Diabetes Voice

Global perspectives on diabetes

Volume 59 – December 2014

Tackling diabetes with healthy living

17

19

27 International Diabetes Federation

All correspondence and advertising enquiries

Promoting diabetes care, prevention and

should be addressed to the Managing Editor:

a cure worldwide

International Diabetes Federation, Chaussée de

Diabetes Voice is published quarterly and is freely available online at www.diabetesvoice.org.

Phone: +32-2-538 55 11 – Fax: +32-2-538 51 14

This publication is also available in French and Spanish.

Editor-in-Chief: Rhys Williams Managing Editor: Olivier Jacqmain, diabetesvoice@idf.org Editor: Elizabeth Snouffer Editorial Assistant: Agnese Abolina Advisory group: Pablo Aschner (Colombia), Ruth Colagiuri (Australia), Maha Taysir Barakat (United Arab Emirates), Viswanathan Mohan (India), João Valente Nabais (Portugal), Kaushik Ramaiya (Tanzania), Carolyn Robertson (USA).

Layout and printing: Ex Nihilo, Belgium, www.exnihilo.be

La Hulpe 166, 1170 Brussels, Belgium

© International Diabetes Federation, 2014 – 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 the IDF Communications Unit, Chaussée de La Hulpe 166, B-1170 Brussels, by fax +32-2-5385114, or by e-mail at communications@idf.org.

The information in this magazine is for information purposes only. IDF makes no representations or warranties about the accuracy and reliability of any content in the magazine. 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 magazine. Through this magazine, 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 an 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.

ISSN: 1437-4064 Cover photo : © MmeEmil, Istockphoto.com

Contents

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37 Diabetes Views News in Brief

4

clinical care

8

The double burden of diabetes and cardiovascular disease

35

The DiRECT route to remission?

37

40

g l o b a l c a m pa i g n Schools take the lead in the fight against diabetes 14 David Chaney, Sara Webber and Daniela Chinnici

Lydia Makaroff and Ute Linnenkamp Richard Elliott

IDF World Diabetes Congress 2015

17

Improving healthcare education for type 2 diabetes nutrition

Food health policies established in Mexico

19

Diabetes in society

Bernard Zinman and Jessica Pledge Eduardo Jaramillo Navarrete

h e a lt h d e l i v e r y Should a cure be our primary target for type 1 diabetes?

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Diapedia: A better way of learning about diabetes

25

Global “food insecurity” report

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Jeffrey Brewer

Edwin Gale and Frits Holleman

Carrie Hetherington, Emily Westfall and Keegan Hall

December 2014 • Volume 59 • Issue 4

Carolyn Robertson and Elizabeth Snouffer

Diabetes Voices: How has serving the diabetes cause as a volunteer changed you?

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VOICEBOX

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3

Diabetes views

Together our voice is stronger Even in the middle of the 20th century news and information was communicated rigorously to a small yet developing network of professionals connected to diabetes. IDF was critical then to the dissemination of news and information and it remains so today in 2014.

Sixty years ago the precursor to today’s Diabetes Voice was essentially the IDF News Bulletin – the first news and information source for the IDF community. The quarterly, simply typewritten and then copied using the technology of the day, contained news from a variety of medical journals, similar in theory to modern news aggregate sites online today. It was small in stature and length, but hugely important to the global scientific and medical expert community working for the diabetes cause in 1954.

IDF President who, as one of the early recipients of insulin, dedicated his life to the welfare of those affected by diabetes especially in Great Britain; and the American, Elliott P. Joslin, MD, the first doctor to specialise in diabetes care and progress treatment. Writers and readers of the IDF Bulletin, renamed in 1957, were a small, yet distinguished global group. Incidentally at this time, the US National Health Interview Survey (NHIS) reported in 1958 that 1.6 million people living in the US had diagnosed diabetes (versus nearly 20 million diagnosed today) and prevalence was less than 1%.

No world based surveys yet existed.

In reviewing the esteemed history of IDF and how its communication power has evolved, it is helpful to remember critical milestones. In 1961, the IDF Bulletin reported on the resolution delivered to the World Health Organization (WHO) urging that Contributors to those early reports included diabetes be recognised as a condition of growing pioneers such as Charles Best, Canadian worldwide importance and as a result of that letter, physiologist and medical researcher who with led to today’s close collaboration between WHO Frederick Banting co-discovered insulin as a and IDF. At the 9th IDF World Congress, the treatment for diabetes in 1922; R.D. Lawrence, former Prime Minister of India, Indira Gandhi 4

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prophetically commended the 1976 IDF Congress for bridging the gap between the developing and the developed world thus benefitting all people with diabetes living around the globe. In 1982, a major restructuring of IDF into seven regions, each with their own representatives, was proposed and adopted by IDFs Executive Board, giving a democratic decentralization of power and thereby fostering the retrieval of important news and information worldwide. In 1991, the first ever World Diabetes Day was launched and has become the most visible international campaign for diabetes awareness. By this time, IDF was growing rapidly to become the global voice of all those living with diabetes.

It reported that an estimated 151 million people lived with diabetes in all IDF regions.

While much of this structure has remained intact for IDF and its publications in 2014, the world of diabetes, including the number and needs of people living with or at risk for diabetes, has exploded putting our world in a perilous state. Worldwide numbers have shot up from 151 million to 387 million people today, and are projected to grow at an ever-increasing rate to 592 million by 2035.

Surprisingly, although information technology and the Internet have dramatically changed the way in which people access information and make choices, it is astounding that the digital platform has not yet made a significant dent in finding In 1997, IDF President, Maria L de Alva of the undiagnosed. Our challenge in the years Mexico, who also lived with diabetes, crafted ahead will be to determine our role in a variety the catchphrase “Together we are stronger” of communication channels and to expand our which perfectly encapsulated the broad reach reach to communities and individuals most at risk. of the diabetes international community as the Millennium approached. It was at this time that The need for a powerful voice to represent and IDF publications were made available not only in report on the impact and advances of diabetes is French and English but also in Spanish. more important than ever today. Diabetes Voice continues to deliver news and information crucial to It was no surprise that with the expansion of IDFs all those who can further the promotion of diabetes reach and influence came an urgency to redesign IDFs care, prevention, and a cure worldwide: scientists, Bulletin. In 1999, the publication was reformatted medical professionals, carers, and most importantly, as a 4-color magazine and renamed, Diabetes Voice. people living with diabetes.

In the year 2000, the first edition of IDFs Diabetes Atlas was published marking IDFs 50th anniversary. Together our voice is stronger.

Michael Hirst President, International Diabetes Federation

December 2014 • Volume 59 • Issue 4

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Diabetes views

News from Vienna In September last, the European Association for the Study of Diabetes (EASD) held its 50th Annual Meeting in Vienna. In his opening address, EASD President, Andrew Bolton, referred to the momentous decisions that had been made in that city 100 years previously.

Austria-Hungary's intention, that it should wage a short and localised punitive war against Serbia, didn't work out quite as planned. Instead, the continent, and a good deal of the rest of the world, had to endure a conflict in which millions died. Professor Bolton made reference to the fact that around four and a quarter million people each year perished on the battle fields of that war. He reminded us, though, that IDF’s estimate of over five million people dying (in 2013) as a result of diabetes exceeded even that terrible annual total. He also drew a notable parallel between the potential preventability of both the 1914-1918 conflict and what he termed the “conflagration of diabetes” worldwide.

There was new science presented at that Vienna meeting but it was also a time to look back. One of the meeting’s symposia did just that in relation to the development of the care of people with 6

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diabetes over the 50 years since EASD's first meeting. Guntram Schernthaner’s review began by reminding us that, 50 years ago, there was: no structured diabetes education; no self monitoring of blood glucose; no HbA1c; no screening for microalbuminuria; no insulin pens and no insulin pumps. All insulins were of animal origin; the only oral hypoglycaemics were sulphonylureas and biguanides and there were no lipid lowering agents and no ACE inhibitors for the control of blood pressure. Striving for control of blood pressure, blood lipids and blood glucose was largely a matter of blind faith with no major studies of the effects of this on long-term outcome.

As a result, most patients’ metabolism was poorly controlled, cardiovascular complications were common and premature mortality high with most people with diabetes not living long enough to endure end stage renal failure as so many do now.

Progress has resulted in a significant decline in lower limb amputations; also in blindness as a result of diabetic retinopathy; in deaths through diabetic ketoacidosis and in the incidence of myocardial infarction and stroke. As a result, the excess mortality of people with diabetes compared

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Diabetes views

with their non-diabetic peers has also declined. A recent study from Canada and the UK estimated this fall in excess mortality, from 1996 to 2009, to be over 40%. Of course, as I have pointed out in a previous Diabetes Voice editorial, these results, though welcome, still mean that the risk of premature death in people with diabetes is still over one-and-a-half times that of people free of diabetes.

Professor Schernthaner's account was inspiring and reassuring and, by inference, challenging in terms of what needs to be achieved in the next half century. Nevertheless, readers of Diabetes Voice will need no reminding that there are vast swathes of the world where these advances, though known about, are not available in practice or, if available, are only available to the privileged few.

Novel insulins, DPP4-inhibitors, GLP-1 agonists, SGLT2 inhibitors and all the other members of the alphabet soup of newer diabetes therapies are simply not available and perhaps never will be, at least in publicly funded healthcare settings.

IDF and its Member Associations still have work to do to ensure optimum care for everyone in all settings.

An incident, which occurred in 2002 when I was based at WHO, Geneva, will stay with me for some time as a heart-rending indication of the different technological conditions under which healthcare professionals work. We received a letter, from a clinic in a low-income African country, requesting our help in providing simple blood glucose monitoring equipment.

They had nothing, either for blood glucose or urinary glucose measurement. As a result of this lack of technology, and in order to gauge the extent of glycosuria in their patients, they were forced to ask them to urinate in the garden so they could monitor the speed with which ants clustered around the freshly-voided urine: the faster the ants gathered, the higher the glucose concentration. We assisted them with their problem but neglected to ask them whether they knew that the ancient Greeks had described this phenomenon or whether they had arrived at the observation themselves.

Rhys Williams is Emeritus Professor of Clinical Epidemiology at Swansea University, UK, and Editor-in-Chief of Diabetes Voice.

December 2014 • Volume 59 • Issue 4

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News in brief

World Diabetes Day 2014 Tackling diabetes with the first meal of the day World Diabetes Day 2014 once again united the global diabetes community in a powerful display of awareness in support of the 387 million people currently living with diabetes. The first of the International Diabetes Federation’s (IDF) threeyear campaign on “Healthy Living and Diabetes,” activities for the day and throughout the month of November focused on the importance of starting the day with a healthy breakfast to help prevent the onset of type 2 diabetes and effectively manage all types of diabetes to avoid complications.

Campaign messages also highlighted the huge burden that unhealthy nutrition is contributing in terms of economic cost and lost productivity in every country.

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Throughout the globe, IDF Member Associations in over 170 countries and territories led awareness activities that encouraged local communities to learn more about the foods that can help reduce diabetes risk and manage the condition effectively. “Go blue for breakfast” was the slogan that informed worldwide communities and fostered nutritional activities where local and national personalities also demonstrated their support for the diabetes cause by wearing the blue circle pin.

IDF marked World Diabetes Day by releasing its IDF Diabetes Atlas Sixth Edition update, containing the latest figures on the global prevalence of diabetes. The update reinforced the importance of coordinated and multi-sectoral action today to achieve a healthier future tomorrow.

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News in brief

IDF Diabetes Atlas 6th edition,

Update 2014

The new estimates of the global burden of diabetes even middle- and high-income countries. In the from the IDF Diabetes Atlas update for 2014 were light of this, IDF now calls for greater advances revealed on World Diabetes Day, 14 November. in the evidence-base for diabetes epidemiology in By these estimates, 387 million adults in the world order to produce better quality estimates on the today live with diabetes type 1 or type 2, and al- global impact of diabetes. most half of them do not know about it. If all the adults with diabetes formed a single country, this The IDF Diabetes Atlas is available for download country would be third largest in terms of popu- at: www.idf.org/diabetesatlas lation after China and India. The 20 highest prevalence is found in the 14 IDF DIABETES ATLAS Sixth edition UP International Diabetes Federation’s DA TE (IDF) North America and Caribbean Region, where one adult in nine lives 7 SECONDS healthcare 1 in 2 people with diabetes with diabetes. Every year, the numDO NOT KNOW they have it in 9 bers of cases are increasing and even people with IS SPENT ON DIABETES with a conservative approach, IDF DIABETES estimates that 592 million people will be living with diabetes by 2035.

1

every

/12

1 person dies from diabetes

In 2014 diabetes expenditure reached US $ 612 billion

4.9 million deaths in 2014

33.1%

undiagnosed

27.1%

undiagnosed

52 M

39 M

people living with diabetes

people living with diabetes

NORTH AMERICA AND CARIBBEAN

undiagnosed

48.6%

undiagnosed

37 M

people living with diabetes

PREVALENCE

PREVALENCE

8.3%

9.7%

MIDDLE EAST AND NORTH AFRICA

27.4%

PREVALENCE

8.5%

22 M

people living with diabetes

people living with diabetes

PREVALENCE

PREVALENCE

8.1%

5.1%

SOUTH AND CENTRAL AMERICA

AFRICA

WESTERN PACIFIC

people living with diabetes

undiagnosed

25 M

undiagnosed

138 M

SOUTHEAST ASIA

62.5%

undiagnosed

53.6%

75 M

people living with diabetes

46.3%

undiagnosed

77% of people with diabetes

N AC

ME

NA

SA

CA

AFR

expected increase

WORLD

387 M

+205 MILLION

people living with diabetes

live in low- and middleincome countries

PREVALENCE

8.3%

R

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52.8%

EUROPE

EU

This year, 173 studies were reviewed from all over the world and analysed for the 2014 estimates. However, IDF found a noticeable lack of data for an alarmingly large number of countries,

7.9%

11.4%

WP

This year, health expenditures for the treatment and management of diabetes exceed USD 612 billion globally. However, more than 82% of the total diabetes expenditure is spent in high income countries where only 21% of all people with diabetes live.

Furthermore, 90% of all deaths due to diabetes among people younger than 60 years old occur in low- and middle-income countries.

PREVALENCE

PREVALENCE

SE A

CORPORATE SPONSORS IDF would like to express its thanks to the following sponsors for their generous support of this update of the IDF Diabetes Atlas:

2014

2035

Want more information?

Supported through an unrestricted grant by the Novo Nordisk Changing Diabetes® initiative

See www.idf.org/diabetesatlas or scan the QR code for the app available for iPad

DiabetesVoice

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News in brief

Harvard team gets

one step closer to cure Harvard stem cell researchers announced that, for the first time, they were able to generate massive quantities of human-insulin-producing beta cells similar in almost every way to normally functioning beta cells. In a paper published on October 9th in the journal Cell, Professor Doug Melton, who led the team, announced that they produced an unlimited supply of the cells that are deficient in people with type 1 diabetes. When the researchers transplanted the cells into mice with diabetes, the results were clear and fast. In less than ten days, the mice were cured.

Melton, who also is co-scientific director of the Harvard Stem Cell Institute and the University’s Department of Stem Cell and Regenerative Biology, says the discovery is “50% of the solution to the problem” facing people living with type 1 diabetes today. The other half of the solution involves developing an implantable device to protect the beta cells from rejection by the immune system.

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Melton will be working with Massachusetts Institute of Technology applied biology professor Daniel Anderson to design an implantable device.

Melton and his research team, including 50 graduate students, took 15 years to track the formation of beta cells during development looking carefully at which genes are turned on and off. By emulating the process and triggering those same genes using chemicals and growth factors they coaxed human embryonic stem cells or induced pluripotent stem cells into beta cells. The resulting procedure takes about 40 days and involves six steps to generate a functioning beta cell. Melton predicts it will take at least one year for the government to approve testing in people and hopes to have human transplantation trials, using the cells, under way in a few years.

“We are nearly at the finish line,” said Melton whose son and daughter both developed type 1 diabetes at six months and 14 years respectively.

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News in brief

on the Bookshelf THE DIABETES RESET: AVOID IT. CONTROL IT. EVEN REVERSE IT. A DOCTOR'S SCIENTIFIC PROGRAM

By George King (Author) 352 pages, English, Workman Publishing Company (January 13, 2015)

Dr George King, Research Director and Chief Science Officer at Harvard’s Joslin Diabetes Center, explains how to effectively reset your body’s glucose metabolism for a longer, healthier life. Based on cutting-edge research, The Diabetes Reset translates the latest findings into a plan that will let readers avoid, control, and even reverse type 2 diabetes. The programme begins with weight-loss and shows why losing only 5% of body weight makes a life-changing difference. It explains how a good night's sleep can significantly lower blood glucose levels (and why sleep deprivation works in reverse).

It disentangles the carbohydrate confusion, reveals how to decrease the body’s inflammatory response, and explains the importance of moderate exercise.

OBESITY INTERVENTIONS IN UNDERSERVED COMMUNITIES: EVIDENCE AND DIRECTIONS

By Virginia M. Brennan (Editor), Shiriki K. Kumanyika (Editor), Ruth Enid Zambrana (Editor) 416 Pages, English, Johns Hopkins University Press (November 20, 2014)

The obesity epidemic has a disproportionate impact on communities that are hard-hit by social and economic disadvantages. In Obesity Interventions,

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a diverse group of researchers explores effective models for treating and preventing obesity in such communities. The volume provides overviews of the literature targeting certain aspects of society and health (e.g., the effectiveness of preschool obesity prevention programmes), as well as commentaries that shape our understanding of the obesity epidemic and reports on approaches to combating obesity in underserved populations in the United States.

VITAL CONVERSATIONS: IMPROVING COMMUNICATION BETWEEN DOCTORS AND PATIENTS

By Dennis Rosen (Author) 264 pages, English, Columbia University Press (September 23, 2014)

The healthcare system in the US is by far the most expensive in the world, yet its outcomes are decidedly mediocre in comparison with those of other countries. Poor communication between doctors and patients, Dennis Rosen argues, is at the heart of this disparity, a pervasive problem that damages the wellbeing of the patient and the integrity of the healthcare system and society. Drawing upon research in biomedicine, sociology, and anthropology and integrating personal stories from his medical practice, Rosen shows how important good communication between physicians and patients is to high-quality care. Rosen concludes with a prescriptive chapter aimed at building the cultural competencies and communication skills necessary for higher-quality, less-expensive care.

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News in brief

Volume 1 Issue 1 September 2013 ISSN 0379-0738

DIABETES

RESEARCH AND CLINICAL PRACTICE Official Journal of the International Diabetes Federation

Currently in Diabetes Research and Clinical Practice

From pancreatic islet formation to beta-cell regeneration The double burden of diabetes and tuberculosis – Public health implications Serum uric acid levels and incidence of impaired fasting glucose and type 2 diabetes mellitus: A meta-analysis of cohort studies Evidence-based management of hyperglycemic emergencies in diabetes mellitus

DRCP is the official journal of IDF. The following articles have appeared recently or are about to appear in that journal. Access information can be found in the QR code.

COST-OF-ILLNESS STUDIES IN DIABETES MELLITUS: A SYSTEMATIC REVIEW Ng CS, Lee JYC, Toh MP et al. Diabetes Res Clin Pract 2014; 105: 151-63.

“The aims of this study are two-fold: (1) to describe the methods used in ... cost-of-illness studies of DM [Diabetes Mellitus] and (2) to summarise their study findings regarding the economic impact of DM. ...

The systematic search yielded 30 articles. These studies varied considerably in their study design ...

Estimates for the total annual cost of DM ranged from US$141.6 million to US$174 billion ... Inpatient cost was the major contributor to direct cost in half of the studies that included inpatient costs.”

DIABETES CARE MAY BE IMPROVED WITH STENO QUALITY ASSURANCE TOOL – A SELF-ASSESSMENT TOOL IN DIABETES MANAGEMENT Bjerre-Christensen U, Nielsen C, Binder JB et al.

Diabetes Res Clin Pract 2014; 105: 192-98.

This study aimed “to evaluate if improvements in the quality of diabetes care in Indian clinics can be obtained by simple self-surveillance PC-based software. ... Data was entered for an initial 3 months 12

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period. Subsequent data were analysed by the users, who designed plans to improve indicator status [frequency of foot examination and lipid, urine albumin excretion and HbA1c measurements] and set goals for the upcoming period. ... Outcome parameters [blood glucose and blood pressure] improved significantly.”

INTERVENTIONS TO MAINTAIN CARDIAC RISK CONTROL AFTER DISCHARGE FROM A CARDIAC RISK REDUCTION CLINIC: A RANDOMISED CONTROLLED TRIAL Taveira TH, Wu W-C. Diabetes Res Clin Pract 2014; 105: 327-35.

This study aimed “to evaluate the efficacy of two maintenance strategies compared to usual care after discharge from a pharmacist-led cardiovascular risk reduction clinic (CRRC). ... Participants were randomised to either [1] quarterly group medical visits or [2] quarterly CRRC individual clinic visits, or [3] a usual care control arm with the standard primary care alone. ... both individual and group interventions are more effective in maintaining glycaemia and blood pressure control for patients with diabetes than usual care after 1-year of follow-up.”

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Broaden your horizons with

SCE in Endocrinology and Diabetes 10 June 2015 Developed in partnership with the Association of British Clinical Diabetologists and Society for Endocrinology

Registration opens: 11 February 2015 Closing dates: 11 March 2015 (international) 6 May 2015 (UK) sce.international@mrcpuk.org or visit www.mrcpuk.org/mrcpuk -examinations/specialty-certificate-examinations

GLOBAL CAMPAIGN

Schools take the lead in the fight against diabetes David Chaney, Sara Webber and Daniela Chinnici

Approximately 79,000 children are diagnosed with diabetes each year around the world.1 Schools play an important role in protecting the rights of children and teenagers with diabetes. However, the lack of knowledge within schools about diabetes can lead to isolation, stigma and discrimination.2-5 The International Diabetes Federation (IDF), International Society for Pediatric and Adolescent Diabetes (ISPAD) and Sanofi Diabetes launched the Kids with Diabetes in Schools (KiDS) project in 2013. The project addresses the lack of diabetes knowledge in schools, fosters a supportive school environment for children with diabetes and introduces all children to the importance of engaging in a healthy lifestyle. Currently, KiDS is running pilot programmes in Brazil through the Associação de Diabetes Juvenil (ADJ) and in India through the Public Health Foundation of India (PHFI).

This valuable resource provides information on diabetes prevention, diabetes management and tips for leading a healthy lifestyle.

Quick reference sections are featured in the pack giving essential details on how to deal with hyperglycaemia (high blood glucose) and hypoglycaemia (low blood glucose). For teachers and parents, the pack also provides a diabetes management plan which serves as guidance and may offer protection for the needs of a child with diabetes during a typical school day.

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As part of KiDS in-school training sessions, teachers, parents and children are provided with a culturally tailored Diabetes Information Pack.

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December • Issue 4 9 e/kqegs 2014 ¼Mk;fcVht+½•ijVolume tkudkjh nsus ds59 fy, ,d iqfLrdk

GLOBAL CAMPAIGN

information pack for TEACHERS

K DS A project of the International Diabetes Federation

Kids & Diabetes in Schools

A toolkit to inform on

diabetes in schools The KiDS pack is available in eight languages, including Portuguese and Hindi, from the IDF website. A KiDS app for iPad in English was launched in September. By the end of 2014, the app will also be available in the same eight languages.

The KiDS pilot sites in Sao Paulo and New Delhi have been running school trainings since June 2014.

Both cities are experiencing increasing prevalence of childhood type 2 diabetes, partly due to rapid urbanisation and changing lifestyle. In total, 15 school trainings will take place in each city. Early results following the first trainings are encouraging. In Brazil, all nutritionists working in Sao Paulo will be trained using KiDS materials. Trainings in Brazil are now expected to reach 15,000 students.

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e/kqegs ¼Mk;fcVht+½ ij tkudkjh nsus ds fy, ,d iqfLrdk : “kjr Qslcqd ij ^ ds;j�QkWj Mk;fcVht+ (care for diabetes) * ls�tqM+s %� www.facebook.com/youthforhealth

seeing the benefits of the project, and one school administrator advocates KiDS as an empowerment tool: “KiDS is an excellent opportunity for us to empower teachers for reaching out to parents and seeking their cooperation – both in terms of caring for people with type 1 diabetes and for making efforts to prevent children from developing type 2 diabetes later in life,” said Ms. Madhulika Sen, Principal, Tagore International School, Vasant Vihar.

In New Delhi, the Ministry of Health has made a commitment to train 30,000-40,000 teachers with KiDS materials. Schools in New Delhi are clearly

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GLOBAL CAMPAIGN

Additionally the KiDS project has also been released in Toronto, Canada with the support of the Canadian Diabetes Association (CDA). More information will be forthcoming as the Canadian pilot progresses.

Looking ahead The KiDS project will be evaluated in India and Brazil in 2015 with results being discussed at the World Diabetes Congress in Vancouver (in December, 2015). Other countries including Iran, Kuwait, Taiwan and Turkey have expressed an interest in running the KiDS project in schools.

Within the next months a toolkit to help new countries introduce the KiDS packs in schools will be available on IDF website.

David Chaney, Sara Webber and Daniela Chinnici David Chaney is Senior Education Specialist at the International Diabetes Federation, Brussels, Belgium.

Sara Webber is Media and PR Coordinator at the International Diabetes Federation, Brussels, Belgium.

Daniela Chinnici is Programmes and Policy Administrator at the International Diabetes Federation, Brussels, Belgium.

For more information on the KiDS project and to download the Diabetes Information Pack, visit the IDF website www.idf.org/education/kids

References 1. I nternational Diabetes Federation. IDF Diabetes Atlas Sixth Edition. IDF. Brussels, 2013.

2. Amillategui B, Calle JR, Alvarez MA, et al. Identifying the special needs of children with type 1 diabetes in the school setting. An overview of parents' perceptions. Diabet Med 2007; 24: 1073-9. lympia RP, Wan E, Avner JR. The preparedness of schools to respond 3. O to emergencies in children: a national survey of school nurses. Pediatrics 2005; 116: e738-45. ellems MA, Clarke WL. Safe at School: A Virginia Experience. Diabetes Care 4. H 2007; 30. DOI: 10.2337/dc07-0121 inelli L, Zaffani S, Cappa M, et al. The ALBA project: an evaluation of needs, 5. P management, fears of Italian young patients with type 1 diabetes in a school setting and an evaluation of parents' and teachers' perceptions. Pediatr Diabetes 2011; 12: 485-93.

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GLOBAL CAMPAIGN

IDF World Diabetes Congress 2015 Bernard Zinman and Jessica Pledge

In 2015 the International Diabetes Federation (IDF), in partnership with the Canadian Diabetes Association, is bringing the World Diabetes Congress to Vancouver, Canada. From November 29th to December 4th the global diabetes community will convene to experience a world-class programme.

The Programme Committee, made up of international experts, is developing sessions that will appeal to delegates from around the world including the host country Canada. With 220 hours of

December 2014 • Volume 59 • Issue 4

scientific sessions and over 350 speakers, the programme promises to deliver an exceptional experience for delegates. Symposia, lectures and debates will run alongside interactive sessions including open forums and workshops which will provide delegates with a range of learning opportunities.

The programme is divided into six streams: ■T he Basic and Clinical Science stream is led by Steven Kahn. This stream will showcase advances in clinical research and basic science. It will also outline the latest in diabetes treatments.

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GLOBAL CAMPAIGN

■T he Public Health and Epidemiology stream is led

by Edward Boyko. This stream will present current trends in diabetes and its complications. It will also showcase the latest prevention methods.

■T he Education and Integrated Care stream is led

by Unn-Britt Johansson. This stream will demonstrate up-to-date education tools for healthcare practitioners and people with diabetes. It will also introduce innovations in patient care and management.

■ The Living with Diabetes stream is led by Gordon Bunyan. This stream will deal with the issues faced by people with diabetes on a daily basis and how best to manage these. It will also discuss how people with diabetes can best advocate for their rights.

■ The Global Challenges in Health stream is led

by Gojka Roglic. This stream will tackle global challenges stemming from the diabetes epidemic.

It will also debate how people and governments can act to combat them.

■T he Diabetes in Indigenous Peoples stream is led

by Malcolm King. This stream will present the specific problems facing indigenous populations around the world. It will outline the latest education techniques and the most recent advances in management and care. It will also present trends in diabetes and its complications within these populations.

The programme of the IDF World Diabetes Congress addresses the causes, prevention and management of diabetes and promotes improved education for all people living with diabetes. The Congress also advocates diabetes awareness in part by providing a global platform for people who live with diabetes to discuss their experiences and for all healthcare and government sectors to examine and consider ways to stop the epidemic.

The broad nature of this programme attracts delegates from all fields of diabetes. Physicians and

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scientists will come for the basic science, public health and epidemiology sessions. Nurses and educators will mostly attend the clinical care and education sessions. Policy-makers, government representatives and advocates will be most drawn to the global and patient-perspective sessions.

However, by bringing all of these specialities together, delegates can broaden their knowledge outside their fields of expertise and increase understanding and cooperation.

The IDF World Diabetes Congress is the most important bi-annual congress for global diabetes care.

It brings together experts from all over the world.

The congress is an ideal platform for individuals to present their work to a wide audience. Over 2,000 abstracts will be submitted and over 1,300 posters will be displayed.

We look forward to welcoming you to Vancouver.

Bernard Zinman and Jessica Pledge Bernard Zinman is Chair of the Programme Committee, World Diabetes Congress 2015.

Jessica Pledge is Programme Coordinator at the International Diabetes Federation, Brussels, Belgium.

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GLOBAL CAMPAIGN

Food health policies established in Mexico Eduardo Jaramillo Navarrete

The problem According to our Health and Nutrition National Survey (ENSANUT) 2012, approximately seven in ten adults in Mexico are overweight. Furthermore, the Organisation for Economic Co-operation and Development (OECD) Health Statistics 2014 ranks Mexico second in the world for obesity prevalence.

As a result of this, type 2 diabetes has a critical dimension in Mexico, with the country occupying first place for the greatest number of people between 20 and 79 years suffering from diabetes.1 Additionally, the combined national prevalence for overweight and obesity in children in 2012, using criteria from the World Health Organization (WHO), was 34.4%. In adolescents, the prevalence was 35%.2 Other results from ENSANUT 2012 regarding physical activity and sedentary

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lifestyles show that 58.6% of children and adolescents from 10 to 14 years have not taken part in any organised physical activity during the previous 12 months.

Given the current situation, the Mexican Government developed a National Strategy for Overweight, Obesity and Diabetes Prevention and Control whose fundamental principle relies on the coordinated participation between the Government, the private sector and society as a whole.

The response If not addressed, Mexico’s future as a nation will be compromised. The negative impact on school performance and labour productivity will be adversely reflected in poor economic competitiveness.

This type of predicament would affect the most vulnerable groups in Mexican society.

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GLOBAL CAMPAIGN

The National Strategy sets out four principles: 1. Health should be part of all public policies.

2. Focused attention should be based on social factors, under an integrated approach for health promotion and healthcare.

3. All sectors and stakeholders must combine efforts and align activities.

4.

Accountability and monitoring the National Strategy impact are essential.

The aim The aim of Mexico’s National Strategy is to improve welfare levels of the population and contribute to the sustainability of national development by decreasing overweight and obesity prevalence among the Mexican population. With public health interventions, an integrated model of healthcare and intersectoral public policies, the epidemic of noncommunicable diseases (NCDs), especially type 2 diabetes, should be reduced.

Pillar 1. Public health. The Strategy seeks to preserve the health of all citizens by promoting healthy lifestyles, with education campaigns, as well as monitoring the incidence of NCDs and some of their main determinants.

Also, prevention programmes like screenings for those with risk factors will be executed.

Pillar 2. Healthcare. Ensure effective access to healthcare through medical interventions for people with risk factors or for those already diagnosed with type 2 diabetes in order to provide the adequate care and avoid any diabetes-related complications.

Pillar 3. Health Regulation and Fiscal Policy. The Strategy aims to generate effective initiatives to fight NCDs, meeting social demand to regulate the labelling and advertising of food and drink, especially

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GLOBAL CAMPAIGN

Figure. Mexico's National Strategy 1. Public health

Increase public and individual awareness on obesity and the link to NCDs

Prevention

2. Healthcare Quality and effective access

3. Health regulation and tax policy

Guiding principles

Health promotion and educational communication

Research and scientific evidence Responsibility Transversality Intersectoriality Impact assessment Accountability

Epidemiological monitoring

Guide the National Health System towards early detection

Resolve and control on first contact

Labelling Slow the increase on overweight, obesity and NCD prevalence

Advertising Tax measures

those targeted to children, and suggest tax policies be directed to reduce the consumption of food with low nutritional value.

To provide a greater scope and depth to the efforts undertaken the Strategy defines six main guiding principles: research and scientific evidence; responsibility; transversality; intersectoriality; and impact assessment and accountability.

The challenge is daunting but certainly an organised Government and societal effort will achieve positive results.

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Eduardo Jaramillo Navarrete Eduardo Jaramillo Navarrete is General Director of Health Promotion, Federal Health Secretariat, Mexico.

References 1. OECD. Health at a Glance 2011: OECD Indicators. OECD Publishing. 2011.

2. S ecretaría de Salud, México. Encuesta Nacional de Salud y Nutrición 2012.

Resultados Nacionale. http://ensanut.insp.mx/

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Health Delivery

Should a cure be our primary target for type 1 diabetes?

Jeffrey Brewer

It is possible, of course, to quibble with the wording of the International Diabetes Federation’s (IDF) mission statement in that “a cure” (singular) for diabetes is highly unlikely ever to be achieved, despite all our best efforts. When cures come (and they surely will), they are likely to be multiple: different cures for type 1 and type 2 diabetes; perhaps different cures for diabetes at different stages and in different people, and even further complexities. The only thing of which we can be reasonably certain is that there will not be just one cure which will be effective for all. Here, Jeffrey Brewer takes what might be regarded as a much more controversial stance with regard to the quest for a cure ...

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As both a parent of a child living with type 1 diabetes (T1D) for the last 12 years and the Chief Executive Officer (CEO) of Juvenile Diabetes Research Foundation (JDRF) for four years, I have dedicated my personal and professional life to advocating for a cure to this pernicious disease. Just like the unrelenting disease itself, our family has never stopped our best effort to work for the elimination of T1D from our son’s life, and by extension the lives of the millions of others who suffer. In addition, I want whatever damage has been done to my son’s body to be fixed and restored to normal physiology.

While I’m not at all extraordinary in what I want for my loved one afflicted with T1D, my engagement with the community has provided me with some unique insights into the T1D fundraising,

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health delivery

investment, research and clinical development landscape. Everything I know indicates that the idealised “cure” I want for my son is not likely to be possible for many decades, and certainly not in the meaningful adult years of my son’s lifetime. T1D is not a single disease but is a clinical syndrome that likely includes multiple diseases that may have different aetiologies, pathogeneses, and rates of progression and, thus, may require different therapeutic approaches. Our understanding of the human immune system is only preliminary at best. My acceptance of this unpleasant but inarguable state of affairs has greatly influenced my prioritisation of the life transformative therapies that, while not cures, hold the potential to profoundly transform and improve life with T1D. Instead of a vaguely imagined cure that may happen one day in an indeterminate and far off future, it may be the case that something short of a “cure” is what patients want and need today.

More importantly, it is what’s possible if we devote sufficient resources to truly create meaningful clinical breakthroughs.

I make the provocative argument that “cure” is the wrong paradigm for structuring our efforts in the battle against T1D and that our historical focus on perfection has undermined our progress toward the good or the potentially great. While the concept of a cure is motivating and resonant, I believe the predominant focus on a cure – to be reached one glorious day in the future – constantly distracts us from the critical work that can be done in a near-term and predictable timeframe. In other words, there should not be one cure, but a series of therapeutic advances that reduce the burden of this terrible disease, improve health outcomes and ultimately restore physiology to that of a person without T1D. This will only happen if we shift the research paradigm to be more balanced among academic research and translational research done in collaboration with industry.

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Technology supporting insulin therapy for type 1 diabetes. Photo: Elizabeth Snouffer

Whatever we call it, a cure or a series of meaningful advancements in treatment, there is a consensus for progress and better therapies to improve life with T1D. The way we define our mission as a T1D community is going to determine what we get as a result of our efforts. Maybe the right question to ask is: what does the person living with a disease consider victory? Is it restoration of normal physiology that a person with T1D wants, or is it a safe, easy and cost effective way to eliminate the symptoms of a disease? The former will take many decades. Does the person living with T1D want to eliminate his or her autoimmune condition or exist without the need for insulin shots? How about freedom from the need for constant carbohydrate counting and blood glucose testing? The latter might be done through a variety of approaches that could be accomplished much sooner.

Even though as a community we have made great progress in reallocating resources to more technologically achievable and commercially viable therapies such as the artificial pancreas, encapsulated implantable islets and glucose responsive in-

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sulin, my perspective on the budgets of the diabetes non-profit organisations and the National Institutes of Health (NIH) lead me to believe we are still greatly over-allocated in research dollars towards the far off cure for T1D. Potential revolutions in treatment have been starved of resources both in government and private philanthropy, mostly because the expertise and institutions needed to advance these practical efforts, for the most part, do not reside in those academic research institutions that have historically been our strongest and most funded partners.

The overwhelming preponderance of research dollars is being spent exclusively in academic laboratories without collaboration with industrial partners. Furthermore, research programmes often are not informed by the practical considerations of clinical development efforts or regulatory concerns, let alone any thoughtful incorporation of healthcare economics. To be sure, early stage academic medical research is critical to prime the pipeline.

Unfortunately, most funders today almost exclusively allocate resources to this area. That means too much of what is funded will not be relevant to people with T1D in a relevant timeframe. Our historically exclusive focus in this realm has led to overpromising of therapeutic advances and even cures, with too few meaningful advances that have any real chance of impacting the majority of people living with diabetes today.

As a general rule, any discoveries happening in academia should be thought of as at least 10-20 years away from any opportunity for broad clinical application. And that is only for the small percentage of discoveries that ever do translate. Academic research labs do not translate science into cures or meaningful therapies because that is normally done by the private sector. While charities are historically loath to use their resources in support of industry development efforts, it is the case that allocating the money raised for clinical development part-

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nership within the pharmaceutical industry could have the biggest impact on behaviour change in a for-profit setting. The goal should be to encourage more companies to co-invest in new disease spaces and undertake clinical development initiatives considered too risky to stimulate transformational change in treatment. This progress can and will only happen within the realm of industry.

I have great confidence that before we will be able to “cure” my son, we will be able to stop the immune attack before it results in insulin dependence. And shortly thereafter, we may achieve a vaccine that ultimately prevents T1D. Just like the polio vaccine, the general public may consider that “the cure”, but my son and millions of others will continue to struggle with the disease. Don’t get me wrong, I also want that vaccine and consider efforts in that area worthy of investment. However, I consider efforts in such a direction cure or prevention for my grandchildren. Unless we adequately prioritise spending on the achievable in the next decade or two, then I will not have achieved my goal. I think that starts with abandoning the fuzzy but comforting concept of a cure and committing to what is possible now.

Jeffrey Brewer Jeffrey Brewer is an entrepreneur and philanthropist who recently served as CEO of JDRF from 2010-2014.

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Health Delivery

Diapedia: a better way of learning about diabetes Edwin Gale and Frits Holleman

Death of a dinosaur We all know the diabetes textbook: massively heavy, very expensive, never there when you need it, and always a bit out-of-date. The Internet outperforms it in all respects and yet, the passing of the medical textbook leaves a void that needs to be filled. The Internet is now clearly the primary source of information about diabetes (or anything else), but finding what you need is not as straightforward as it might seem. When Diapedia was “just a twinkle in the eye”, we commissioned a survey of diabetes resources on the web. Readers of this item will already know what we found: a chaotic barrage of information, opinion and sales messages. What we failed to find was an authoritative, independent, peer-reviewed and regularly revised source for investigators, students and members of the public seeking up-to-date information about diabetes.

The diabetes textbook is dead – but what will take its place?

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Beyond Wikipedia Our starting model was, of course, Wikipedia.

Wikipedia is free, crowd-sourced and regularly updated, but it has its problems. The quality of the entries about diabetes varies widely and there is no formal review process. This works very well for most topics, but less well when there are powerful commercial interests and strident private prejudices at work, and no one to act as referee.

The second limitation of Wikipedia is that, like any encyclopaedia, it is merely an index of entries.

It cannot replace a textbook when it comes to the provision of contextual, structured information.

PubMed, comprising more than 23 million citations for biomedical literature from MEDLINE, life science journals, and online books, is another important source of information, but is not easy to search and most articles are not freely available to those who lack access to a medical library.

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Health Delivery

Up-to-Date is another widely used and excellent facility, but is strongly focused on clinical practice in the USA and is, of course, not freely available.

Why Diapedia?

With all this in mind, Diapedia was planned around several founding principles. It must be open access, and it must aim for a worldwide audience, allowing for the enormous variation in the challenge diabetes represents in different environments. The standard textbook is written from a Euro-American perspective, and is not necessarily appropriate for those in Africa, Asia or the Middle East. Therefore, we need to reach out in these directions.

The second founding principle is impartiality. This is essential, not only in the interests of science, but also because of the powerful commercial interests involved. Needless to say, no one can lay claim to perfect impartiality, including contributors to Diapedia, but safeguards can be in place. These include peer review of all contributions, and (above all) reader review.

Diapedia is a living textbook, which means that it is designed to be continuously updated. To facilitate this, we have no ownership of entries: the person/people who make the first draft are acknowledged as the creator of the page (which has a digital object identifier (DOI) and is thus citable). In addition, each page has a moderator, the referee who ensures fair play, and a section editor. Access to the site is free and does require registration, but readers who wish to post a comment must sign on to do so.

Each comment is responded to, adjudicated and incorporated in the text.

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The third founding principle is that Diapedia can be used either as a textbook (offering structured, contextual information) or accessed as an encyclopaedia. The three dimensional nature of the Internet allows easy passage from one theme to another within the text, and easy outreach to other good quality sites on the web. Given the various backgrounds of potential users (from the interested lay-person to basic researchers) the knowledge base within Diapedia will be accessible at various entrylevels, with key words linking the more superficial layers to deeper layers.

Our target readership includes anyone with an interest in diabetes and a basic biology vocabulary, ranging from motivated members of the public, medical students, clinicians and nurses to diabetes specialists and researchers. The aim is to provide up-to-date high quality information; Diapedia does not set out to provide practical advice about living with diabetes nor does it set out to provide a guide to practical clinical management; this type of advice should be sought from national or other professional guidelines. Nor is Diapedia in competition with anyone (except the old medical textbooks!). We wish to link to all that is best about diabetes anywhere.

Diapedia is wholly sponsored by the European Association for the Study of Diabetes (EASD), whose support is gratefully acknowledged, and has no involvement with any commercial entity. You can access our site at www.Diapedia.org. At the time of writing (September, 2014), we have been going for 18 months and have already attracted ~420 entries (average length 1,500 words), and we are growing rapidly. It is designed for use by the entire diabetes community, so why not you?

Edwin Gale and Frits Holleman Edwin Gale is Editor-in-Chief of Diapedia, University of Bristol, United Kingdom.

Frits Holleman is Deputy Editor of Diapedia, Academic Medical Center, Amsterdam, the Netherlands.

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Health Delivery

Global “food insecurity” report

Diabetes Voice asked three representatives from the International Diabetes Federation’s (IDF) Young Leaders in Diabetes Programme (YLD) to report on the issue of “food insecurity” and its effect on children in their home countries. Food insecurity may be defined as the state of being without reliable access to a sufficient quantity of affordable, nutritious food. The Food and Agriculture Organization of the United Nations (FAO) World Food Summit of 1996 defined food security as existing “when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life”. Commonly, the concept of food security includes both physical and economic access to food that meets people's dietary needs as well as their food preferences. In many countries, health problems related to dietary excess are an ever-increasing threat.

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Food insecure people on low incomes have limited resources and lack of access to healthy, affordable food; experience cycles of food depravation and over-eating and high levels of stress, and are subjected to a higher level of the marketing of unhealthy foods. They also have limited access to healthcare. The combination of all these elements fosters the development of non-communicable diseases (NCDs) including type 2 diabetes.

In our report, Carrie Hetherington asks why almost 200,000 children do not have access to nutritious food in New Zealand. Defined as a “hot button” issue in the US, Emily Westfall discusses how food insecurity continues to increase in the US even with government assistance. President of YLD, Keegan Hall, describes the dual burden of chronic malnutrition and obesity that faces South Africa today.

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Building a better foundation for New Zealand’s children Carrie Hetherington

New Zealand has a population of 4.5 million, and is ranked seventh on the United Nations Human Development Index. Bloomberg ranks New Zealand as the 15th most healthy country in the world with a total health score of 87.87%.

Why then is it estimated that 265,000 of New Zealand’s children live in poverty? Approximately 28

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180,000 are failing to receive basic requirements such as nutritious food. Rising food prices are a significant issue and adversely impact New Zealand’s population. Families categorised in a low-income bracket are often forced to buy unhealthy foods because they are more affordable. Food insecure or low-income populations are vulnerable to obesity because of their limited resources and lack of access

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Health Delivery

to healthy, affordable foods. The effects of New Zealand’s food inequality problem have serious consequences, particularly on children, as one in nine are now officially considered “obese”.

Helen Clark, New Zealand’s former Prime Minister and the current United Nations Development Programme (UNDP) Administrator, has spoken very plainly about the world health challenge in relation to NCDs saying, “Obesity and type 2 diabetes are now a major global health threat. All countries need to focus on nutrition, education for nutrition and physical exercise to avoid premature mortality, illness and disability which could be averted.” One of the most critical UNDP objectives is to develop policies which focus on nutrition largely because access to a healthy diet improves a person’s potential. Although the UNDPs objective largely refers to people in developing countries, many wealthy nations face a similar challenge.

New Zealand has the fifth highest rate of childhood obesity according to the Organisation for Economic Co-operation and Development (OECD) and Diabetes New Zealand has emphasized how children as young as eight years are being diagnosed with type 2 diabetes. However, New Zealand is taking action in both the private and public sectors to curb the rising epidemic of obesity in children and to promote healthy lifestyles.

In 2005, the “Food for Kids” programme was launched as part of collaboration between the Ministry of Social Development and the “Kids Can” charity. Together their collaboration serves as a link between individuals, communities, businesses and the Government. The programme is dedicated to the provision of nutritious food for disadvantaged children within the school setting.

Food for Kids successfully supplies food packages everyday supporting over 12,500 children per week, and is also consistently expanding its reach.

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In the private sector the “Kickstart Breakfast” concept was introduced in 2009 by two of New Zealand’s largest companies. Fonterra and Sanitarium joined forces to provide wholesome breakfasts to schools nationwide serving over 95,000 breakfasts per week. In 2013, the Government added full support to the programme.

New Zealand’s Ministry of Health also introduced an initiative called, “Fuelled4life” in 2012.

Fuelled4Life was specifically designed to give young people a good start to life through access to healthier food and beverages. The Fuelled4Life classification system is considerably sustainable as it not only teaches children long-lasting skills about nutrition in the school setting, but also challenges New Zealand’s food industry to supply foods which are both healthy and appealing to children.

Although New Zealand has a long way to go, the success of these and other initiatives is increasingly maximising the effect of improved nutrition for healthier lifestyles. Families on government benefits feel assured knowing that their children will receive a healthy breakfast and lunch at school and those who are on higher incomes learn about nutrition through their children’s education. Our country is laying stronger foundations for future generations who, understanding the importance of healthy nutrition, will adopt healthier habits thereby helping to reduce the rising levels of obesity and type 2 diabetes in New Zealand.

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Addressing child nutrition and food insecurity in the US Emily Westfall

The United States - according to the World Bank1boasts a declining unemployment rate and a rising per capita income in 2013-2014. However, the US also reports an alarming increase in food insecurity and childhood hunger. Families above the poverty line with a stable income are still forced to turn to government assistance programmes such as the Supplemental Nutrition Assistance Food Program (SNAP, formerly Food Stamps) and school lunch programmes in order to feed their families.

Food insecurity – when a household is uncertain of having, or is unable to acquire enough food to meet the needs of all the family because of insufficient funds – is a “hot button” issue. The US Government offers The Special Supplemental Nutrition Program for Women, Infants and Children (WIC), an assortment of childhood nutrition programmes including National School Lunch, School Breakfasts and a programme called “Special Milk” along with SNAP. First Lady Michelle Obama is a strong voice for children in need and, in 2010, encouraged the US Department of Agriculture to pass the “Healthy, Hunger-Free Kids Act”. In this Act, the 2014-15 amendment includes nutrition requirements for all snacks sold in schools during the day, adds more fruits and vegetables to lunch options, reduces 30

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sodium chloride contents and requires some use of whole-grains in all meals.2 Despite government assistance and school nutrition requirements, many children do not know where their next meal may come from or what it will be.

Locations with the highest levels of food insecurity are surprising: families in urban neighbourhoods and suburbs as well as farmers growing much of the country’s bulk crops report the highest rates.

As families struggle to provide food for every meal, nutrition is often sacrificed for price. Kids subject to food insecurity are at a higher risk of obesity, type 2 diabetes, negative impacts to emotional development and misbehaviour in school.

Addressing the issues of poverty and food insecurity will likely help address the rising levels of obesity in the US. While some developed countries have less obesity overall, the US is among those that stand apart. In those areas where 35% of the population live below the poverty line, obesity levels are 45% higher than averages of developed countries. The rise in obesity, resulting in the development of type 2 diabetes is costly, with 70% of healthcare costs addressing complications associated with diabetes.3

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Health Delivery

No Kid Hungry campaign. Picture: Channing Johnson

Currently, there is a movement driven by people who, frustrated with gaps in governmental assistance programmes, have been inspired to create ways to bolster the nutritional content of food provided by schools. A component of the global non-profit organisation Share Our Strength, the “No Kid Hungry Campaign”, works at the local, state and national levels to provide more families with access to SNAP.4 They assist schools with providing breakfast, after-school and summer meals to children and educate families with the “Cooking Matters” programmes. By providing classes on how to cook nutritious meals on limited budgets, Cooking Matters teaches families to better feed themselves on a tight budget.

The non-profit organisation, Feeding America, works with local food pantries to provide children and their families with food for the weekend (“Back-Pack

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Program”), provides meals in safe locations where children already congregate after school such as churches and Boys and Girls Clubs (“Kids Café”) and, in 2010, launched the Child Hunger Corps.5 Corps members are assigned to a food bank for two years in order to assess conditions in the community and launch or assist current child hunger initiatives.

Despite the ambitious assistance provided to more than 25 million Americans each year by federal government and hunger-relief programmes, current policies have done little to adequately address the problem. Even as the US economy improves, levels of food insecurity remain much higher than before the economic recession in 2007. Until improvements in US policy focus on the root causes of food insecurity and how to combat it, children will continue to face a host of health problems with a less than promising future.

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Dual burden of malnutrition and obesity in South Africa Keegan Hall

Like many countries in the world, South Africa faces a challenge when it comes to ensuring children are well nourished at an early age. Early adequate nutrition provides the foundation for life from growth to cognitive development. Currently in South Africa there are an estimated 3.3 million children who go hungry every day.

The National Food Consumption Survey (NFCS), conducted in South Africa in 1999, focused on the nutritional status and dietary intake of children between the ages of one and nine years. This study found that 23% of these children were low heightfor-age, also known as “stunted” or suffering from chronic malnutrition.

This finding implies that 23% have widespread long-term developmental risks. The prevalence of malnutrition was higher in rural areas (26.3%) and especially in commercial farming areas (30.8%).

Younger children aged 1-3 years old (25.5%) were 32

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also more affected by malnutrition than older children. Approximately 6.3% of children in South Africa are severely affected.

However, according to a recent study low- and middle-income countries, like South Africa, are undergoing rapid economic transition and urbanisation which is having a direct increase in levels of obesity, despite the persistence of undernutrition.6,7 The 2012 South African National Health and Nutrition Examination Survey (NHANES-1) report documented a combined overweight and obesity prevalence of 13.5% for South African children aged 6-14 years.8 This is higher than the global prevalence of obesity (10%) in schoolchildren, but lower than current levels in the USA.9 Certain factors have been shown to have a significant influence on the behaviour of eating healthily or otherwise, and engaging in physical activity. It is generally accepted that industrialization and

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Health Delivery

urbanization, dietary behaviour, lack of access to healthy and affordable foods, limited access to health information, physical inactivity, and poor social and physical environmental factors can be aligned with childhood obesity.10 In this way, both under nutrition and obesityrelated diseases are contributing to the burden of disease in South Africa. Documentation of undernutrition, particularly malnutrition at an early age is cause for concern given South Africa’s transition into a middle-income country. Food insecurity and malnutrition are issues that need to be addressed.

Government interventions are desperately needed to address the dual burden of chronic undernutrition and the rapidly rising trend of overweight and obesity in children in South Africa.

There are other challenges that make the situation even more complex. HIV/AIDS in the South African population has impacted chronic malnutrition. Studies have shown a close relationship between HIV and malnutrition. The malnutrition begins from birth, as HIV positive mothers are strongly encouraged not to breastfeed in order to reduce the risk of transmission from mother to child. Unfortunately, the child does not receive the highly beneficial aspect of breastfeeding.

The Food Bank of South Africa (FoodBank SA) sources donated food items and then arranges for these products to reach those who need it most through their beneficiary organisations. These organisations are registered non-profits in local communities that provide food to the needy. Beneficiary organisations include orphanages, crèches, senior citizen homes, shelters, community kitchens and HIV/AIDS clinics.

Kellogg’s South Africa has launched a campaign called “Breakfast for Better Days”. In South Africa, almost one in five children go to school every day

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hungry. With the help of the South African population and corporate companies, Kellogg’s donates more than ZAR10 million (approximately USD 900,000) in cereal and milk to food banks which will in turn distribute this to needy schools across South Africa in 2014. This translates into 25,000 children having a free breakfast every school day.

Seventeen years ago the Department of Basic Education in South Africa launched the National School Nutrition Programme (NSNP). In 2012-2013, the NSNP made a tremendous contribution to the Department of Basic Education’s goals of improving learner performance and access to education by providing daily nutritious meals to 9,159,773 students nationally. Children perform to the best of their ability when they are not hungry. A nutritious meal can aid in learning and development of the next South African generation.

The central focus for the NSNP is continued improvement in the quality of meals served to students and so the Department of Basic Education has conducted a total of 351 capacity building workshops for volunteer food handlers, school governing bodies, educators, students and guardians. This ensures that all parties involved in the NSNP are continually updated and in the loop as to what is best for the children of South Africa.

Child hunger is a reality and it needs to be taken seriously, but in the same instance countries, like South Africa, need to take cognisance of the increase in obesity in children. It is time to make the healthier option less expensive and therefore more available to consumers. Healthy food options need to become the convenient choice.

Once we have accomplished this South Africa can then start to see the long-term benefit on the population. If we do not take action now it is inevitable that we shall see a rise in NCDs including type 2

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diabetes. Gone are the days that type 2 diabetes only affects the older generation. Today, there is a huge rise in type 2 diabetes in people below the age of thirty and given that 50% of the world’s population is under the age of thirty, the impact that diabetes, (both type 1 diabetes and type 2 diabetes) will have on the world is tremendous.

Carrie Hetherington, Emily Westfall and Keegan Hall Carrie Hetherington is Western Pacific Region – New Zealand representative of the IDF Young Leaders in Diabetes Programme (YLD).

Emily Westfall is Research Assistant at the Barbara Davis Center for Childhood Diabetes, Aurora, Colorado, USA. Emily is North America and Caribbean Region – USA representative of the IDF Young Leaders in Diabetes Programme (YLD).

Keegan Hall is President of the IDF Young Leaders in Diabetes Programme (YLD). Keegan was diagnosed with type 1 diabetes 10 years ago at the age of 16 and currently works for Diabetes South Africa.

References 1. T he World Bank. Unemployment, total (% of total labor force) (modeled ILO estimate) http://data.worldbank.org/indicator/SL.UEM.TOTL.ZS/countries 2. U nited Stated Department of Agriculture Food and Nutrition Service.

Overview www.fns.usda.gov/pd/overview 3. Levine JA. Poverty and obesity in the U.S. Diabetes 2011; 60: 2667-8.

4. No Kid Hungry Center for Best Practices http://bestpractices.nokidhungry.org/ 5. Feeding America http://feedingamerica.org opkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of 6. P obesity in developing countries. Nutr Rev 2012; 70: 3-21. opkin B. The nutrition transition in the developing world. Dev Policy Rev 2003; 7. P 21: 581-97.

8. S hisana O, Labadarios D, Rehle T, et al. South African National Health and Nutrition Examination (NHANES-1). HSRC Press. Cape Town, 2013.

9. Flegal KM, Carroll MD, Kit BK, et al. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010.

JAMA 2012; 307: 491-7.

10. Gupta N, Goel K, Shah P, et al. Childhood obesity in developing countries: epidemiology, determinants and prevention. Endocr Rev 2012; 33: 48-70.

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clinical care

The double burden of diabetes and cardiovascular disease Lydia Makaroff and Ute Linnenkamp

The important relationship between diabetes and cardiovascular disease (CVD) may not be widely realised. However, CVD is a major cause of morbidity and mortality in people with diabetes since people with diabetes, both those with type 1 and those with type 2, have an increased risk of developing CVD compared to people without diabetes. The term CVD includes a range of diseases which affect the heart and the circulatory system. The major types of CVD that affect people with diabetes are coronary artery disease and stroke. They are the number one cause of death and disability among people with type 2 diabetes. People with both types of diabetes have at least a two-fold higher risk of having heart disease or a stroke compared to people without diabetes.

High blood glucose can make the blood coagulation system more active compared to that in people without diabetes and compared to people with

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diabetes whose blood glucose is close to the normal range. Thus, blood vessels are more likely to be blocked, producing conditions such as thrombotic stroke and myocardial infarction (MI). Moreover, uncontrolled diabetes causes damage to the blood vessels making them more prone to damage from atherosclerosis and hypertension. People with diabetes develop atherosclerosis at a younger age and more severely than people without diabetes.

Women with diabetes lose some of the protective effects that female hormones have on CVD so that their morbidity and mortality from these conditions are significantly higher than that seen in their pre-menopausal peers who are free from diabetes.

In addition to damaging blood vessels, diabetes can also damage nerves. This can mean that the typical chest pain that usually occurs with an MI, and often acts as an important warning of the risk of an MI in a person diagnosed with angina, may be absent or diminished in people with diabetes.

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Although CVD is a complication of both type 1 and type 2 diabetes, it is more common among people with type 2 diabetes. This is mainly because people with type 2 diabetes tend to be older compared to people with type 1. Moreover, they have a number of other metabolic abnormalities, in addition to high blood glucose levels, which also contribute to an increased risk of CVD. These factors include high blood pressure (hypertension), abnormal cholesterol and high triglycerides and obesity. This complex picture is exacerbated by smoking and lack of physical activity. The rising number of young people being diagnosed with type 2 diabetes is a particular cause for concern since, in them, the metabolic factors which confer a higher risk of CVD are present from a young age.

CVD is the number one cause of death worldwide, causing 17.1 million deaths annually in the general population, with 80% of these deaths occurring in low- and middle-income countries. Furthermore, 80% of people with diabetes live in low- and middle-income countries causing a two-fold impact on these countries. Global estimates of the precise impact of CVD in people with diabetes are not readily available.

In recognition of this deficiency, the International Diabetes Federation (IDF) and the Baker IDI Heart and Diabetes Institute have launched the CVD in Diabetes project. In collaboration with a global panel of experts, this project will update the evidence base relating to CVD and diabetes and produce global and regional estimates of the impact of CVD in people with diabetes. These estimates are crucial to quantify the extent of the elevated CVD risk in people with diabetes.

Primary prevention of diabetes is paramount for the overall prevention of CVD and CVDrelated mortality. Diabetes marks an important entry point into the healthcare system for overall,

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comprehensive cardiovascular risk management.

Lifestyle modification can delay the progression to type 2 diabetes, as well as delay the onset of CVD. Regular, moderate physical activity reduces the risk of developing type 2 diabetes and improves cardiometabolic risk factors. People at risk should also be encouraged to keep their blood glucose, blood pressure and blood lipids under tight control, have regular medical examinations, choose foods wisely, and quit smoking.

The CVD in Diabetes project is supported by AstraZeneca.

Lydia Makaroff and Ute Linnenkamp Lydia Makaroff is Epidemiology and Public Health Manager at the International Diabetes Federation, Brussels, Belgium.

Ute Linnenkamp is Public Health Administrator at the International Diabetes Federation, Brussels, Belgium.

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clinical care

The DiRECT route to remission?

Richard Elliott

Overweight and obesity, labels for ranges of weight that are not considered healthy, are not the only causes of type 2 diabetes, but they are the most important modifiable risk factors for the condition.

They are also the reason why type 2 diabetes has transformed from a problem for older adults into a global epidemic affecting all ages. From 2009 to 2011, Diabetes UK funded research at Newcastle University that explored the mechanisms underlying type 2 diabetes and the possibility of remission using diet alone. Under close medical supervision, 11 people with type 2 diabetes ate an intensive lowcalorie liquid diet for eight weeks, with startling results. After only a week, fat levels in the liver of each participant decreased sharply and liver insulin sensitivity returned to normal. After eight weeks, fat levels in the pancreas of each participant also decreased and insulin production returned to normal. With an average weight loss of around 15 kilograms, everyone who took part had put their diabetes into remission. Some participants later regained weight but after three months of normal eating with no special follow-up, most still had non-diabetic blood glucose control.

The liquid diet used in the study was challenging for participants and by no means a “quick fix” for

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their type 2 diabetes. However, the possibility of remission without invasive and expensive weight-loss surgery was a revelation for researchers. Diabetes UK was quick to see the value of this evidence and in 2013 we committed over £2.4 million, the single largest grant in our 80-year history, to a new study that will help us take the next step. Professor Mike Lean, Professor of Human Nutrition at the University of Glasgow and Professor Roy Taylor, Professor of Medicine and Metabolism at Newcastle University will work in partnership with Counterweight Ltd, the dietitian-led UK weight management provider, to study the long-term effects of a new approach to weight management. DiRECT (Diabetes Remission Clinical Trial) will combine a low-calorie liquid diet as used in 2011 with a structured plan for long-term weight control, and compare this approach, over two years, with the best possible existing treatment for type 2 diabetes. The aim of the trial is not just to help participants achieve and maintain type 2 diabetes remission, but to break important new ground by demonstrating the potential of this approach for widespread use as part of routine primary care.

DiRECT will not be accepting individual patients directly, but will work with selected General Practice (GP) practices across Scotland and Tyneside to DiabetesVoice 37

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From left to right: Professor Taylor and Professor Lean in Professor Lean’s lab at Glasgow Royal Infirmary

recruit 240 people aged 20–65 who are overweight and have been diagnosed with type 2 diabetes in the last six years. Participants at half the practices will receive the best-available type 2 diabetes care, according to current clinical guidelines. Participants at the remaining practices will receive a lowcalorie, nutritionally-complete, formula diet for 12-20 weeks, and then be reintroduced gradually to carefully designed meals using normal foods, over 4-8 weeks. The need for flexibility emerged from a feasibility pilot study published in 2013, as 38

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Professor Lean explains, “The aim is not to test a rigid dietary prescription, but to achieve the best possible weight loss for as many patients as possible, to give them the best chance of remission from diabetes.” They will also receive expert support to help them maintain their weight loss in the long term. Professor Taylor explains the trial objective: “We need to evaluate how well people do using this approach and uncover problems that might be faced. Our work will focus on long-term outcomes and standard clinical care because the ultimate goal

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diabetes coming back. Gallstones are also a possible risk of intensive weight loss, although this is uncommon and should be minimised using a lowcalorie diet that is less restrictive than others used previously. “The reason for doing this research,” says Professor Lean, “is that we do not know at present whether the extra effort, and stress, of following a very restrictive diet will indeed bring benefits in the long term. Although benefits are possible, we know that weight regain after liquid diets has been common in the past, and could have harmful effects. We need to study sufficient numbers of people for long enough to be sure that the benefits outweigh the costs.”

is to help people with type 2 diabetes to change their eating habits for life through routine visits to their own GP.” It is important to emphasise that the approach of the trial is intensive, challenging and will not be suitable for everyone with type 2 diabetes. Participants on the diet will be consuming so few calories that they are likely to feel hungry for much of the time, and those who do achieve remission will still have to maintain a healthy lifestyle to stop their type 2

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If DiRECT shows that intensive weight management can bring about and maintain type 2 remission in the long term, it could lead to significant changes in the way that type 2 diabetes is managed by the UK National Health Service (NHS) and provide an accessible way to help people with type 2 live for longer, with fewer complications. The study will last for five years, but both researchers are optimistic about the practical improvements it will yield. “If our analysis shows that this approach to weight loss and weight management is both effective and cost-effective,” says Professor Lean, “our aim will be to produce a programme that can be implemented in the NHS as soon as possible.

Healthcare professionals in primary care will then be able to offer a high proportion of their type 2 patients the possibility of remission as well as the pathway to help them get there.”

Richard Elliott Richard Elliott is Research Communications Manager at Diabetes UK, United Kingdom.

Further information about DiRECT is available at www.diabetes.org.uk/direct

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Improving healthcare education for type 2 diabetes nutrition Carolyn Robertson and Elizabeth Snouffer

According to the American Diabetes Association (ADA), the complexity of nutrition issues in type 2 diabetes care warrants the use of a skilled and registered dietician to implement nutrition therapy into individualised diabetes management and education.1 Today, however, people with type 2 diabetes are becoming a larger part of practices of primary care clinicians, and may not always have access to a specialised nutritionist or diabetes educator. For this reason, it is essential that healthcare professionals responsible for the primary care of people with diabetes learn about basic diabetes nutrition, and implement supportive strategies linked to individual dietary habits.

Healthy eating patterns, regular physical activity, and, often, pharmaceutical treatment are integral parts of diabetes management. However, for many people with diabetes, one of the most challenging aspects is selecting what to eat and how much to eat. While it has been generally accepted that there is not a “one-size-fits-all” meal plan for individuals with diabetes, there are a few basic nutritional recommendations that need to be followed for the health of the patient. These are listed in the Box. 40

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Medical nutrition therapy (MNT) In comprehensive care practices, a registered dietician or nutrition professional administers medical nutrition therapy (MNT) to the person living with diabetes. However, MNT is not available everywhere, and is especially scarce in under-resourced communities and at underresourced care centres and clinics in developed countries. MNT assesses the person with diabetes, establishes a nutritional plan and then evaluates and modifies that plan as necessary. Characteristics of the individualised MNT plan typically consist of dietary composition recommendations, monitoring of carbohydrate intake, and developing a weight loss programme for overweight or obese individuals who have type 2 diabetes.2 In lieu of specialised MNT treatment, the healthcare practitioner and person with diabetes will benefit from a basic understanding of diabetes-related nutrition, carbohydrate counting, and general effects of dietary intake on blood glucose.

Healthcare practitioners who have the opportunity to teach diabetes nutrition basics may require practical

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Basic nutritional recommendations for people with diabetes: To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, in order to improve overall health and specifically to: 1. Attain individualised glycaemic, blood pressure, and lipid goals. General recommended goals from the ADA for these markers are as follows: ■ HbA1c <7%.

■ Blood pressure <140/80 mmHg. ■ LDL cholesterol <100 mg/dL; triglycerides <150 mg/ dL; HDL cholesterol >40 mg/dL for men; HDL cholesterol >50 mg/dL for women.

■ Achieve and maintain body weight goals.

■ Delay or prevent complications of diabetes.

■ Address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful food choices, willingness and ability to make behavioural changes, as well as barriers to change.

■ Maintain the pleasure of eating by providing positive messages about food choices while limiting food choices only when indicated by scientific evidence.

■ To provide the individual with diabetes with practical tools for day-to-day meal planning rather than focusing on individual macronutrients, micronutrients, or single foods.

The American Diabetes Association.

Standards of Medical Care in Diabetes—2013.

educational tools to share with the newly diagnosed or patients with longstanding diabetes who may never have received any nutritional education. What follows is a basic review of essential information for the healthcare practitioner to teach people living with type 2 diabetes so they might become actively engaged in nutrition self-management.

Diabetes nutrition It is generally accepted that those at risk for and living with type 2 diabetes eat a varied diet with foods containing carbohydrate, particularly from whole grains, fruits, vegetables, and dairy. The contributions of carbohydrate and monounsaturated fats to energy intake should be based on individual nutrition assessment, metabolic profiles, and

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treatment goals of the individual.3 Flexibility is key and should include the philosophy that almost everyone living with diabetes should be able to eat a variety of foods with enjoyment. Emphasis in practice should always be placed on what a person with diabetes “can do”, not, “can’t do.”

Carbohydrates Carbohydrates are one of the three macronutrients in our diet (fat and protein are the others).

Carbohydrates provide energy for the body, especially the brain and the nervous system. It is generally accepted that people without diabetes should get between 40% and 60% of total calories from carbohydrates, preferably from complex carbohydrates (starches) and natural sugars.

Carbohydrates are converted to blood glucose almost 100% within approximately 90 minutes after a meal.2 Complex carbohydrates provide calories, vitamins, minerals, and fibre. Examples of complex carbohydrates include: whole grain breads and cereals, legumes and starchy vegetables like sweet potato. Not all complex carbohydrates are equal in terms of their metabolism and many are absorbed faster than others such as white rice and white bread.

Simple carbohydrates are present in fruit and dairy products but are also found in refined sugar and processed foods such as sweetened cereals, candy, sodas and other snacks such as cookies. Foods that are high in processed, refined simple sugars provide calories, but very have very little other nutritional value and cause spikes in blood glucose.

Carbohydrate counting Teaching a person living with diabetes how carbohydrates affect their diabetes is critical for their health. Typically, teaching a patient about carbohydrates is divided into basic skills and advanced skills. Basic involves teaching consistency and helping individuals learn to identify starches and measure portions correctly. The “plate method” is being used in the US with success to

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Figure 1.

Figure 2.

help individuals with portion control and balanced eating. ChooseMyPlate.gov is a website developed to provide practical information about healthy nutrition to individuals, health professionals, nutrition educators and the food industry. The MyPlate icon (see Figure 1) is a tool designed to help people build a healthy plate of food emphasizing appropriate portion sizes and healthier food choices. MiPlato is the Spanish-language version of MyPlate. A part of the guidance MyPlate delivers is simple messages to remember when shopping or planning a meal including: avoiding oversized portions, building a plate 50% full of fruits and vegetables, drinking water instead of sugary drinks and aiming for less sodium (as common salt) in soups, bread and frozen foods.

For more information about weight management, physical activity, tracking tools and more for basic skills, please consult the website.

MyPlate delivers simple messages including: avoiding oversized portions, building a plate 50% full of fruits and vegetables, drinking water instead of sugary drinks and aiming for less sodium.

Carbohydrate counting is an advanced skill that can be an effective nutritional self-management tool for people treated with insulin including those with type 2 diabetes. Understanding the number and quality of carbohydrates consumed can greatly influence therapeutic decisions and lead to improved blood glucose results.4 Carbohydrate counting is a method of calculating the grams of carbohydrate consumed during mealtime and snacks. Foods that contain carbohydrate have the greatest effect on blood glucose compared to foods that contain protein or fat. Advanced carbohydrate counting teaches someone to actually count grams rather than merely noting portions and how to manipulate the portions of carbohydrate and adjust medication or activity to maintain blood glucose at target levels.

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Measuring tools are indispensible when counting carbohydrates. In order to calculate amounts, people with diabetes need to be accurate with their portion sizes of foods. Investing in a food scale to weigh foods such as fruit and grains or at least, using measuring cups and other tools to measure amount of cereal, pasta and rice, or milk and other liquids containing carbohydrates will help the patient better manage their blood glucose.5 Unfortunately measuring tools are not always available. The University of California at Berkeley has devised a simple visual guide6 (Figure 2) for people to measure amounts with the use of their fist (=1 cup of rice or pasta) or the size of a tennis ball (= one serving of fruit). When people with diabetes understand how nutrients affect their blood glucose levels they are often

more receptive to strategies designed to improve their diabetes health. A hands-on approach can often effect change in behaviour.

Carbohydrate counting shows people first-hand that it is not just sugar that affects blood glucose and diabetes health but the total amount of carbohydrates consumed. All types of carbohydrate count. Carbohydrate counting can also reflect a potential problem in portion sizes and may foster improvement in individual choices when deciding how much to eat at mealtime.

Food labels For the person living with diabetes, food labels are an essential tool. Understanding the information on food labels may allow the person with diabetes

Figure 3.

The serving size for the food is 1 cup.

There are 3 servings or 3 cups in this container.

The total carbohydrate tells how many grams of carbohydrate are in 1 serving.

Sugar is already included in the total carbohydrate amount. This value shows the amount of natural or added sugar.

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to compare foods, make better choices and understand serving sizes in relation to carbohydrate amount. When reviewing food labels (Figure 3), it is important to start with the list of ingredients, which are listed by weight from most to least.

■P romote

heart health: aim for ingredients such as whole-wheat flour, soy and oats.

Monounsaturated fats – such as olive, canola or peanut oils are good, too.

■ Avoid unhealthy ingredients, such as hydrogenated or partially hydrogenated oil and refined sugars. Look for foods that contain less fat, sugar and salt.

■L ook at total carbohydrates, not just sugar.

Evaluate the grams of total carbohydrates – which includes sugar, complex carbohydrate and fibre – rather than only the grams of sugar. If you zero in on sugar content, you could miss out on nutritious foods naturally high in sugar, such as fruit and milk. And you might overdo foods with no natural or added sugar, but plenty of carbohydrates, such as certain cereals and grains.

■D on't miss out on high-fibre foods. Pay special attention to high-fibre foods. Look for foods with three or more grams of fibre.

■S ugar-free doesn't mean carbohydrate-free.

■ No sugar added, but not necessarily no carbohydrates.

■ Sugar alcohols contain carbohydrates and calories, too.

Rather than taking a restrictive point of view on the dietary intake of a person with diabetes, it is important to support the person ambitious to selfmanage their diabetes with the view that a “diabetes diet” is a healthy-eating plan rich in nutrients, with an emphasis on fruits, vegetables and whole grains.

Tools like carbohydrate counting and learning how to interpret food labels can be the first steps in helping to educate a person with diabetes on how to make better food choices for better health.

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Carolyn Robertson and Elizabeth Snouffer Carolyn Robertson is a member of Diabetes Voice Advisory Group.

She is a Clinical Nurse Specialist (ACNS-BC) who is certified as a diabetes educator (CDE) as well as board certified in Advanced Diabetes Management (BC-ADM) and is currently in private practice in California and New York, USA. Elizabeth Snouffer is Editor of Diabetes Voice.

To learn more about diabetes nutrition, please consult these free online resources: ■A cademy of Nutrition and Dietetics www.dce.org/publications/ education-handouts ■C reate your plate by ADA www.diabetes.org/food-and-fitness/food/ planning-meals/create-your-plate/ ■H ealthy Eating: Incorporating Nutritional Management into Lifestyle www.diabeteseducator.org ■A merican Academy of Clinical Endocrinologists www.empoweryourhealth.org/nutrition

References 1. E vert AB, Boucher JL, Cypress M, et al., American Diabetes Association.

Nutrition therapy recommendations for the management of adults with diabetes.

Diabetes Care 2013;36: 3821-42. ranz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and 2. F recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002; 25:148-98.

3. P astors JG, Warshaw H, Daly A, et al. The evidence for the effectiveness of medical nutrition therapy in diabetes management. Diabetes Care 2002; 25: 608-13.

4. J ohnson MA. Carbohydrate counting for people with type 2 diabetes.

Diabetes Spectrum 2000; 13: 149.

5. J oslin Diabetes Center. Carbohydrate Counting 101 www.joslin.org/info/ Carbohydrate_Counting_101.html al Dining. Serving Size Guide http://caldining.berkeley.edu/nutrition/ 6. C serving-size-guide

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Diabetes in society

Diabetes voices: How has serving the diabetes cause as a volunteer changed you?

In every series of Diabetes Voices, we present individuals from all over the world who share their perspective on life with diabetes. In this instalment, three people living with diabetes share their volunteering experience in the diabetes community and how it has changed any aspect or perspective of living with the condition. For many volunteers, helping others, mentoring or working to improve

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the diabetes cause can boost confidence and lead to a sense of empowerment. It can have a positive effect on how they understand diabetes and its impact on the community or the world. Volunteering can also foster new friendships, expand knowledge, decrease isolation, and may even help an individual living with diabetes become more physically and mentally healthy.

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Diabetes in society

Turning the invisible into the visible

It was a normal Saturday afternoon when Alexio rang our doorbell. I could hear the desperation in his voice and his heavy breathing. On the intercom I listened while he explained that he has diabetes and was feeling very ill. Over a drink of water, and while waiting for our family doctor to return my call with instructions, he told us his story.

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After two days without insulin, Alexio had travelled from a village about 100 km away to look for help in the capital city of Harare, Zimbabwe where we live. He had been diagnosed with type 1 diabetes eight months prior and had lost his job following a diabetes episode at work. Alexio is a single parent to two small children and does not have a job to support them and take care of his diabetes. The largest state run hospital had turned him away and told him to source his own insulin which would require him having cash. This is what led him to my doorstep begging for our help.

Sadly Alexioâ&#x20AC;&#x2122;s story is just one of many. He was fortunate enough to land on our doorstep and speak to me, as I have lived with type 1 diabetes for 24 years and I could easily recognise that he was suffering from diabetic ketoacidosis (DKA).

Thanks to a request by our family doctor, Alexio was seen by a physician at the state hospital and given care for his diabetes. The Zimbabwe Diabetes Association (ZDA) gave him free insulin. My family and I continue to support Alexio with what he needs to remain healthy. I am pleased to report that he is well and his blood sugar is under control.

There have been many similar stories in Zimbabwe but, as diabetes is largely misunderstood in our country, people with untreated diabetes are often thought to be drunk or high on drugs and turned away. Many individuals with diabetes just die unattended on the roadside. Con-men have also jumped on the bandwagon posing as people

DiabetesVoice

Suraiya Essof lives with her husban d and two sons in Harare, Zimbabwe. She has lived with type 1 diabetes for 24 years.

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Diabetes in society

living with diabetes. These thieves beg for money to buy insulin and quote exorbitant prices for the insulin that they falsely require. This and a lack of education on recognising the symptoms of DKA and hypoglycaemia have led to the general public being unwilling to help. Genuine cases of untreated diabetes are sadly ignored.

For me, the incident with Alexio highlighted the great need for diabetes awareness. It helped me realise how much more should be done in order to help people with diabetes and with little resources get what they need to survive. While I was sure that not enough was being done, this direct encounter definitely changed my perspective and urged me to start doing something to help. There are many other issues that affect people in Zimbabwe but, since diabetes is so close to home for me, the need to spread Alexio’s story and the plight of people with diabetes like him here and all over the world became very important to me.

I was diagnosed in 1990 in a small mining town in Zimbabwe. I was fortunate enough to have access to private care as my family could afford the treatment. I have since led a normal healthy life thanks to access to adequate private medical care available here in Zimbabwe. For example, there are no shortages of insulin or diabetes care products in the private sector. However, treatment requires money to buy medicine and, even if treatment is sourced through medical aid schemes, there is a cost attached to that, too. Here in Zimbabwe, we do not have “fancy” accessories like insulin pumps or continuous glucose monitor (CGM) devices, but we manage to live satisfactorily and happily without these “luxuries.” We are thankful for what we have available as we know how much worse it could be.

The ZDA has worked very hard to bridge the gap between the two “third worlds” when it comes to diabetes care. They lead “Zimbabwe and

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sub-Saharan Africa in the fight against diabetes through sustainable education, prevention and treatment programmes.”

The mission of the ZDA is to improve the spiritual, physical and socio-economic welfare of people with diabetes in Zimbabwe and sub-Saharan Africa. In the words of Mr Ngoni Chigwana, CEO of ZDA, the list of the ZDAs activities is comprehensive: ■R einforce the case for action on diabetes.

■S upport and strengthen ZDA provincial, district and rural diabetes healthcare education centres.

■ Improve the health outcomes of people with diabetes and prevent people with diabetes from developing complications.

■P revent country escalation of type 2 diabetes.

■ Champion a country free from discrimination and stigma to people with diabetes.

■B uild effective partnerships to maximise the outcomes of the UN Political Declaration on NCDs including diabetes.

■ Ensure the effectiveness of ZDA country organisation on the implementation of IDFs Life for a Child programme.

As well as providing free insulin, the ZDA provides free blood glucose monitors and blood glucose testing strips, as well as offering free HbA1c and kidney function testing. It is also working on getting an ECG machine. In Zimbabwe the main challenge continues to be strengthening diabetes awareness. The ZDA needs funding for better awareness campaigns, and to uplift its image and exposure to the public.

Since my meeting with Alexio, I have since been volunteering my time at the ZDA by spreading awareness over various platforms especially through free social media.

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Diabetes in society

Carrying the torch for diabetes Although living with diabetes can be challenging at times, I have found that volunteering for diabetes offers a positive experience, even though it comes out of a difficult situation. Volunteering within the diabetes community can be rewarding, can make a difference to others and is something that I greatly recommend.

Put simply, the act of volunteering has had a lifechanging impact on me, and the way I view my diabetes. I think there is a volunteering role out there to suit everyone’s interests, and my varied volunteering experiences are an example of this. My voluntary

Melanie was featured in the UK Independent newspaper as the Diabetes UK Media Ambassador

Melanie (centre row, third from right) is photographed at the Diabetes UK Cymru family event at the Welsh Institute of Sport in Cardiff in September 2014.

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roles have ranged from speaking about the positive side of living with diabetes in the national press, TV and radio to helping facilitate short breaks for families and children with diabetes. I enjoy spending time with other volunteers, working together to achieve the goal of making things better for others.

Volunteering has helped me develop better skills of communication too, whether that’s speaking to government ministers about healthcare or giving presentations about diabetes.

In 2012 my volunteering contributions led me to the opportunity of carrying the Olympic torch, thanks to Diabetes UK’s nomination, which was an amazing chance to put the spotlight on my other passion, participating in sport whilst living with diabetes. Volunteering has enabled me to make new friends and network with others throughout Europe, whether that be as a representative in the Diabetes UK Young Leaders Action Group or through the delivery of keynote speeches on diabetes in other countries. These experiences have been a great opportunity to share knowledge and expertise in living with type 1 diabetes, which has also helped me enrich my own diabetes knowledge and the way I view my diabetes care. I truly believe that when people with diabetes come together, something amazing happens. When people who have never met before, meet and find they have something in common, it can feel like being a part of a special community.

Melanie Stephenson, 26, is a professional athlete and a diabetes youth advocate. Currently, she is Media Ambassador and Young Person’s Project Leader for Diabetes UK and has an active role as a presenter for JDRF. She lives in Cardiff, Wales, UK.

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Diabetes in society

The power of volunteering Working as a volunteer is something that I do with passion, enthusiasm and dedication. I have been living with diabetes for 33 years and actively working as a volunteer for more than 15 years. Instead of describing my experiences with volunteering over that decade and a half, I would like to focus on the reasons why I still love volunteering for diabetes.

I am working as a volunteer because I want to help others. I truly believe that my work as a volunteer has made, and will continue to make, a difference to the lives of other people living with diabetes.

This is through direct contact with individuals in multiple activities as a fellow participant such as diabetes summer camps, peer-to-peer education and campaigns or as a result of the lobbying activities in which I am involved.

Working as a volunteer has given me so much!

To feel that I had the chance to touch a person’s life in a positive way is the most rewarding for me. It fills my soul with joy, happiness and builds my self-esteem.

Another positive aspect for me is the enhancement of my diabetes control. Since I became more involved with diabetes associations my diabetes has improved a lot. Working together with youngsters made me look at diabetes with different eyes.

I worked on the first summer camp of the Portuguese Diabetes Association (APDP) as a camp leader and since then I got deeply involved on APDP activities.

Among other activities, I have created two associations in Portugal and over the last few years and have

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João and Europe Region – Portugal representatives of the IDF Young Leaders in Diabetes Programme (YLD).

been involved in political lobbying activities at the national and European level. From my experience, I can say that politicians tend to listen more when people with diabetes are involved. We have huge power in our hands, but sometimes people with diabetes don’t know it.

Currently, I am the President of IDF Europe, a position that I hold with passion and commitment to people living with diabetes, parents and healthcare professionals.

Working as a volunteer is a part of me. I am sure that this is something that I will do forever.

I would like to invite all of you to try working as a volunteer; you will see that you will be helping others, but you will be helping yourself as well.

João Manuel Valente Nabais is President of the International Diabetes Federation, Europe Region (IDF Europe). João was diagnosed with type 1 diabetes in 1981. In addition to the many activities he mentions in this article, he is a member of Diabetes Voice’s Advisory Group providing valuable insight into the contents of the publication from the perspective of a person living with diabetes.

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VOIceBOX

The diabetes voicebox The content of our section “Diabetes Voices” in the last issue of Diabetes Voice prompted the following response from one of our readers (well known to me and whose opinions I hold in high regard): ‘This article really says to the readers that health professionals (particularly doctors) do not do the diagnosis thing well, I am not sure it is in the best interest of IDF to slam the medical profession like this.’

While, of course, we did not have the intention to ‘slam the medical profession’, these observations were genuine recollections of people with diabetes about the ways in which their first encounters with medical professionals in relation to their own diabetes could (and, indeed should) have be better. We have no regrets in having made these public.

However, if there are similar views to those expressed by this reader then we would be most interested in hearing them. Of course, also, if there are recollections, by our readers living with diabetes, of particularly supportive, considerate and empowering encounters with health professionals at diagnosis, we would like to hear about those, too.

Rhys Williams, Editor-in-Chief, Diabetes Voice

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Act t day, to change tomorrow Champion a world free of diabetes

Global Diabetes Scorecard Check the scores now The Global Diabetes Scorecard enables the global diabetes community to track and report progress on diabetes, to highlight areas of good practice and to identify areas that may need targeted advocacy to encourage government action. The Scorecard is an International Diabetes Federation (IDF) publication.

www.idf.org/global-diabetes-scorecard/

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