each otherâ&#x20AC;&#x2122;s experiences and be inspired by our stories. BCV can serve as a bridge for greater accessibility of information globally, so that anyone with diabetes will be exposed to what is happening outside of their home country.

IRAN

sweetened beverages has replaced fresh water and/or traditional healthier drinks. At one time, Iranians traditionally drank plain unsweetened tea for refreshment but this has been widely replaced with sweetened creamed coffee. Westernized diet and lifestyle factors are a major contributor in the widespread development of diabetes in Iran. What do you hope BCV will achieve for Iranians? The most exciting part of participating in BCV is to become a voice for diabetes barriers and difficulties in Iran. We believe our unique voices within the BCV network will be a channel to bring diabetes awareness to Iran. Iranian society needs representatives, including the younger generation specifically, to participate in diabetes programs worldwide. Together we can make a difference to advance better care for people with diabetes in Iran and this is also aspirational as we hope to impact diabetes around the globe. We look forward to developing improved communication between communities where the threat of diabetes isnâ&#x20AC;&#x2122;t fully understood to better more informed and aware communities. This, we believe, will build a better future. For more information about the Blue Circle Voices network, please visit www.idf.org/ bluecirclevoices.

Sina and Niloufar Mobasherfar, 33 and 32 years, married couple both living with type 1 diabetes.

Lorenzo Piemonte is Senior Communications Coordinator at IDF.

What factors do you believe are contributing to the rise of diabetes in Iran? Several factors contribute to accelerated diabetes epidemic in Iran. To name a few, we can initially mention specific diet and nutrition issues which are more related to the current culture. The typical Iranian diet is based on a high intake of refined carbohydrates. For example, white rice and bread are staples in daily meals. The other main factor for the rise in type 2 diabetes is dramatically decreased physical activity levels for the population especially among the younger generation. Evidence also indicates that higher consumption of sugar-

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DIABETES IN SOCIETY

INTERVIEW

THE INSULIN EXPRESS A Memoir by Oren Liebermann

Oren Liebermann, a CNN correspondent based in Jerusalem, was diagnosed with type 1 diabetes in February, 2014. Type 1 diabetes interrupted a year-long travel adventure and Oren’s diagnosis was revealed just after he tackled the Annapurna Base Camp trek in Nepal. It was there that Oren and his wife realised life might never be the same when they returned to the US to assess Oren’s health and learn more about diabetes. Wanting desperately to get back to the travel adventure they had dreamed up and planned, Oren decided that his diabetes wasn’t going to prevent him from doing the things he loved. Within one month he and his wife were back on the road prepared for another 6-months of travel with all the required insulin and supplies. Oren writes about his travel experience and diabetes in his first book, The Insulin Express, available in May 2017. Diabetes Voice had the chance to meet Oren and ask him about his book, type 1 diabetes and life as an international correspondent.

Why did you write The Insulin Express? I wanted to write a book, especially as a reporter, about travelling around the world but I didn’t know what was compelling about my story. Then I got diagnosed with type 1 diabetes and I thought my story had just become compelling, although not in the way I wanted it to be! Parts of writing The Insulin Express were very difficult but it was a catharsis for me. Even today, I can feel the IV that was put on my right hand when I was first diagnosed in Nepal. I still don’t know that I have dealt with everything about developing diabetes but it was important for me to put it all down and share my experience with others. Everyone with type 1 diabetes has been there – we all have our diagnosis story. Writing the book was a part of the healing process for me.

30 Diabetes Voice

Why did you name your book The Insulin Express? The original title was “Home is a verb” which for me was excellent because it reflects the idea that “home” is active, moving. My editor convinced me to change it. I am glad we called it The Insulin Express, because the most important decision I made was to get right back on the road after I developed diabetes and continue travelling. My wife and I had been travelling for six months when the trip was interrupted by my diagnosis. We had six more months to go! After my diagnosis, it would have been so easy to say “I am staying home – hanging it up.” I couldn’t do that. After talking to my doctor, we decided that we could safely continue with my type 1 diabetes if I planned and prepared for everything.

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Oren and his wife at the beginning of their trip and before the diabetes diagnosis.

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I believe if I had given into accepting perceived limitations, then there’s a good chance I would have always felt limited with diabetes. I am proud to be on the road with diabetes. Before you were diagnosed with type 1 diabetes in 2014, were you aware of any type of diabetes? Had you ever known or met someone with diabetes? No one in my family has diabetes, and I knew nothing about the condition. I had a friend in high school who had type 1 diabetes, but I have to admit, I just didn’t get it. He had a pump and sometimes he had lows and would need to eat sugar, but I was completely ignorant about what he needed or why. In college, my Resident Advisor also lived with type 1 diabetes but like I said I had no understanding of it. Fortunately for me, these friends reached out to me during and after my diagnosis. Having a network of people who understand diabetes is very important. During your travels, your story looks back in time and allows the reader to see a trend. As you made your way around the world, your wife comments on your weight-loss; in Bangkok, your constant thirst is blamed on the heat; and finally in Nepal, a friend says you have all the classic symptoms of diabetes but you decide that it just can’t be. The first Nepalese doctor you see diagnoses you with a minor infection, gives you antibiotics, and tells you to “drink more juice and eat chicken.” Of course, this fails. What do you think is going on here? In terms of thirst it was easy to write it off. In the desert in Israel, I was drinking a lot of water and it seemed natural to be thirsty there. I was drinking a lot so I had to go to the bathroom a lot. When we were in Thailand the heat was the hottest I had ever experienced in my life with temperatures around 105 degrees fahrenheit and I was sweating so it seemed logical I was really thirsty. It was the dry season in Nepal so again it seemed natural that I would be dehydrated. 32 Diabetes Voice

In terms of weight loss, I didn’t think I had lost so much weight but now that I look back, it was dramatic. I had lost 40-45 lbs over the space of two months. I didn’t think much of it then; I was eating less and exercising a lot. Plus, there was so much to do and we were on the road. We were busy and there wasn’t time to waste. In Nepal, when I didn’t know what was wrong we reached out to a few doctors at home who had known me my whole life and they said, “It sounds like symptoms of diabetes but there’s just no way you have it.” I had no family history so it just didn’t seem to make sense. Even the doctors in Nepal were confused at first. Once they saw my glucose was so high, we all knew - but the questions didn’t end there. “Does he have type 1 diabetes or type 2 diabetes?” As soon as the Nepalese endocrinologist saw me and realised I had developed diabetic ketoacidosis (DKA), she knew. There was just no question I had developed type 1 diabetes as an adult. You describe your type 1 diabetes diagnosis as a very “dark” time and you discuss the intensity of your emotions in detail. What were you feeling in those first days of diagnosis, and how has your understanding about your health and type 1 diabetes changed today? It was like being on a roller coaster those first days. I couldn’t really process it. Things have changed but it’s not like it has been all positive. I am not always in the perfect range. There have been a lot of highs and lows and I am certainly not glad I have diabetes. However, type 1 diabetes is one of the most manageable chronic diseases you can have and if you respect it and handle it well, it shouldn’t slow you down or stop you in any way. Diabetes hasn’t prevented me from doing anything. It’s also changed me in ways for the better -- it’s motivated me to eat healthier. If my book brings greater understanding and makes someone smile enough to realize that with diabetes you can still do anything you want with good planning, then for me the book has succeeded.

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have survived. I was on the trajectory to be in very bad shape with DKA and without that blood test, I could have passed out in a coma, nowhere near medical care. Given the situation, I was very lucky.

Oren with his IV after being diagnosed with type 1 diabetes

Now that you have seen much of the world including areas that have poor healthcare resources such as villages in Kenya and remote locations in Southeast Asia, I wonder what you think about people who live in these areas who also have to struggle with serious chronic conditions like diabetes? I had the luxury of 1st world medical care within days of my diagnosis after I flew home to be with my family in the US. I can’t imagine what it’s like to need insulin and not having access. I certainly want to help and it’s important to bring diabetes care and education and raise money for diabetes supplies to places in need. I certainly felt vulnerable being diagnosed with a serious condition in Nepal but even in that situation I had an advantage. The first doctor I saw was in the tourist area in a very basic clinic, but he was far, far too expensive for the locals. He misdiagnosed me at first and given my experience with first-rate medical care, I knew he had missed something. So I went back and I wasn’t going to leave his clinic without a blood test. I may have not known to go back to see that doctor if I hadn’t grown up with great healthcare. We were in the clinic for four nights which included very basic food, treatment, the bed, doctor visits and supplies which cost just under $200 US. The locals couldn’t afford this and they would take a sleeping mat in the lobby of the clinic and that’s how they stayed over night. If I had been from a local family and had not gone back to see the doctor because I had no more money, then I can see how I might not

Although you don’t discuss your work as a CNN correspondent in The Insulin Express how do you balance the chaos of international broadcast news with the need to self-manage type 1 diabetes? It was important for me to be honest with my colleagues. When I joined the CNN bureau in Jerusalem, I pulled the team together and told them about my type 1 diabetes. I showed them the glucagon kit and what to do for extreme hypoglycaemia, and explained if I ever passed out to call the paramedics right away. It’s not always easy to get the right balance. It can be tough on busy days to do everything I need to for diabetes. When I had to cover the funeral of Israel’s former Prime Minister, we were out all day and it can be tough to accommodate testing and eating. I am fortunate, my work environment is very supportive and my boss is extremely sensitive. I am very comfortable about having diabetes at CNN. What’s next for you? When is your next trip? We have been to 40 countries – but we still have a list of places to visit. In 2018, we are planning to climb Mt Kilimanjaro which will take a good deal of planning for my diabetes. I also need to add that one day I will return to Nepal to thank my host family there for helping us through such a difficult time. Given I climbed and reached Annapurna Base Camp sick with undiagnosed type 1 diabetes, I want to do it again but this time experience it with my health. For more information: The Insulin Express website www.insulinexpress.com Oren Lieberman’s official Facebook page https://www.facebook.com/orenliebermannnews/

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