Global perspectives on diabetes
Volume 56 –March 2011
Winning the battle against childhood obesity IDF call to action on diabetes and NCDs
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Contents
Diabetes Views
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News in Brief
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H OW M U C H DO Y O U K NOW… About IDF and its structure
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T H E G LOBAL CA M PAI G N Taking IDF into the 21st century – what got us here will not get us there!
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Luc Hendrickx
Calling the world to action on diabetes
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Jean Claude Mbanya
Tackling NCDs: a catalyst to strengthen country health systems – 17 an interview with Badara Samb
The Middle East and North Africa Diabetes Leadership Forum
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Gestational diabetes: an invisible maternal health issue
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Ann Keeling
International Diabetes Federation Promoting diabetes care, prevention and a cure worldwide Diabetes Voice is published quarterly and is freely available online at www.diabetesvoice.org. This publication is also available in French, Spanish and Russian. Editor-in-Chief: Stephanie Amiel, UK Managing Editor: Olivier Jacqmain, olivier@idf.org Editor: Tim Nolan, tim@idf.org Advisory group: Pablo Aschner (Colombia), Ruth Colagiuri (Australia), Patricia Fokumlah (Cameroon), Attila József (Hungary), Viswanathan Mohan (India). Layout and printing: Luc Vandensteene, Ex Nihilo, Belgium, www.exnihilo.be All correspondence and advertising enquiries should be addressed to the Managing Editor: International Diabetes Federation, Chaussée de la Hulpe 166, 1170 Brussels, Belgium Phone: +32-2-5431626 – Fax: +32-2-5385114 – olivier@idf.org
Katie Dain
S p o t l i gh t o n a n i d f m e m b e r a s s o c i at i o n The Dutch Diabetes Association
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Maarten Ploeg, Annemarie Bevers
h e a lt h d e l i v e r y Prevention and control of type 2 diabetes by Mediterranean diet: 29 a systematic review
Katherine Esposito, Maria Ida Maiorino, Antonio Ceriello, Dario Giugliano
Diet and diabetes: lessons from the ruby red slippers
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Caroline Trapp
CLINICAL CARE Diabetes education for people with type 2 – a European perspective
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© International Diabetes Federation, 2010 – 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.
Monika Grüsser
DIABETES IN SOCIET Y
ISSN: 1437-4064 Cover photo © Snezana Skundric - Fotolia.com
Preventing diabetes in the avenues and alleyways – homes and cities as exercise machines
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Avi Friedman
Green shoots of hope: obesity prevention in US schools
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Francine Kaufman
March 2011 • Volume 56 • Issue 1
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Diabetes views
Time to start progressing responsibly A recent report by the World Bank warns of an impending health crisis sparked by rising rates of type 2 diabetes and other non-communicable diseases (NCDs) – not among the SUV-driving suburban middle classes of Europe or North America, but in South Asia, home to the world's largest population of poor people, where more than 1 billion are living on less than 2 USD a day. Unsurprisingly for those of us striving to rouse the world to the geographically and socioeconomically global threat from NCDs, it is the poor families in the region who are disproportionately affected – by worsening poverty as they are forced to pay for medical treatment out of their household budget, as well as by avoidable disability and premature death.
The report, Capitalizing on the Demographic Transition: Tackling NCDs in South Asia, covers Bangladesh, India, Nepal, Pakistan, Afghanistan, Maldives, Bhutan and Sri Lanka and makes for grim reading: NCDs account for more than half of all ill health in a region already struggling to control infectious diseases; heart disease is now the leading cause of death in people aged between 15 and 69 years; on average, South Asians suffer their first heart attack at 53, six years earlier than other groups worldwide. Low birth weight is common among historically poor families in South Asia and is an important risk factor for NCDs. But we know also about the role of changes in diet and exercise. Economic development and urbanization away from the crushing poverty and privation endured by people in rural areas have brought tangible benefits: average life expectancy in Bangladesh, for example, is now 64 years (and rising). However, people there are getting older without better living conditions, healthier nutrition or access to good healthcare. Moreover, development is driving a transformation in lifestyles: the motorization of the urban environment and the televisionization of free time are resulting in the sedentarization of adult and, more worryingly, child behaviour. This is one of the downsides of 'progress'. The other is the increased consumption of unhealthy processed foods. Together, these negative corollaries have contributed to a situation in Bangladesh where 61% of people now die of NCDs – and this chronic burden will only increase as the population gets older. The emerging economies of the eight South Asian countries and – to varying degrees – those in South-East Asia, Latin America and Africa are like a modern-day Klondike to the corporate prospectors of the commercial and manufacturing sectors, including the food industry.
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In a 2005 report, Agriculture and Agri-Food Canada described the opportunities that lay in the active and growing market in Pakistan. With a consumer base for processed and imported foods of 37 million people (a quarter of its 149 million population), “Pakistan provides a market larger than Canada for consumer goods.” With colossal profits on the horizon, shifts away from traditional habits and lifestyles must look finger-licking good to the big players in the processed-food industry! But there is an urgent need for corporations to invest responsibly and act in the interests of the individuals and families that comprise their valued consumer base. That is why UN Secretary General Ban Ki-Moon, speaking recently to a plenary session of the World Economic Forum in Davos, called on businesses leaders, particularly in the food industry, to cooperate in curbing the risk factors behind an epidemic that is set to increase by half in low- and middle-income countries by 2030. "We cannot allow chronic diseases to even further amplify the health challenges faced by developing countries, especially when we know the solutions." We must not lose sight of the big picture: that the global epidemic of diabetes is an indicator of the deep flaws in our very perception of development. Diabetes and the other NCDs are linked to entrenched social and environmental determinants – transport and urban planning, education and social policies, poverty, access to medical and social services. And that is why IDF led the call for the UN Summit on NCDs, to raise awareness at the highest level and stimulate the all-of-society, multi-sectoral action needed to remove the insidious threat posed by diabetes, and protect our future generations in all regions.
Jean Claude Mbanya is IDF President for the period 2009 to 2012. He is Professor of endocrinology at the University of Yaounde, Cameroon, and Chief of the Endocrinology and Metabolic Diseases Unit at the Hospital Central in Yaounde.
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Diabetes views
Making an impact on diabetes outcomes
In this issue of Diabetes Voice, IDF continues its campaign to raise the profile of diabetes with healthcare organizations, governments and people everywhere. We have an exclusive interview with Badara Samb, who brings the experience he has had with other diseases of global significance to bear on our diseases of diabetes. And IDF’s Katie Dain builds on the focus of our last issue on women’s health, discussing the important condition of gestational diabetes, with its implications for future diabetes in both the mother and baby – and its enormous potential for diabetes prevention.
Eat less and walk more! Readers of Diabetes Voice will all be familiar with this refrain and know that lifestyle is critically important for the optimal management of type 2 diabetes. Dr Samb points out that tried and tested therapies for diabetes should not be ignored just because there are newer (and often more costly) options available. There is no doubt that while new and better treatments for diabetes are desirable and needed, we certainly can do better with the tools already to hand – through better education in their use by both healthcare professionals and users. Monica Gruesser discusses some issues in diabetes education, based on her work with the very successful models from Germany.
On the subject of eating, we have two articles on different dietary approaches that may be beneficial in prevention and treatment. Many diets have their advocates – it is important that we accommodate people’s own preferences and good that we have different options to offer them. In our two articles, we look at a vegan and a Mediterranean diet – both probably sharing some features of benefit, such as a focus on whole grain products and low proportion of saturated fat. People following such diets often practise other healthy behaviours, making it difficult for observational studies to determine which aspects of the lifestyle are providing the benefit; but randomized controlled trials are shedding light on the issues.
What about the walking? We are delighted to feature a paper by Avi Friedman, which describes how we have been creating living environments and neighbourhoods that positively discourage physical activity and discussed some of the ways in which we might change this for the better. And finally, Fran Kaufman brings a ray of hope. She describes her pioneering work in engineering the school environment to encourage better health. A recent research programme in the USA testing an intensive school-based intervention to improve lifestyles, which did show changes in parameters such as waist circumference, may have failed to show benefit on overall overweight and obesity – only because of a comparable fall in overweight and obesity in the control schools.1 It may be that the messages are starting to get through!
It is always important to have alternatives to offer and structure dietary guidelines in line with people’s choices. One size never has fit all, and there is emerging evidence that genetics may determine our response to different diets, so that some diets work well for some people and others for others. Care must be taken when following any restrictive dietary pattern to ensure adequate intake of all essential nutrients but we do know that moderation in all things is good, and diet is a perfect example where quantity (aka portion size) matters too! Transferring expert knowledge to the general public is especially important when talking about lifestyle; the need for an informed population as well as healthcare professionals has never been greater. Stephanie Amiel is the RD Lawrence Professor of Diabetic Medicine at King's College London and Consultant 1
EALTHY Study Group. School-based intervention for diabetes risk reduction. H N Engl J Med 2010; 363: 443-53.
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physician to diabetes services at King's College Hospital, UK.
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News in brief
Eating more fruit and vegetables is advisable Epidemiological studies have generated mixed results regarding the protective properties of fruit and vegetables. A recent linked systematic review (BMJ 2010; 341: c4229) looked at six large prospective studies from the USA, China, and Finland. The researchers found that increased intake of green leafy vegetables was associated with a 14% reduction in the risk of developing type 2 diabetes and called for further investigation. See the article on page 29 for a review of current knowledge on the properties of the Mediterranean diet, which has as a key component the regular and balanced consumption of fresh fruit and vegetables.
Diabetes Voice reaches out to China For the first time, Diabetes Voice has been published in Chinese. With the invaluable support of the Chinese Diabetes Society, last year’s autumn issue was translated and published both online and on paper to coincide with the major World Diabetes Day celebrations held in the Chinese capital, Beijing. The release of new figures for the prevalence of type 2 diabetes in China in March 2010 showed a dramatic increase over recent years and reflected the urgent need for increased awareness of diabetes issues in the region.
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IDF is committed to producing and distributing high-quality diabetes information in the world’s six major languages – Spanish, French, English, Russian, Chinese and Arabic. Currently available in five of these, Diabetes Voice will continue efforts to reach out to the global diabetes community. Work to produce the magazine in Arabic is ongoing. Visit www.diabetesvoice.org to download the Chinese version.
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News in brief
A major step forward for diabetes: UN Modalities Resolution adopted On 23 December 2010, the United Nations General Assembly adopted the Modalities Resolution, a key milestone in the road towards the UN High Level Summit on Non-Communicable Diseases (NCDs) that will take place in New York in September. The Modalities Resolution, adopted by governments at the UN, determines the length, outcomes and other key details of the UN Summit and strongly influences the potential of the Summit to catalyze real change for diabetes and NCDs.
The Resolution contains a number of key provisions, including: opening statements by the UN Secretary General Ban Ki Moon and WHO Director General Margaret Chan representation at the Summit by heads of state or heads of government as well as representatives from civil society a doption of a concise action-oriented outcome document by member states at the close of the Summit. The full Resolution is available for download at the IDF website.
Traffic may be driving
the diabetes epidemic
A study carried out in Germany found that urban air pollution, in particular the particles and gases produced by traffic, can increase the risk among older women of developing type 2 diabetes (Environ Health Perspect 2010; 118: 1273-9). The study authors concluded that pollution could represent a “novel and potentially modifiable risk factor” for the condition. The Düsseldorf-based researchers analyzed data from 1,775 women aged
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around 55 years and healthy when they entered the study 16 to 25 years ago. Most came from coal and steel regions in Germany, although some were recruited from small towns with little industry. At entry and then again between 1990 and 2006, several biomarkers of inflammation were assayed in the women. These proteins complement the work of antibodies by killing bacteria, producing inflammation and regulating other
aspects of immunity. The new study also assembled data on the pollution to which the women had been exposed. Throughout the study, 187 participants developed type 2 diabetes. Overall, the greater a woman’s exposure to pollution, the greater was her chance of developing diabetes. The researchers argued that should this link to type 2 disease be confirmed, it might also help to explain the higher rates of prevalence in urban compared to rural areas.
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News in brief
Spotlight on ‘the elephant in the room’ at EU Development Days
IDF and the NCD Alliance challenged the global development community’s neglect of non-communicable diseases (NCDs) at the recent European Development Days in Brussels, Belgium, which convened 7000 stakeholders and organizations from the development community to discuss international development and approaches to cooperation. A meeting convened by the NCD Alliance focussed on the ‘elephant in the room’, a metaphor for the international development community’s continuing neglect of NCDs – diabetes, cancer, cardiovascular disease and chronic respiratory disease. “You will notice we are in the presence of an elephant in the room” IDF President Jean Claude Mbanya told the
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room, describing an IDF staff member dressed in an elephant suit. “This is not any old elephant, it is an NCD elephant and it is here to make a statement!” NCDs are the biggest killer worldwide, causing 35 million deaths every year, 14 million of which could be averted or delayed. Nearly 11 million deaths from NCDs are in low-income countries, where those affected are more likely than people in the developed world to suffer disabling complications and place a crippling burden on health systems and domestic as well as national economies.
The NCD Alliance will have a chance to address this funding gap and other issues this September in New York at the UN High Level Summit on NCDs. The UN Summit is seen a once-in-ageneration opportunity to address the world’s costliest silent epidemic. A similar UN Summit on HIV/AIDS in 2001 proved to be a turning point for the disease, resulting in significant funding and political commitment to a coordinated action plan.
Yet only a fraction of the money available to address infectious diseases like HIV/AIDS goes to NCDs, with the funding being shared between NCDs, mental health and injuries.
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How much do you know about...
How much do you know about IDF and its structure? 1. I DF’s global membership is structured in a number of Regions. How many? A. Seven B. Six C. Five 2. Which of the following is not among the key aims of IDF’s activities? A. To influence policy B. To increase public awareness and encourage health improvement C. To promote the exchange of highquality information about diabetes D. To provide education for people with diabetes and their healthcare providers
5. The IDF World Diabetes Congress is arguably the most important event in the diabetes events calendar. When and where will the Federation hold the next World Diabetes Congress? A. 2011 Dubai B. 2012 Brussels C. 2013 Melbourne
7. Who can join IDF? A. Individuals with diabetes and their family members B. Diabetes healthcare professionals C. Diabetes-related organizations
6. Which IDF programme aims to provide insulin and other essential supplies to young people with diabetes in low-income countries? A. World Diabetes Day B. Life for a Child C. BRIDGES
3. Who is the IDF President-Elect? A. Jean Claude Mbanya B. Ann Keeling C. Michael Hirst 4. H ow is IDF financed? A. Grants from the EU and a number of other government and public bodies B. Funds from philanthropic organizations including the Bill Gates Foundation C. Both of the above D. None of the above
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Answers on page 10
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How much do you know about...
Answers 1. A IDF has seven Regions: Africa (AFR) Europe (EUR) Middle East and North Africa (MENA) North America and Caribbean (NAC) South and Central America (SACA) South-East Asia (SEA) Western Pacific (WP) The development of the seven Regions of IDF is vital to the strength and growth of the Federation and diabetes associations worldwide. The regionalization of IDF based on the regional structure of the World Health Organization. 2. C Trick question! IDF, leader of the global diabetes community since 1950, is committed to promoting diabetes care, prevention and a cure worldwide. In 2006, the Federation secured a UN Resolution on diabetes, which encourages countries worldwide to develop national policies for the prevention, treatment and care of diabetes – and we continue to lead the global effort to implement Resolution 61/225 under the Unite for Diabetes banner. Through our World Diabetes Day campaign, IDF raises awareness of diabetes and the rights and needs of those affected globally. Our Taskforces and Consultative Sections are constantly engaged in disseminating high-quality diabetes information and sharing best practices in care and education. Visit www.idf.org and click on ‘Activities’ for a detailed description of these and many other IDF activities.
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3. C Michael Hirst from the UK is the current President-Elect of IDF. He will take office as President of the Federation in 2012. He became interested in diabetes over twenty years ago when his youngest child was diagnosed with type 1 diabetes at a very young age. You can read his full profile on the IDF website (www. idf.org/sir-michael-hirst). Jean Claude Mbanya is currently the President of IDF, an office he has held since 2009. Ann Keeling is the Federation’s Chief Executive Officer. See the article on page 11 of this issue to find out more about the inner workings of IDF. 4. E IDF actively seeks financial support for our activities from corporate partners. The Federation remains entirely independent and absolutely transparent - IDF accounts are in the public domain. IDF is particularly grateful to the following corporations for their resources and support towards helping promote diabetes care, prevention and a cure worldwide: Lilly, SanofiAventis, Novonordisk, Abbot, AstraZeneca, BD, Boehringer Inglheim, Boston Scientific, Bristol-Myers Squibb, Lifescan, Kuwait Finance House, Medtronic, MSD, Novartis, Pfizer, Roche, Servier, Takeda.
The 2013 World Diabetes Congress will be held in Melbourne, Australia. Keep up to date with all Congress news at www.worlddiabetescongress.org. 6. B IDF’s Life for a Child Programme currently supports the care of close to 8000 children in 27 countries worldwide. The programme meets the children's immediate needs (insulin, syringes, monitoring and education), builds local capacity and lobbies governments to establish sustainable solutions (www.lifeforachild.org). For more on BRIDGES and World Diabetes Day, follow the links at www.idf.org. 7. C A national or international association that is addressing issues relating to diabetes and associated conditions can apply for membership of IDF. The Federation no longer accepts applications from individuals (the article on page 11 explains why). Applications are first considered by the appropriate Regional Council, which can then recommend the organization to the IDF Board for provisional membership. Provisional Members then submit their written application for full membership to the General Council. For more information on how to join, please contact the IDF Executive Office.
5. A The 21st World Diabetes Congress will be held in Dubai, UAE, from Sunday 4 to Thursday 8 December 2011. Previously held every three years, this global event is now staged by IDF every two years.
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the global campaign
Taking IDF into st the 21 century – what got us here will not get us there! Luc Hendrickx
We all know those maps in shopping malls that say “You Are Here.” They exist to orient us in unfamiliar territory, tell us where we are, where we want to go and how to get there. Organizations need guidance too. Like people, they do not have a built-in GPS system to help them take the right strategic direction every time. Sometimes, they have been going in a particular direction for some time without realizing they might have taken the wrong turn somewhere. Even the ones that seem successful on the outside may well struggle on the inside.
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Organizations need to take a step back once in a while and ask themselves: do the ways in which we are structured and governed still meet our strategic and operational ambitions? Are they in sync? And, if not, what do we do about it? Meet the International Diabetes Federation. We celebrated our 60th anniversary last year. During the previous triennium, we took a critical look at ourselves and revamped our governing structures to bring them in line with the demands of the external environment and with our own strategic and operational ambitions. In the late 1990s, the International Diabetes Federation (IDF) set up a department to take responsibility for the organization, strategic direction and operations of its international congress. Shortly after a successful World Diabetes Congress in Cape Town in December 2006, we mobilized the en-
tire world to stand united for diabetes and succeeded in bringing the UN to pass a Resolution on diabetes – no mean feat! The landmark achievement and momentum that ensued led to the `blue circle' campaign, and the creation of the global symbol for diabetes, that pushed the organization into higher gear almost overnight. As a direct result, more and more was expected of IDF. Increasingly, we developed and took on even larger projects. We helped propel World Diabetes Day from being celebrated locally on the 14th day of November to a truly global, year-long campaign. We became seriously involved in global diabetes education. The Diabetes Atlas, our flagship publication, was now feeding the data and projections published by the World Health Organization, the World Bank, the Organization for Economic Co-operation and Development and
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the World Economic Forum. Many other projects and programmes were initiated and the Executive Office in Brussels grew exponentially. Clearly, the systems and strategies that got us there had worked. Our organizational compass seemed to orient us flawlessly to our next success. We seemed to know who we were and where we were going. Or so we thought. Amidst the whirlwind of achievements and successes, one small problem came at us out of left field. Our structure and governance – the backbone of the organization and the constitutional and statutory basis for everything we did – had remained largely unchanged for many years. The system was coming under
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more and more stress to cope with the rapidly changing internal and external environment. Over the years, our organization had taken a strategic and operational direction that no longer matched its underlying structure and governance. The statutory Articles of Association were getting disconnected from the By-laws and the day-to-day operations as such. Governance and operations were travelling at different speeds. The need for a thorough re-thinking of our governance had not only given in to the internal changes but had been accelerated by external, global events in the financial world as well. With the global economy not doing so well, we were forced to respond. IDF needed to
be an agile organization that provided answers to the rapidly changing external environment. We needed to embrace opportunities and build on the activities that had triggered the organization to develop and grow in the first place. But we also needed to face the threats they brought with them. Under the looking glass So, in May 2007, the Executive Board set up a governance review committee to review the structure and governance of the organization and prepare a set of recommendations to be presented to the General Council in October 2009. It was given the following official remit: to propose recommendations for governance change; to propose recommendations to increase the frequency
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the global campaign
of meaningful interaction between the Board and the membership; and to review and prepare amendments to the Articles of Association to reflect the proposed changes. The committee drew up a work plan based on the strong foundation that their predecessors had already created. Indeed, the desire and process for change were based on essential amendments voted by prior General Councils – in 2003 and 2006. The three constituents – medical healthcare professionals, other healthcare professionals and other people – had been balanced in the Board. The Country Representatives had been removed, all Regional Chairs had been included in the Board of Management and the Articles of Association had created a Financial Officer with recognized financial experience to sit on the Board. The committee took it from there to address new issues. More simple, but not any simpler When the committee started their work, they soon realized that the task was not really about legal structure; it was all about the very nature of the Federation, our core beliefs and ethical values. It was also about the best possible governing structure that supported and recognized them. Basically, the committee took the structure and processes of IDF apart and put them back together again. But as they found out, it was not so easy to do. In fact, it was much easier to add to existing structures or leave things as they were. Re-shaping, re-sculpting, re-designing the Federation was about making it simpler, but not any simpler than it needed to be. Six months later, the committee presented their ideas to the Board and
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then went into each of the IDF Regions for further consultation, a process of listening to our membership worldwide. After the regional response, the committee fine-tuned the concept accordingly. The result was presented at the General Council in Montreal in October 2009. Three guiding principles and four key recommendations For the final concept, the Governance Review Committee had been guided by three related guiding principles: create maximum efficiency with minimum means keep what is important while choosing to let go of what is not essential make it simple, but no simpler than it needs to be. How did they do this? Following the regional consultation workshops, the Governance Review Committee submitted its final report to the Executive Board, who accepted four key recommendations. Small is beautiful Firstly, they proposed to have a single Board. At the time, IDF had two boards: an Executive Board and a Board of Management. Members of the Board of Management were also members of the Executive Board. Two Boards were expensive to run and created duplication and overlap. It took many thousands of Euros to cover the cost of travel, hotel accommodation and meeting facilities and services to bring the Board members together several times a year. There were 28 members on the Executive Board. For the triennium starting in 2009, the committee proposed to reduce this number to 21 by bringing down the number of regional officers from 14 to seven. For the triennium after that,
they planned to reduce the number of Vice-Presidents from 12 to six, leaving a total of 15 members on the Board consisting of a President, President-Elect, six Vice-Presidents and seven Regional Chairs. This single, smaller Board would be cheaper to run, take speedier decisions, focus on strategy and direction and would be capable of meeting in the Regions, inviting the Regional leadership to participate. Too many cooks spoil the broth The committee felt that the Board’s primary role should be a strategic one. Until then, Boards of Management had been very much involved in day-to-day operations. Now the committee wanted to create a governing structure that used volunteer expertise for strategic vision and direction rather than daily management. The second recommendation was to create the function of Chief Executive Officer (CEO). Since her appointment in November 2008, Ann Keeling had already carried the title of CEO. But strictly and legally speaking, IDF had an Executive Director. The operational position needed to be made official in the Articles. Less is more The committee further proposed to shorten the terms of office of the Board members. There was a general realization that serving on the Board was a major commitment in time and energy. The President, for instance, served on the Board for three years as PresidentElect; then for another three years as President. And, in most cases, she or he had served on the Board for a few more years in yet another function, expending a lot of energy over the years. The complexity of the responsibility and commitment of the Board was not getting easier. The Federation needed officers who could focus and be at their best at all times. IDF needed a structure
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that would allow it to bring in new people more easily and frequently, who would bring with them new ideas and experiences. Long terms of office only increased the risk of volunteer burnout. So the committee boldly proposed to reduce the term of office from three to two years, starting in 2016. The heart of the matter The final recommendation was to phase out individual membership. The committee recognized that the greatest strength of any organization lies in its community and membership. IDF was (and is) a federation of national member associations, more than 200 and growing. That had to be the focus. The Federation itself was not equipped to serve individual members; individual membership belonged to the Member Associations. The proposal, therefore, was to further the development of association membership by eliminating individual membership. The category of individual Life Members would still continue but new applicants would not be accepted after 2009. The categories of Honorary Presidents and Members would remain in tact. Hitting the ground running The four key changes were sufficiently substantial to make a real difference without being too far-fetched – a gentle but noticeable face-lift. But what would they mean for Member Associations? The changes were believed to lead to a more dynamic organization, creating stronger strategic leadership from the Board. They had increased the opportunities for volunteers to serve on the Board due to the shorter terms of office, and there would be more frequent Board meetings because they would be less expensive to run, enabling the Board to hold
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its meetings in the Regions and invite the Regional leadership to participate. The changes need to be reflected in the Articles of Association. The committee wanted to hit the ground running. They wanted to start the process of change immediately and not lose time by taking another year or so to change the Articles of Association before the real start. To be able to do this, in the anticipated hope of a positive decision at the General Council, they worked with the lawyers to prepare and modify the amendments of the existing Articles of Association, introducing the new and improved proposed structure in its stead. A new set of Articles had already been prepared in time for the General Council meeting.
Why was change needed? The Regional consultations produced a strong consensus. There was clearly a need for change in the governance structure and processes of our Federation in order to meet the challenges of the future. As we live through an era of widespread economic recession, the need for increased efficiency and effectiveness of IDF has never been more imperative. We have to build a stronger IDF that will meet the challenges faced by all people affected by diabetes around the world. We believe that the proposed and approved changes will do just that.
On 18 October 2009, the General Council in Montreal approved all the recommendations with an overwhelming majority of 94% of the votes. A period of gradual change The transition period for moving to a single, smaller Board and the two-year terms will be from 2009 to 2015. This period of gradual change will work like this: Those elected to the single Board in 2009 will serve for three years until 2012. In December 2012, the officers completing their second three-year term will retire and not be replaced. The officers who are re-elected in 2012 will serve their second and final three-year term until 2015. They will then be replaced by new officers with a two-year term. The current and next Board will have 21 members from 2009 to 2012 and from 2012 to 2015, and 15 members after that. The final transition will be completed by the end of 2015.
Luc Hendrickx Luc Hendrickx is IDF Director of Congresses and Governance
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the global campaign
Calling the world to action on diabetes Jean Claude Mbanya
IDF is gearing up for an exciting year. When heads of state convene at the UN headquarters in New York in September to discuss the scale of and solutions for diabetes and related non-communicable diseases (NCDs), we hope to witness commitments made as never before and a resource flow to match. The UN Summit on NCDs is undoubtedly the political opportunity of a lifetime for the global diabetes community. This is why IDF is launching a Year of Action for Diabetes. All activities this year will be geared around continuous, visible action for diabetes and we will issue a monthly advocacy-toaction newsletter to inform and update interested partners, share good practice and galvanize action as we move full speed ahead towards the UN Summit. Our advocacy and action in 2011 is guided by the landmark advocacy publication launched on World Diabetes Day last year. A Call to Action on Diabetes is the first milestone from IDF’s new programme of work dedicated to the UN Summit, the Diabetes Roadmap Programme, and acts as a tool for unifying the global diabetes community in this pivotal year. It aims to bring the global diabetes epidemic to the attention of world leaders, outlines the case for investing in this major global health and development challenge, and offers strength and inspiration in our fight against a disease that is predicted to affect half a billion people within a generation. Developed over a period of two months, kick-started by an IDF Expert Meeting held in Brussels followed by extensive consultation with a large group of diabetes and public health
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experts from all over the world, the Call to Action brings four headline messages to the world from the diabetes community: Diabetes is a major global threat to human security and prosperity. Diabetes kills and disables people, impoverishes families, imposes a huge economic burden on societies and governments and overwhelms health systems. It affects rich and poor, young and old. The majority of people with diabetes are in low- and middle-income countries and have limited access to affordable treatment. The global failure to invest in diabetes has led to the current crisis. The evidence of the magnitude of diabetes has been largely ignored by policy makers. Serious investment is needed now in essential diabetes medicines and technologies, proven diabetes management and care, and research into the causes of diabetes and a cure. The news is bad but we have solutions. Most diabetes can be prevented or delayed. Investment in prevention makes economic sense. Effective, low-cost treatments and care exist for diabetes that cannot be prevented. With early diagnosis and effective management, people with diabetes can live a long, healthy and productive life, and health systems can save on expensive complications such as kidney failure, blindness and amputations. Diabetes affects everyone and requires a collective response. Diabetes is not just a health issue. Its causes are diverse. Its impact is felt by all of society. The solutions and response must therefore be multi-sectoral and coordinated.
DiabetesVoice 15
DS AI V/ HI
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DIABETES
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framework calls for coordinated action on: Improving health outcomes of people with diabetes Preventing the development of type 2 diabetes Ending discrimination against people with diabetes.
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To support this coordinated global movement, A Call to Action on Diabetes signposts a framework of concerted action for all stakeholders in the lead up to the UN Summit. It appeals to governments, business, the UN and international bodies, civil society, health professionals, researchers, philanthropic organizations and the general public to focus on Ca nce three key areas. This three-point r framework provides the foundations for IDF’s diabetes-specific hopes and objectives for the Urbanisation UN Summit, and will ensure that the political opportunity translates into lives saved from diabetes and related NCDs – te cancer, cardiovascular disease, Climage n a chronic respiratory disease. The ch
losis
The global campaign
IDF used the framework for action as the basis for consultation with our Member Associations to understand regional diabetes priorities for the UN Summit. That consultation has ensured that IDF’s actions at the global level in the lead up to, during and after the UN Summit are guided by reality on the ground. A consultation report is being released this month, and the results will feed into IDF’s regional advocacy and support global diabetes advocacy. We also will produce IDF Advocacy Toolkits for the UN Summit for our members, which will include tailored regional messages drawn from the consultation. A Call for Action on Diabetes is a key document ensuring that the UN Summit on NCDs is a turning point for diabetes. Be a part of this by supporting the Call to Action on Diabetes. Disseminate it and promote it, use its key messages to lobby on diabetes. Let it inspire you, and help to spread the message that global neglect of diabetes is an outrage! Together, as individuals, organizations, companies and governments we can choose a healthy, prosperous and sustainable future for our children and for generations to come.
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Jean Claude Mbanya Jean Claude Mbanya is IDF President. A Call to Action on Diabetes is available free of charge from the IDF website at www.idf.org/webdata/Call-to-Action-on-Diabetes.pdf
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Towards the policy reforms we need to tackle NCDs – an interview with Badara Samb In an exclusive interview with Diabetes Voice, Badara Samb, the World Health Organization’s Coordinator for Health Systems Strengthening, tells us why NCD programmes have remained at the bottom of the agenda for global health development and outlines the factors that limit countries' capacity to implement proven strategies for chronic diseases. Professor Samb is an experienced epidemiologist and public health physician, who started working with UNICEF early in his career, and later undertook research at INSERM and work with the UN on AIDS. In addition to his role with WHO, he has a chair in health and international relations at the Geneva School of Diplomacy and International Relations.
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You are Advisor to the WHO Assistant Director General of Health Systems and Services. Could you briefly explain your role? I use my knowledge, expertise, and experience on health systems to advise the WHO Assistant Director General on innovative and strategic approaches to strengthen country health systems. I put a special emphasis on the interactions between country health systems and global health systems. Multiple health and social concerns are competing for attention on the world stage. Are we at IDF making a mountain out of a molehill? How great is the threat from diabetes and other non-communicable diseases (NCDs)? It is right to say that low priority is given to chronic NCDs as compared with other pressing health issues, both globally and nationally. This is despite the fact that NCDs will account for 69% of all global deaths by 2030; 80% of these will occur in low- and middleincome countries. Yet only 2.3% (503 million USD) of overall development assistance for health in 2007 was dedicated to NCDs. So what is ‘wrong’ with NCDs? Why have they remained a neglected health issue for so long? Six explanations come to my mind when trying to understand why NCD programmes are languishing at the bottom of the agenda for global health development. The first relates to the nature of chronic disease prevention, treatment, and care. An effective response to chronic diseases demands long-term planning, inter-sectoral responses, and consistent investment that can be sustained over a long period. Returns on such investment, in terms of population health
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outcomes, are generally not seen in the short term, which has been a factor in the failure to mobilize resources and build coalitions with those working in many other areas of development. Secondly, chronic diseases are often seen incorrectly as the result of individual choices, with too little recognition of underlying social determinants. The third relates to the emphasis on highly technical and specialist curative interventions for chronic conditions, which need high-cost tertiary care, combined with scarce public resources for healthcare. This has contributed to a predominantly private-sector response to chronic disease in low- and middle-income countries, despite the availability of low-cost and cost-effective interventions. Fourth: there is a collective failure to define and identify chronic diseases as a coherent group for advocacy and accountability, and to generate robust data for the implications of such diseases as a subset of overall public health needs – as seen in the fragmentation of programmes for chronic diseases. Although in many countries there has been concerted action on specific conditions such as diabetes, cancers or cardiovascular disease, there are very few examples of an integrated response. Fifth: scarce data for chronic diseases have hindered understanding of the profound economic consequences of chronic disease-related premature death and disability. And sixth: there has been a failure to create a social movement that can draw attention to the neglect of chronic diseases. The effect of chronic diseases as a whole has not had a sufficiently mo-
tivating effect on public opinion or on global or national political leadership. How can the Health Systems and Services department help fight against the global epidemic of diabetes and other NCDs? Every effort must now be made to embed the discourse on NCDs firmly within the emerging agenda for health-systems strengthening, and to promote the needs of health systems to chronic disease advocates. A shared agenda will aim, from the outset, to build national health systems that can respond to the full spectrum of evolving population health needs. From this shared global vision will follow policy reforms that can encourage greater appropriateness, relevance and efficiency in healthcare financing; instruments and structures for health governance; recruitment, training and deployment of health workers; health information systems; supply management; and delivery of health services – all very important factors for an efficient response to NCDs. You have worked on HIV/AIDS under the auspices of the UNAIDS programme. What challenges face NCDs if they are to achieve appropriate recognition given their impact on health worldwide – and in low- and middle-income countries in particular? One important challenge will be to resist the temptation to focus on one disease or a small group of diseases and their causes. That will create fragmentation and verticalization. The world does not need other vertical programmes, we are in an era of integration. Another equally important challenge will be to keep the momentum, thus to avoid donor fatigue. Finally, without strong health systems, NCD programmes will not be sustainable.
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ence, psychosocial interventions – are strategies borrowed from diabetes and other chronic disease care. Given the similarity of models of care between HIV and other chronic conditions, the global mobilization for HIV prevention, care and support could be leveraged to advance other chronic disease programmes. You make a number of important points in your recent article in The Lancet, ‘Prevention and management of chronic disease’. Can you give our readers a brief outline of your conclusions? The main message in our recent Lancet paper is that there is emerging evidence that chronic disease interventions could contribute to strengthening the capacity of health systems to deliver a comprehensive range of services, provided that such investments are planned to include these broad objectives. Most importantly, we believe that because effective chronic disease programmes are highly dependent on well-functioning national health systems, chronic diseases should be a litmus test for healthsystems strengthening.
Can you see synergies between HIV/ AIDS and diabetes in terms of the model for chronic care required in response to the diseases? Well, with the availability of antiretroviral drugs, HIV has become a chronic
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condition like diabetes. The main strategies for prevention, treatment and care of HIV/AIDS – early detection and monitoring of risk factors, populationbased interventions, continuing care, regular monitoring of treatment adher-
The UN General Assembly will hold a Summit on NCDs in September 2011. How did the 2001 UN General Assembly Special Session on HIV/AIDs affect the fight against AIDS? What are the prospects for diabetes and NCDs after the 2011 Summit? The 2001 UN General Assembly Special Session on HIV/AIDS was a turning point in the global fight against AIDS and has resulted in a significant access to HIV/AIDS services throughout the world. If lessons learnt from the AIDS movement post-2001 are applied to the nascent global movement on NCDs, one should reasonably expect even greater impact of the 2011 summit on the management of NCDs.
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The Middle East and North Africa Diabetes Leadership Forum Ann Keeling
In December 2010, key stakeholders, leaders and highprofile speakers gathered in Dubai to discuss the overwhelming human and financial burden imposed on the Middle East and North Africa (MENA) region by diabetes. The MENA Diabetes Leadership Forum, sponsored by Novo Nordisk and supported by IDF, was a high-level advocacy meeting aimed at confronting the diabetes epidemic in the region and exploring and sharing ways to tackle the issue at the highest level. The Forum was the fifth in a series of such meetings, with previous events in the USA, Russia, China and South Africa.
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The MENA region is one of the hotspots of the global diabetes epidemic. Progressive urbanization, increased life expectancy and economic development associated with a shift in lifestyles have contributed to an explosion in the number of people with type 2 diabetes in the region over the last 30 years. IDF estimates that there are currently 26.6 million people living with diabetes in the MENA region and the number is set to almost double to 51.7 million people by 2030.1 The United Arab Emirates has the second highest prevalence of diabetes globally, and five out of the 10 countries with the highest prevalence rates are in this part of the world (Bahrain, Egypt, Kuwait, Oman, Saudi Arabia, UAE). Co-hosted by the UAE Ministry of Health, the Executive Board of the Health Ministers Council for the Gulf Cooperation Council States, the World Bank Group (MENA region) and the World Diabetes Foundation, the Diabetes Leadership Forum provided a timely platform to discuss the unique challenges faced by the MENA region and reinforce commitments for the way forward.
With just months to go until the UN Summit on Non-Communicable Diseases (NCDs), the Leadership Forum catalysed dialogue about the forthcoming political opportunity and the preparations required to translate this unprecedented high-level meeting into tangible commitments and resources. From start to finish, the UN Summit remained central in discussions.
From start to finish, the UN Summit remained central in discussions. The Forum opened with an IDF Special Session, ‘Looking towards the UN Heads of State Summit on NCDs’, during which IDF President Professor Jean Claude Mbanya gave a stirring keynote speech on IDF’s hopes for the UN Summit. Drawing on the framework for action laid out in IDF’s recently launched Call to Action on Diabetes2 (see page 15 for more on the Call to Action), Professor Mbanya rallied for renewed commitment and energy to improve health outcomes for people with diabetes, preventing the development of type 2 diabetes wherever possible and ending
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discrimination against people with diabetes. Speaking in front of regional experts and leaders, the President invited participants to join IDF in our year-long process of awareness, engagement and mobilization for diabetes in the lead up to the UN Summit. In his opening speech, IDF’s President highlighted the importance of MENA in global as well as regional advocacy: “for a successful UN Summit, it is of utmost importance we galvanise a ground attack, particularly in regions such as MENA where the epidemic is raging. We need the MENA States to be leading this movement at the political level, as well as at the policy and programmatic levels”. The MENA Diabetes Leadership Forum provided the opportunity for experts, leaders and officials from the region to discuss regional diabetes priorities and needs for the UN Summit. Much discussion centred on existing regional action plans and declarations, such as the 2009 IDF MENA Regional Diabetes Action Plan3 and the Integrated Gulf Executive Plan for Diabetes Control 2008-2018, the Riyadh Declaration, the Jeddah Declaration and the Doha Declaration. Building on these, the Leadership Forum adopted a Dubai Declaration and national delegations formed breakout sessions at the end to discuss follow-up activities at the national level. Sharing good practice will be key component in driving change in the MENA region during the approach and immediate aftermath to the UN Summit. Sessions during the Forum dedicated to good practice in awareness, early detection and improving quality of care demonstrated the breadth and quality of the cutting-edge work being done in the MENA region. The discussions in these sessions reflected the great diversity in the region, in terms of diabetes
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prevalence and the challenges faced by some countries in coping with the human and financial strain of the diabetes epidemic. Innovative partnerships and practices, such as Member Association twinning, will be required to support the poorer countries in the region, and by doing so, achieve equitable and sustainable diabetes care and prevention.
There is a clear way forward: conscious, organized, deliberate and sustained action. Indeed, the recurring theme of the UN Summit was punctuated by frequent assertions of the importance of partnerships and the need for a multistakeholder approach to fight the global diabetes epidemic. Representatives from the UN and international organizations, governments, businesses, healthcare professionals and civil society were in agreement: only with a unified approach through robust partnerships and strong leadership will we be able to make a real difference for the 300 million people living with diabetes today. During the official opening, former US President Bill Clinton led this call when he stated, “there is a clear way forward: conscious, organized, deliberate and sustained action. No one can do this alone; we need every level of society”. In his keynote speech, Clinton reaffirmed his commitment to fighting diabetes and related NCDs, and cited the Annual Clinton Global Initiative (CGI) meeting as an opportunity to launch innovative public-private partnerships for diabetes. The Medtronic Foundation committed USD 1,000,000 to the NCD Alliance at the CGI last September, part of which is specifically for IDF’s Diabetes Roadmap Programme for the UN Summit. We can expect to see
further pledges to NCDs at the September 2011 CGI, which will coincide with the UN Summit. Undoubtedly Clinton’s presence at the Forum is testament to the growing international recognition of diabetes as a major global health and development issue. Not only was this a unique opportunity for the MENA region to prepare the groundwork for the 2011 UN Summit on NCDs, it was also a key meeting in the run up to IDF’s World Diabetes Congress in Dubai on 4-8 December 2011. The MENA region will be host to the global diabetes community just a few weeks after the UN Summit, and IDF intends for this sequence of events to build momentum and facilitate the implementation of commitments made at the UN Summit in the MENA region and at the global level. A new element of the World Diabetes Congress, a Global Diabetes Forum, will be introduced in Dubai to facilitate this process. The Global Diabetes Forum will provide the opportunity for key decision makers to reflect on the Summit and carve out the next steps. For a region that is buckling under this health tsunami, high-profile events, such as the MENA Diabetes Leadership Forum and IDF’s World Diabetes Congress, will bring much-needed attention to diabetes. Ann Keeling Ann Keeling is IDF Chief Executive Officer.
References 1 I nternational Diabetes Federation. Diabetes Atlas 4th ed. IDF. Brussels, 2009. 2 I nternational Diabetes Federation, A Call to Action on Diabetes. IDF. Brussels, 2010. www. idf.org/webdata/Call-to-Action-on-Diabetes.pdf 3 I nternational Diabetes Federation. IDF MENA Regional Diabetes Action Plan. IDF¬-MENA. Cairo, 2009. www.idf.org/ webdata/docs/IDF-Action%20-Plan-EN.pdf
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The global campaign
Gestational diabetes: and serious maternal Katie Dain
Gestational diabetes, defined as ‘any degree of glucose intolerance with onset or first recognition during pregnancy’ has increased over the last 20 years, reflecting the increasing frequency of type 2 diabetes in the underlying population. Despite being associated with several pregnancy complications, and increasing the risk of both mother and child developing type 2 diabetes later in life, gestational diabetes remains a neglected maternal health issue. Indeed, the low political priority given to gestational diabetes on the global stage is a missed opportunity for accelerating progress towards the Millennium Development Goal 5, the most off track, to improve maternal health. This article seeks to explain the underlying causes for the invisibility of gestational diabetes on the global development agenda, and identifies potential strategies to increase the visibility of gestational diabetes.
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the global campaign
an invisible health issue
An issue without numbers is invisible to policy makers. Arguing for the prioritization of an issue that cannot be quantified in terms of its scale and impact is almost impossible. Evidence is important for many reasons, including raising awareness, focusing political and technical attention on finding solutions and shaping the delivery of that solution. IDF collects and collates diabetes incidence and prevalence data from primary studies around the world for these reasons and publishes them biannually in the IDF Diabetes Atlas. Figures from this authoritative source are arresting, revealing that today there are over 285 million people with diabetes worldwide, and by 2030 this number will increase to around half a billion.1 These numbers have been a driving force behind the political elevation of diabetes in the last five years and lie at the heart of IDF’s successful global advocacy and campaigning to date. Key campaign messages such as “every 10 seconds, a person dies from diabetes” from the Unite for Diabetes Campaign
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in 2006 were based on evidence from the IDF Diabetes Atlas and were influential in securing landmark UN Resolution 61/225 on diabetes.
The absence of an international approach to generating prevalence estimates is a key barrier to understanding the true scale of gestational diabetes. However, IDF’s Diabetes Atlas currently does not hold the same weight for gestational diabetes as for the other two main types of diabetes. The reason for this is that the evidence does not exist for gestational diabetes as it does for type 2 diabetes. IDF had intended to include a chapter on gestational diabetes in the fourth edition of the Diabetes Atlas with regional and global prevalence estimates. However, when the process of collecting existing gestational diabetes prevalence
studies began, it soon became clear that a reliable profile of the global gestational diabetes burden and distribution would be impossible to present. The current literature is inconsistent in the way that gestational diabetes data are collected and reported in terms of diagnostic methods and definitions. Therefore, data from different studies are difficult to compare. Furthermore, many have been small-scale and are not published in peer-reviewed journals, so would not meet the IDF Atlas standard requirements. The absence of an international approach to generating gestational diabetes prevalence estimates is a key barrier to understanding the true scale of gestational diabetes, at both the regional and global levels. Things may be about to change for the better. There is increasing momentum from different groups and organizations to overcome this critical gap in the evidence base. In March 2010, the International Associations of Diabetes and Pregnancy Study Group published recommendations for diagnosing gestational diabetes, based on the Hyperglycaemia and Adverse Pregnancy Outcome study and the two complimentary randomized controlled trials which demonstrated the effectiveness of treating gestational diabetes in reducing short-term adverse pregnancy outcomes.2,3,4 More recently, in November 2010, the World Health Organization held a Consultation on Diagnosis and Screening for gestational diabetes, which will result in global recommendations that can feasibly be adopted by low-, middle- and high-income countries. IDF has been at the centre of these processes, and is taking a leading role in developing international best practice for gestational diabetes prevalence
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studies by developing an IDF Model Approach to Gestational Diabetes Prevalence, which is aligned with the outcomes of the WHO Consultation. In doing this, IDF will catalyse a consistent approach to generating gestational diabetes prevalence estimates throughout all its regions and ensure that future data are comparable and reliable. This initiative will support the inclusion of a chapter on gestational diabetes in future editions of the Atlas and raise this neglected maternal health issue on the global health agenda. Maximizing political opportunities As has been shown with many other public health issues, it is important to take advantage of political opportunities. For gestational diabetes, there are three main political opportunities on the horizon. The first is the political
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momentum around the health of women and children. World leaders increasingly recognize that the health of women and children is key to progress on all of the Millennium Development Goals (MDGs), not just MDGs 3, 4 and 5. This political awakening is somewhat belated and the failure to invest to date has led to the current crisis surrounding MDG 5 on maternal health, which remains the most off track. Recently, an intensified effort is being led by the UN Secretary General and his Global Strategy for Women’s and Children’s Health, which was launched at the MDG Review Summit in New York in September 2010.5 The unprecedented mobilization of resources for women’s health resulting from the UN Strategy (over USD 40 billion committed over the next five years), com-
bined with the UN Strategy’s focus on a more comprehensive and integrated approach to women’s health, provides a key political opening for advocates of gestational diabetes.
IDF and the NCD Alliance are working to ensure that the outcomes of the UN Summit on NCDs are beneficial to women’s empowerment and health. The second and third political opportunities are linked. As Diabetes Voice readers will know, in September 2011, the UN will host the first ever UN HighLevel Summit on NCDs. IDF and the
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NCD Alliance have been campaigning for such a Summit since January 2009. The 2001 UN Summit on HIV/ AIDS is considered by many to be the turning point for that disease, resulting in the Global Fund to Fight AIDS, Tuberculosis and Malaria and a mechanism requiring UN Member States to report back on progress every two years. With the right preparation and packaging of the evidence, the 2011 UN Summit has the potential to secure commitments from heads of government for a coordinated global response for all types of diabetes and NCDs and a resource flow that finally matches the scale of these epidemics. It is crucial that gestational diabetes remains visible. IDF and the NCD Alliance are working to ensure that the outcomes of the UN Summit on NCDs are beneficial to women’s empowerment and health more broadly. Practical policy solutions Finally, the evidence on gestational diabetes must be complemented by evidence-based and cost-effective solutions to encourage policy makers to take action. A key practical solution for gestational diabetes is informing women about their health and empowering them to take it into their own hands. Due to many misconceptions about diabetes and a lack of awareness of the magnitude of the threat posed by diabetes to women’s health in developing countries, gestational diabetes generally has not been integrated into broader efforts on maternal and child health. There is an opportunity to link information on the prevention and early detection of gestational diabetes to interventions for reproductive and maternal and child health. Antenatal care visits, as well as contact with the health system around family planning and childcare, provide a number of opportunities to reach young
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women with key information about diabetes and gestational diabetes, and detect it early. Undiagnosed diabetes in pregnancy can be life threatening for both mother and child. This is especially relevant in many developing countries, where demographic and epidemiological transitions, driven by economic development, are associated with increasing risk factors for diabetes and gestational diabetes, such as obesity.
IDF is advocating for the integration of diabetes and gestational diabetes into existing maternal health programmes. Just as IDF is calling for the integration of diabetes into existing health systems, particularly at the primary care level, we are advocating for the integration of diabetes and gestational diabetes into existing maternal health programmes. This makes economic sense and is based on the principle that the health system should treat the whole person, rather than compartmentalizing treatment by disease. Maternal health interventions offer an opportunity to promote healthy lifestyles that improve long-term health outcomes for the woman, her unborn child and her family. Integrated care and health system strengthening are key elements of the UN Global Strategy for Women’s and Children’s Health, and provide a useful springboard for future partnerships and coordinated efforts between the maternal health and NCD community. Positioning gestational diabetes as a priority Gestational diabetes will only gain the attention and political commitment it deserves once we have the numbers and
solutions to put forward a compelling case. We have a number of unprecedented opportunities to raise this important maternal health issue but without the evidence these will be missed opportunities. Gestational diabetes has a potentially devastating impact on maternal and child health and therefore requires urgent action. IDF will continue to work with a range of partners to ensure that gestational diabetes is not overlooked. Katie Dain Katie Dain is the Advocacy and Programme Development Co-ordinator of IDF.
References 1 I nternational Diabetes Federation. Diabetes Atlas 4th ed. IDF. Brussels, 2009. 2 I nternational Association of Diabetes and Pregnancy Study Group. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010; 33: 676-82. 3 HAPO Study Cooperative Research Group. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study: associations with neonatal anthropometrics. Diabetes 2009; 58: 453-9. 4 C rowther CA, Hiller JE, Moss JR, et al; Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005; 352: 2477. 5 U nited Nations Secretary-General Ban Ki-moon. Global Strategy for Women's and Children's Health. United Nations. New York, 2010.
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Spotlight on an idf member association
Spotlight on an IDF Member: the Dutch Diabetes Association Maarten Ploeg and Annemarie Bevers
Like many of its fellows, the Dutch Diabetes Association (DDA) is faced with a growing number of people with diabetes — currently nearly 1 million out of a total population of 16 million people. About 58,000 of these people with diabetes are members of the DDA. In order to support members’ diabetes management, and attract new members, the DDA has developed several Internet-based applications to reach out directly to increasing numbers of people. In our 65year history, we have evolved from an organization that secured insulin for people with diabetes into an organization with ties to the general public, politicians and policymakers, insurers and a range of other stakeholders.
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Much effort is put into the prevention of type 2 diabetes in The Netherlands. The DDA participates in the National Action Programme, funded by the Ministry of Health. Since organization represents people with diabetes, these are our main focus. Our guiding principle is that people with diabetes should be able to take care of themselves at all times. That is entirely possible given the current status of healthcare in our country. Insurance companies and healthcare providers are equipped and able to share responsibility with people affected by diabetes. Empowering people with diabetes to take up a central role in their own care is an important area of our work. Our next key goal is to gain access to confidential digital health records – without these becoming available to any other party. In this article, we will explain how. Reaching out online To start with, the DDA connects people with diabetes with one another through several websites linked to the main Association site (www.dvn.nl). There are websites for diverse target groups: children with diabetes up to the age of
12 years; teenagers and young adults (12 to 18 years); adults and parents – through a forum for sharing concerns and knowledge about diabetes issues. A DDA diabetes Wikipedia offers a range of diabetes information that has been assembled over the years.
The DDA e-shop ensures the wide availability of reasonably priced diabetes supplies. To connect these and several other interesting DDA Internet initiatives, we created a personalized Internet portal, ‘my diabetes online’ (www.mijndiabetes. nl). Here, users can set up their own account and arrange diabetes information in an order that is relevant to their own situation – creating in this way a personalized ‘diabetes dashboard’. The DDA has incorporated in the portal an online e-shop, where essential diabetes supplies can be purchased. Up and running since 2008, the role of the e-shop is to ensure the wide availability of diabetes supplies at reasonable prices.
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Spotlight on an idf member association
Personal health information available on a personal level Our mission, to support all people with diabetes in accessing good care and living a normal, healthy life with diabetes, underpins all of our decisions and activities. To this end, the personalized Internet portal will, in the long run, offer a range of personal diabetes information to individuals. Personal health records currently belong to healthcare providers; the DDA adheres to the belief that this type of information should belong to the person with diabetes. We encourage diabetes healthcare providers to make personal health status available online. Access to this information via the DDA portal will remain confidential and free of charge for all users. Going out tonight? Check your dinner! The DDA’s most recent initiative is called ‘Check your dinner’, where people with diabetes (and people
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without diabetes) can calculate the carbohydrates and calories on offer in a restaurant’s menu before choosing a place to eat. Under the scheme, restaurants make their menus available to the DDA’s nutrition experts, who then calculate these values. This simplifies decisions regarding the number of units of insulin a person needs to take. Apart from the advantages for people with diabetes, ‘Check your dinner’ offers participating restaurants a new way of presenting themselves to the public – caring and conscientious and playing a part in improving public health.
DDA – totally web based? We have seen a sharp rise in the use of the Internet in The Netherlands. It is essential for our organization to be active online and thus accessible to growing numbers of people. But of course, we also offer offline communication: a monthly magazine, Diabc; a 24-hour phone service for non-medical questions about living with diabetes; a nationwide network of volunteers organizing informative events and inviting people with diabetes and people without diabetes to work out together.
‘Check your dinner’ allows restaurants to play a part in improving public health.
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Spotlight on an idf member association
The DDA has a track record of political advocacy on behalf of people with diabetes. We have managed to influence Dutch and European policymakers in a number of ways. The DDA set up the National Diabetes Federation (NDF) in 1995 in order to compile all current knowledge on the treatment of diabetes. Member organizations of the NDF represent healthcare providers as well as people with diabetes. The combined strength and united voice of these organizations under the NDF umbrella was responsible for launch of the National Action Programme. Dutch Diabetes Care Standard In 2007, the NDF published the Diabetes Care Standard for Dutch healthcare providers, which outlines the basic diabetes care that is necessary to stay healthy. In 2008, this document was adapted for people with diabetes and a checklist added, enabling individuals and their family to check whether they are receiving the full care package to which
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they are entitled. A survey, Diabetes Care Monitor, was conducted in order to determine whether people with type 2 diabetes were aware of their personal care plan. This plan, co-written by the person with diabetes and his or her diabetes healthcare provider, forms the basis for personal diabetes care. It makes living with diabetes easier – for example, by timetabling all necessary check-ups. The survey results told us that a lot of work remains to be done so that people with diabetes can lead a life without many of the burdens of the disease.
Much remains to be done so that people with diabetes can live free from the burdens of the disease. Keep on keeping on The survey was repeated recently and this time also solicited the opinions of people with type 1 diabetes regarding
the care they receive. From the results of these nationwide consultations, it has become clear that incorporating a personal care plan into the personalized webpage is an urgent requirement. Indeed, the options for entering personal data by both the user and the healthcare provider need to be expanded in order to provide a comprehensive and effective personal plan. Patently, our efforts and expertise are still very much needed. We will continue working to advance our mission for as long as we are needed.
Maarten Ploeg and Annemarie Bevers Maarten Ploeg is Director of the Dutch Diabetes Association. Annemarie Bevers is a board member of Dutch Diabetes Association and IDF Europe.
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health delivery
Prevention and control of type 2 diabetes by Mediterranean diet: a systematic review Katherine Esposito, Maria Ida Maiorino, Antonio Ceriello, Dario Giugliano
In the 1950s and 1960s, the Seven Countries Study looked at the dietary patterns of people living in the Mediterranean region, and the term Mediterranean diet was coined for the first time. Traditional diets were considered to be largely responsible for the good health of people living in Greece and southern Italy. There is no single Mediterranean diet; 20 countries, each with its own socio-cultural and economic circumstances, have a coastline in the Mediterranean basin. However, in broad terms, the diet consists of vegetables, fruit and legumes, nuts, cereals and whole grains, olive oil, moderate consumption of fish and poultry, relatively low consumption of red meat and moderate consumption of wine. The authors of this article recently reviewed of all the available studies that have assessed the effect of a Mediterranean diet on people with diabetes, as well as on diabetes prevention and metabolic and cardiovascular outcomes. Here they summarize their findings and look at some of the reasons that might explain any effect.
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Virgin olive oil is a key component of the Mediterranean diet – for cooking, frying, spreading on bread or dressing salads. Regular consumption of virgin olive oil leads to a high ratio of monounsaturated fats to saturated fats in the diet. A recent review of published studies on dietary fat and diabetes suggests that replacing saturated fats and trans (hydrogenated) fats with unsaturated (polyunsaturated and/ or monounsaturated) fats has beneficial effects on insulin sensitivity and is likely to reduce the risk of type 2 diabetes.1 However, one recent long-term clinical study in overweight people with type 2 diabetes was unable to find differences in blood glucose control between a diet that was high in monounsaturated fats (46% of total energy as carbohydrate and 38% as fat) as compared with a highcarbohydrate diet (54% of total energy as carbohydrate and 28% as fat).2
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The protein adiponectin is secreted by adipose (fat) tissue. Adiponectin levels are inversely correlated with obesity and abdominal fat. Also, adiponectin has positive effects on insulin sensitivity and has anti-inflammatory properties. In the Nurses’ Health Study, average levels of adiponectin were 23% higher in women with diabetes who most closely followed a Mediterranean-type diet compared with their peers who did not follow the diet as closely.3 In 13 prospective studies of a range of populations, higher adiponectin levels were found to be associated with a lower risk of type 2 diabetes.4
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This appears to be in line with evidence showing that a combination of dietary factors, like those in the Mediterranean diet, may slow down inflammation.5 A recent meta-analysis that followed more than 1.5 million healthy people for between 3 and 18 years showed that the more strictly a person follows a Mediterranean diet, the lower their risk of cardiovascular-related death.6 We were unable to find such prospective studies in people with type 2 diabetes. However, the results of two interventional studies involving a significant proportion of people
with type 2 diabetes demonstrated that people following a Mediterranean diet after a recent heart attack may have a better chance of survival and have a reduced risk from cardiovascular complications. Some caveats The small number of controlled trials specifically designed to evaluate the metabolic and cardiovascular effects of a Mediterranean diet on people with type 2 diabetes remains a major limitation in terms of the conclusions that can be reached regarding the diet’s cardiovascular benefits for people with the
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condition. Also, in a controlled trial, measuring whether or not a person follows a Mediterranean diet is usually based on a score that involves taking arbitrary decisions about the type and number of foods to be included and the number of points assigned to different levels of intake. Moreover, an analysis of this type cannot provide universally applicable results because diets vary across populations as well as between sections of the same population. In general, dietary pattern scores, such as the Mediterranean diet score, tend to generate fairly consistent results in terms of health benefits, whereas studies focusing on the component foods or food groups are often contradictory.7 Most clinical studies of Mediterranean diet have focused on surrogate markers for early risk assessment, which may be misleading. On the other hand, there are at least two outcome-based trials that demonstrated benefits in terms of
reducing cardiovascular and total mortality in people – including more than 1700 with type 2 diabetes –who had recently suffered a heart attack and were following a Mediterranean-style diet.8,9 A recent systematic search of MEDLINE for prospective cohort studies or randomized trials investigating diet in relation to coronary heart disease found that among the diets that had some kind of notable effect on health, only a Mediterranean diet is related, as a protective factor, to coronary heart disease in randomized trials. Conclusion We do not have enough evidence at the moment to assess in full the healthy benefits of a Mediterranean diet in people with type 2 diabetes. However, the available evidence suggests that adopting a Mediterranean diet may help prevent type 2 diabetes and also improve blood glucose control and cardiovascular risk in people with the condition.
Katherine Esposito, Maria Ida Maiorino, Antonio Ceriello, Dario Giugliano Katherine Esposito is researcher in the Department of Geriatrics and Metabolic Diseases, Second University of Naples, Naples, Italy. Maria Ida Maiorino, Department of Geriatrics and Metabolic Diseases, Second University of Naples, Naples, Italy. Antonio Ceriello, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain. Dario Giugliano is professor in the Department of Geriatrics and Metabolic Diseases, Second University of Naples, Naples, Italy. This report is part of a review article that was originally published in Diabetes Research and Clinical Practice (Prevention and control of type 2 diabetes by Mediterranean diet: A systematic review. Diabetes Res Clin Pract 2010; 89: 97-102). Reproduced with the publisher’s permission.
References 1. R ise´rus U, Willett WC, Hu FB, Dietary fats and prevention of type 2 diabetes. Prog Lipid Res 2009; 48: 44-51. 2. B rehm BJ, Lattin BL, Summer SS, et al. One-year comparison of a high-monounsaturated fat diet with a high-carbohydrate diet in type 2 diabetes. Diabetes Care 2009; 32: 215-20. 3. M antzoros CS, Williams CJ, Manson JE, et al. Adherence to the Mediterranean dietary pattern is positively associated with plasma adiponectin concentrations in diabetic women. Am J Clin Nutr 2006 84: 328-35. 4. L i S, Shin JJ, Ding EL, van Dam RM. Adiponectin levels and risk of type 2 diabetes. A systematic review and meta-analysis. JAMA 2009 302; 179-88. 5. H erder C, Peltonen M, Koenig W, et al. Anti-inflammatory effect of lifestyle changes in the Finnish Diabetes Prevention Study. Diabetologia 2009; 52: 433-42. 6. S ofi F, Cesari F, Abbate R, et al. Adherence to Mediterranean diet and health status: meta-analysis. BMJ 2008; 337: a1344. 7. H u FB. Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol 2002; 13: 3-9. 8. B arzi F, Woodward M, Marfisi RM, et al, on behalf of GISSI-Prevenzione Investigators. Mediterranean diet and all-causes mortality after myocardial infarction: results from the GISSI Prevenzione trial. Eur J Clin Nutr 2003; 57: 604-11. 9. T uttle KR, Shuler LA, Packard DP, et al. Comparison of low-fat versus Mediterraneanstyle dietary intervention after first myocardial infarction (from the Heart Institute on Spokane Diet Intervention and Evaluation Trail). Am J Cardiol 2008; 101: 1523-30.
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Diet and diabetes: lessons from the ruby red slippers Caroline Trapp
The 1939 film The Wizard of Oz provides an interesting metaphor for a discussion on type 2 diabetes. In the story, Dorothy, a young girl, is knocked unconscious during a tornado. She and her dog Toto are swept up in the storm and dropped into the Land of Oz, where she is told that to get back home, she must follow the Yellow Brick Road and seek out the magical wizard. Along the way, she meets the Scarecrow, the Tin Man and the Cowardly Lion, who join her, hoping to receive what they lack themselves (a brain, a heart, and courage, respectively). Together, they seek out the wizard, only to learn that he has no answers. Ultimately, they are rescued when Glinda the Good Witch of the North points out that all along they had possessed exactly what was needed for happiness. It seems that those dedicated to eradicating type 2 diabetes are on a similar journey. Caroline Trapp explains why.
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Like Dorothy and her fellow travellers, we are seeking a road that will lead us to what is needed: prevention and reversal of obesity and diabetes. Yet the road we have long been travelling has not offered a cure. Increased access to medical care and education, new medications and bariatric surgery (now approved as a treatment option for morbidly obese people with diabetes1 and currently one of the most common surgical procedures in the USA2) have brought us no closer to curing diabetes – or preventing it from occurring in the first place. According to the latest figures from the International Diabetes Federation, more than 300 million people worldwide are living with diabetes, a number that is set to reach half a billion by 2030. If only the Wizard could save us.
slightly more focussed lesson: there’s no place like home’s kitchen. A PubMed search on vegetarian or vegan diets and diabetes shows an increasing amount of research has been devoted to this intervention, with noteworthy results. Reducing or eliminating animal products from the diet is an option that has always been available, yet is just beginning to be recognized for its potential in lowering rates of obesity,3 heart disease4 and certain cancers.5 Population studies confirm that around the globe diabetes was rare among those who ate largely plant-based diets.6 Furthermore, when people from those cultures and countries migrate to wealthy developed countries or adopt a more meat-centric diet, rates of diabetes increase dramatically.6
No place like home’s kitchen But we may have our own version of Dorothy’s ruby red slippers. In the story, after a long and dangerous journey, Dorothy comes to find out that she only needs to click her heels together and say, “There’s no place like home.” And for us, we might heed the same,
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The Adventist Mortality Study demonstrated that vegetarian men in the USA had half the risk of developing diabetes, compared to non-vegetarian men.7 In 2009, a study of 60,903 people showed that the more animal protein in a diet – whether from dairy and eggs, fish, fowl or beef – the higher the risk of diabetes, with an almost 3-fold difference in risk between strict vegetarians and non-vegetarians.8 Processed meat intake (such as hotdogs and lunchmeats) has been found to increase diabetes risk by 40%.9
A low-fat plantbased diet has been determined to be effective for people with type 2 diabetes. Research published in Diabetes Care provides evidence on the effectiveness of a dietary shift for those with diabetes.10 Compared to people following a commonly prescribed, low-cholesterol, portion-controlled diet, those who consumed unrestricted amounts of whole grains, vegetables, legumes and fruit (a vegan or plant-based diet) lost twice as much weight. Among those in both groups who had no medication change, those in the vegan group had a drop in HbA1c that was three times greater; 43% of those in the vegan group were able to reduce their
diabetes medications. Furthermore, the vegan diet was found to be surprisingly acceptable to those who were randomized to it, largely because there were no portion or caloric restrictions and high fibre foods promote satiety. Based on this research, a low-fat plantbased diet has been determined to be effective for people with type 2 diabetes, according to the 2010 American Diabetes Association’s Clinical Practice Recommendations: Standards of Medical Care for Type 2 Diabetes.11 The American Dietetic Association has stated that properly managed vegan diets have been shown to be nutritionally adequate, safe across the lifespan, and effective for preventing and treating many chronic diseases.5 Dietary change is often difficult and many barriers must be overcome for individuals or groups to make and sustain any change in diet, including to a plant-based diet. Clinicians, educational institutions, NGOs and governments can begin by simply promoting information about the effectiveness of this approach. They can encourage people to consume a diet of plant foods and warn of the dangers of consuming animal fat and protein. Home kitchens stocked with the right foods offer real hope. Educational resources of special interest are available to help (see below). With the knowledge already available to us, we can find a better path. The solution to diabetes is not somewhere “over the rainbow.” It may be found in an effective, safe, affordable, and ecologically sustainable nutritional approach: a diet comprised of whole grains, fruits, vegetables, and legumes.
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Caroline Trapp Caroline Trapp is Director of Diabetes Education and Care for the Physicians Committee for Responsible Medicine in Washington, USA (ctrapp@pcrm.org). The Physicians Committee for Responsible Medicine (PCRM) is a USA-based not-forprofit organization. It offers support for healthcare professionals and the general public who want to learn more about or use plantbased nutrition for diabetes, heart disease, weight control, and other health concerns. Diabetes education materials are available at www.PCRM.org/Diabetes.
References 1. S tandards of medical care in diabetes – 2009. Diabetes Care 2009; 32 Suppl 1: S13-61. 2. A nstett P. Experience in bariatric surgery lessens problems. Detroit Free Press. July 28, 2010; A: 5. 3. B erkow SE, Barnard N. Vegetarian diets and weight status. Nutr Rev Apr 2006; 64: 175-88. 4. O rnish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA 1998; 280: 2001-7. 5. C raig WJ, Mangels AR. Position of the American Dietetic Association: vegetarian diets. J Am Diet Assoc 2009; 109: 1266-82. 6. C ampbell TC, Campbell TM. The China study : the most comprehensive study of nutrition ever conducted and the startling implications for diet, weight loss and long-term health. 1st BenBella Books. Dallas, 2005. 7. S nowdon DA, Phillips RL. Does a vegetarian diet reduce the occurence of diabetes. Am J Public Health 1985; 75: 507-12. 8. T onstad S, Butler T, Yan R, Fraser GE. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care 2009; 32: 791-6. 9. A une D, De Stefani E, Ronco A, et al. Meat consumption and cancer risk: a case-control study in Uruguay. Asian Pac J Cancer Prev 2009; 10: 429-36. 10. B arnard ND, Cohen J, Jenkins DJ, et al. A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes. Diabetes Care 2006; 29: 1777-83. 11. S tandards of medical care in diabetes – 2010. Diabetes Care 2010; 33 Suppl 1:S11-61.
Editor's note: Users of any restrictive diet should check that they are consuming sufficient essential nutrients, especially true for children, and pregnant and lactating women. Pure vegan diets may need fortification or supplements to ensure adequate intake of calcium, selenium, iodine, B12, Vitamin D and perhaps riboflavin.
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Clinical CARE
Diabetes education for people with type 2 – a European perspective Monika Grüsser
Therapeutic diabetes education is a prerequisite for the effective management of type 2 diabetes. Yet in several European countries, diabetes education remains insufficiently implemented. While effective educational programmes have been developed and evaluated in a number of countries, funding for implementation is still inadequate. Although improvements have been made in recent decades, there is still a long way to go to meet the Europe-wide need for diabetes education. Monika Grüsser reports on some developments to date.
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The first physician to introduce diabetes education for people with type 2 diabetes was Apollinaire Bouchardat. In his book Le Diabète Sucré, published in 1883, he was the first to promote self-testing of urine for glucose as a basis for treating people with type 2 diabetes. He described the daily measurement of glycosuria as being ‘like the compass that guides the sailor on unknown oceans’.1 Bouchardat's approach was to ask people with type 2 diabetes to follow a lowcalorie diet and exercise more until their blood glucose values improved – a method that is as valid today as it was in the 19th century.
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Nowadays, diabetes education programmes are popular with patients and physicians alike.
During the first half of the 20th century, relatively little effort was made by researchers to examine the best approaches to the implementation of diabetes education. However, in some countries diabetologists actively promoted and practised diabetes education. RD Lawrence was one of the first advocates of diabetes education. Co-founder (together with the author HG Wells) of the British Diabetic Association (now Diabetes UK) and founder of the first diabetes department in King’s College Hospital, London, his book The Diabetic Life: Its Control by Diet and Insulin is a manual for practitioners and people with diabetes and one of the rare examples of a medical publication penned with both physicians and patients in mind. Robert Lawrence – Robin as he was popularly known – promoted diabetes education and strived for selfmanagement as the ultimate objective
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for people with diabetes. A founding and Honorary Member of the European Association for the Study of Diabetes (EASD), Lawrence was well aware of the significance of diabetes education, which has since been proven to be the catalyst for successful diabetes therapy.
Assal structured diabetes education with the help of educational specialists and made it an integral part of care. Nonetheless, it was Jean-Philippe Assal who succeeded in introducing the essential role of patient education in the therapeutic approach to diabetes. In the 1970s, Assal established the first diabetes teaching and treatment unit at the University of Geneva. He decided to structure diabetes education with the help of educational specialists and
make it an integral part of care. He transformed the diabetes department of the University Hospital into a specialised educational unit offering a fiveday diabetes education and management programme. People with diabetes were instructed as outpatients on how to manage their diabetes independently. Many young diabetologists from all over Europe participated in these courses and consequently informed their superiors of the need to reform diabetes units. This was one of the driving forces behind the foundation 40 years ago of the Diabetes Education Study Group of EASD. Where do we stand today? Germany Major advances in diabetes education have been seen in many countries. In Germany, for example, educational programmes for people with diabetes and hypertension have been an integral part
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of the healthcare system for many years. General practitioners and their personnel are required to undertake a special two-day postgraduate course. Since 1991, trained office-based physicians have been providing structured treatment and teaching programmes for outpatients with diabetes and/ or hypertension.
companies reimburse approximately 700 EUR per course. As in Germany,
Nowadays, with the nationwide implementation of disease management programmes for diabetes and coronary heart disease, these programmes have become increasingly popular with patients and their physicians alike. Remuneration amounts to 130 EUR per person with type 2 diabetes and/ or hypertension (upon completion of the two-day postgraduate course). In Germany, treatment and education for people with type 2 diabetes must be provided at the primary healthcare level and is paid for by the compulsory healthcare insurance. The prerequisite for programme endorsement by the health authorities is the publication of a scientific evaluation proving the merit of the programme. There are no nationwide statistics on the use of these programmes but it can be estimated that over the last 10 years more than 1.7 million people with diabetes have participated.
the prerequisite for remuneration to general practitioners is the completion of a special two-day postgraduate course provided by diabetologists.1
practitioners, diabetologists and nonmedical professionals. All volunteers received one-day training and physicians were instructed to organise several group education sessions. The authors were able to detect any improvements in diabetes knowledge, which, in turn, resulted in a more positive approach to managing diabetes and improved metabolic control. Nevertheless, a nationwide remuneration policy for diabetes education in France remains underdeveloped in comparison to some of its European counterparts.2
In Austria and Germany, completion of a special course provided by diabetologists is the prerequisite for remuneration.
Austria In several regions of Austria, remuneration has been implemented since the year 2000 of structured treatment and teaching programmes for people with type 2 diabetes at the primary healthcare level. The health insurance
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France Much effort has been made in France to improve the standard of diabetes education. A project published in 2008 evaluated the feasibility and advantages of a group education programme in private practices for people with type 2 diabetes. This programme was initiated by a multidisciplinary group of volunteer healthcare providers, including general
Italy Many years ago, the Italian parliament passed a law which made the provision of diabetes education compulsory. In principle, this was a very positive step. However, consideration was not given to the substantial financial investment that is required to implement such legislation. Portugal The Associação Protectora dos Diabéticos de Portugal is the oldest diabetes association in the world. The
Teaching material for five programmes used in Germany.
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Associação has a unique model for care and education. The largest outpatient clinic in Portugal is owned by physicians and people with diabetes themselves. This centre is by far the largest healthcare provider for people with diabetes in Portugal and possibly Europe. Every year, the centre has a turnover of some 35,000 outpatients and more than 13,000 inpatients. The care provided includes structured treatment and teaching programmes as well as specialised attention for people with complications. The centre is supported by the national healthcare system and is a model for individualised diabetes care. It also includes numerous activities for specialist diabetes training among primary care physicians, nurses and dietitians.
Diabetes education remains an unmet need in Europe. Sweden In the Scandinavian countries, the healthcare system is organised principally by the state. A recent report demonstrated that at the primary healthcare level in Sweden, diabetes education has been implemented effectively. Data from 485 Swedish primary healthcare centres and over 90,000 people with diabetes were reported to the National Diabetes Register in 2008 and the data were published in 2009. According to the authors of the report, improvements are still needed in diabetes education at the primary healthcare level.3 United Kingdom Increasingly in the UK, diabetes education programmes for people with type 2 diabetes are developed and evaluated scientifically. A recent effort is the publication of the DESMOND programme in the British Medical Journal.4
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The programme consists of a structured six-hour course performed by two health professionals either in one-day or in two half-day sessions. People with diabetes and family members or friends can be provided education together. The programme, evaluated in a randomized controlled trial, showed improvements in understanding of diabetes and reductions in cases of depression. People who had received diabetes education smoked less and achieved greater weight loss. Importantly, the programme was found to be a cost-effective tool in the management of diabetes. Outstanding unmet needs There is not enough space to discuss the current status of educational programmes for people with type 2 diabetes in all European countries and the numerous Europe-wide scientific efforts to further improve educational approaches. Healthcare providers with an interest in this area can contact the Diabetes Education Study Group of EASD (diabetes.education@desg.org). People with diabetes and diabetes representative organisations should advocate alongside diabetes healthcare providers to obtain increased support from health authorities. The comprehensive implementation of diabetes education remains an outstanding unmet need in countries throughout the continent.
Monika Grüsser Monika Grüsser is Vice Director of the European Association for the Study of Diabetes.
References 1 P ieber TR, Holler A, Siebenhofer A, et al. Evaluation of a structured teaching and treatment programme for type 2 diabetes in general practice in a rural area of Austria. Diabet Med 1995; 12: 349-54. 2 B oegner C, Fontbonne A, Gras Vidal M-F, et al on behalf of the Diab Educ association: Evaluation of a structured educational programme for type 2 diabetes patients seen in private practice Diabetes Metab 2008; 34: 243-9. 3 A dolfsson ET, Smide B, Rosenblad A, Wikblad K. Does patient education facilitate diabetic patients' possibilities to reach national treatment targets? A national survey in Swedish primary healthcare. Scand J Prim Health Care 2009; 27: 91-6. 4 D avies MJ, Heller S, Skinner TC, et al. Effectiveness of the diabetes education for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ 2008; 336: 491-5.
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Preventing diabetes avenues and alleyw and cities as exerci Avi Friedman
The global obesity epidemic is already staggering – and it keeps on growing. In Canada, for example, one person in five is overweight and nearly one in 10 is obese – a two-and-a-half-fold increase over the past two decades. Moreover, obesity rates among children in Canada have almost tripled in the past 30 years. Our societies are transforming previously healthy children into generations of adults who in future decades will suffer widespread chronic ill-health and overpopulate hospital wards. Efforts to curb the trend have been largely unsuccessful. Avi Friedman looks at the environmental factors associated with the rise in obesity in suburban areas and calls for coherent and realistic steps to provide healthful surroundings for young people in particular.
A recent New York Times article suggested that in the USA, despite attempts by some states to tax soft drinks, promote farm stands, require healthier school meals and mandate caloric information in fast-food restaurants, rates of obesity are still growing. The article goes on to report that an estimated 72.5 million adults are obese (according to recent data published by the Center for Disease Control and Prevention). Obesity costs the US healthcare system a whopping 147 billion USD every year.1 The medical consequences are well documented. Overweight and obese people run a five-fold risk of developing type 2 diabetes and have greater risk of hypertension, gallbladder disease and certain cancers. The overall risk of mortality increases two and half times.2 The rise of the effort-free ‘modern’ lifestyle So why do waistlines keep expanding? The common tendency is to blame people’s poor dietary choices, made worse by their inactivity. Only recently
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in the ays – homes se machines has attention been given to a critical issue: our built environment has been progressively altered to curtail physical activity, even among those who wish to be active. Over the past century, we have planned communities, built homes and welcomed lifestyles that allow us to live and work while burning fewer and fewer calories.
Our built environment has been progressively altered to curtail physical activity, even among those who wish to be active. The motor vehicle and suburbia stand out as principal culprits of our effortfree habits. Some 65% of all North Americans live in suburban or rural locations, where nearly all work, shopping, social, educational and entertainment-related activities require every member of the household to use a private car. We have reduced walking to a bare minimum.
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Urban planning, sedentarism and social alienation Low residential density, the mark of most new suburbs, creates a situation where basic services and amenities that could potentially get people active are not economically viable. There are not enough passengers to justify the provision of public transport and not enough shoppers to support a corner grocery store, for example. In terms of the public health implications of town planning decisions, things have gone from bad to worse.
their traditional location in the heart of the neighbourhood to the outskirts where they can be accessed more easily by residents of several communities – by car. That means that pupils can no longer reach school with a short walk or an easy bike ride. Unfortunately also, the school time allocated to physical activity has also been sharply reduced. In Canada, this stands at one hour per week, far less than that needed to allow a child to burn the number of calories appropriate to their age and stage of physical development. Small play areas near homes have also found their way into the municipal waste basket. Once again, in the name of efficiency, developers argued that there is no longer a need for back lanes where children once played and through which they safely reached a friend in a neighbouring home. Numerous small play yards, known as ‘parkettes’, have been replaced by a huge playing field, to which children have to
In the name of efficiency, schools have been relocated from
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be driven. Play itself has been morphed into regimented leagues with strict schedules. Spontaneity, unfortunately, has been sucked out of children’s play. It is no wonder that watching television and playing computer games has replaced outdoor play. Studies suggest that watching television is the primary leisure activity among young people in North America – an average of up to 2.5 hours a day. Significantly also, some of this time includes watching advertising for high-calorie foods.3
In terms of the public health implications of town planning decisions, things have gone from bad to worse. Another casualty of contemporary suburban planning was the pavement or sidewalk. Since no one walks, some argued, why even bother to provide for pedestrians? Children, older people and parents pushing a pram were forced to share the road with motorists, often putting their lives at risk. Stepping out for a simple healthy walk became uncomfortable. No need to lift a finger – at work or at home! Our work places have not fared much better. Whereas in the early decades of the 20th century the manufacturing and agricultural sectors were the principal employers, service jobs now account for the lion’s share of all employment in the developed world and increasingly in developing countries. The work environment offers little opportunity for physical activity. Workplaces are reached by private cars; a lift is likely to be the first thing that one sees entering an office building lobby. Hard-to-find stairs have been shoved aside and made to function only in case of emergency.
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At home, physical activity has also experienced a sharp decline. When asked, most people will rather reside in a dwelling with fewer stairs, limiting a dose of essential healthy exercise. Many families have acquired effort-free tools, like mechanized lawn mowers or snow blowers. The kitchen has become a store for mechanical devices and electrical utensils which have replaced domestic manual labour. We are spending fewer and fewer calories outside as well as inside the workplace.
We are spending fewer and fewer calories outside as well as inside the workplace. An urban planning response to obesity So, how should we encourage people to become active? The simple answer is to recast in our built environment the features that, over the past half a century, have been taken out. Homes and cities must be regarded as exercise machines. Several strategies need to be placed at the top of planning agendas. Higher- and medium-density communities of greater than 62 units per hectare (25 units per acre) need to be encouraged. It has been demonstrated repeatedly that urban dwellers are more active than their suburban counterparts. Once higher density communities have been built, commerce will also become economically viable. Efficient public transit must be part of every community. Frequent buses during rush hours, covered shelters and clearly displayed schedules may encourage motorists to leave their cars behind and use public transit. Taking back the streets Pedestrians and cyclists must be given priority in all road designs. Slowing traffic, changing the road surface and enlarging pavements are some of the means to help
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make streets people-friendly. Walkable communities need to allow residents to reach every spot in a comfortable 10-minute walk. Bicycles for rent, a growing practice around the world, need to be part of the day-to-day activity of every neighbourhood. It has been demonstrated that obesity rates among children decline when (bicycle) riding time increases. Homes should be built next to or facing play yards so that parents are able to keep a watchful eye on their children. Whenever possible, schools should be placed at the centre of the community and their recreational areas open to the public. Community urban agricultural gardens need to become a valued feature of public green spaces. In addition to growing nutritional food, residents can be active tending to their gardens. When squares and parks are planned, they can be equipped with adult exercise machines. The municipality can appoint a fitness instructor and schedule for those who wish to engage in group activities. The practice of planning neighbourhoods with identical large, single-family homes should be avoided; mixed types of dwellings can accommodate all sorts of residents – young and old. Children should be able to take a leisurely stroll or bike ride to visit their grandparents’ home.
Officials are finally recognizing the link between poor urban planning and its unhealthy consequences. A master plan for healthy living The tide is beginning to turn. Elected and public health officials are finally recognizing the link between poor urban planning and its unhealthy consequences. In recent years, I have consulted established
towns and designed new ones based on the principles of active living. In Stony Plain, Alberta, Canada, we configured a ‘master plan’ for healthy living. Organic models of growth ensure that the town centre could be reached by walking or safe cycling from every home. Pavements, bike paths and traffic-calming features are an integral part of every street. Places for commerce have been allocated in every neighbourhood. A new civic square that functions as a neighbourhood meeting place has been introduced in front of the town hall. Free shuttle buses that reach all neighbourhoods have been proposed and a series of green open spaces have been connected to provide a secondary, more leisurely way of moving around. Mixed types of dwellings, some with commerce on their ground floor, are now an urban reality. It takes time to bring about changes in town planning. Convincing elected officials about the need to invest in health promotion is not simple. However, we must work with urgency to make our case. If we fail to do so, the consequences for people, their communities and nations will be costly – economically, socially and in terms of human suffering. Avi Friedman Avi Friedman is a Professor of Architecture at McGill University in Montreal, Canada, and is the President of Avi Friedman Consultants, Inc. His latest book, A Place in Mind: The Search for Authenticity was published by Vehicule Press. He can be reached at avi.friedman@mcgill.ca.
References 1 S inger N. Fixing a World that Fosters Fat. The New York Times 2010; 22 August: 3. 2 W illet WC, Dietz WH, Colditz GA. Guidelines for Healthy Weight. N Engl J Med 1999; 341: 427-34. 3 L arson RW. How US Children and Adolescents Spend Time: What It Does (and Doesn’t) Tell Us About Their Development. Current Directions in Psychological Science 2001; 10: 160-4.
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Green shoots of hope in US schools – strategies for success in the battle against childhood obesity Francine Kaufman
There is currently an epidemic of childhood obesity in the USA. Data from the National Health and Nutrition Evaluation Surveys from 1963-65 until the present, show that obesity has increased three- to fourfold, so that now 16% of American children are obese (as assessed by body mass index (BMI) greater than the 95th percentile for age and gender) and a third are above the mark to be considered overweight (greater than the 85th percentile). This has fuelled an epidemic of type 2 diabetes in young people. According to the US Centers for Disease Control and Prevention, one in three children born in 2000 will have diabetes sometime in their life and it is likely the current generation of children will not live as long as their parents. And the USA is not alone; many other countries are also facing marked increases in childhood obesity rates.
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Diabetes in society
If obesity could be prevented, type 2 diabetes – and many other chronic diseases – would become rare. Obesity can be avoided by consuming the correct amount of nutrient-dense calories and burning the requisite amount of energy through physical activity, growth and metabolism each day. But for vast numbers of children and adolescents, this is not achievable. Children do not control
what is available to them in their environment. Unfortunately, many young people live in families, inhabit neighbourhoods, reside in countries and go to schools where it is very difficult to adopt healthy lifestyle habits. Over recent decades, a large body of research has focused on both nutritional intake and physical activity – attempting to understand the contribution to the childhood obesity epidemic of individual factors: genetics, family influences, fast-food restaurants, junk food, oversized portions, food additives, food advertising, vending machines, sugar-sweetened beverages, television and computer games. Perhaps the most exciting area of investigation has involved schools and how school programmes and policies affect our children’s health. In most places in the world, schools are charged not only with giving children a basic education, but with feeding them, giving them the opportunity to be physically active and teaching them the principles of health. To be able to coordinate these important missions, the US government in 2004 passed the Child Nutrition and WIC Reauthorization Act, which requires that all schools develop a wellness policy to address goals for nutritional education and physical activity, ensure that government-sponsored school meals meet the minimum recommended nutritional standards, and
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follow guidelines on all other foods and beverages served in school. It has been felt for some time that these other foods and beverages – known as competitive foods because they compete with the government programme – displace nutrients and add calories to our children’s choices.
Schools are charged with feeding children and giving them the opportunity to be physically active. Forcing schools to have a coordinated wellness policy has been critical in creating a healthy environment for students. The 2007-2008 Bridging the Gap school survey, conducted by the Robert Wood Johnson Foundation, showed that 89% of public elementary school students in the USA attended a school with a wellness policy in place.1 Schools with a wellness policy were more likely to meet the nutritional and physical activity goals mandated by the government. For example, 54% of schools with a wellness policy had goals for nutrition education compared to 9% of schools without a policy; 65% of schools with a wellness policy had physical activity goals compared to 38% of schools with no policy; 49% of schools with a wellness policy had nutrition guidelines for competitive foods compared to 20% of schools without a wellness policy.1 Policies should be in place to ensure that the food and beverages served to children in schools meet optimal standards. In the USA, this means that schools should comply with the mandates of the federal government in the National School Lunch Program (28 million children served daily) and the
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Diabetes in society
School Breakfast Program (8 million children served daily) with regards to total calories, caloric distribution and nutrient quality.2 Unfortunately, surveys have shown that these standards are not always met. For example, although the federal standards mandate that the fat content of meals should not to exceed 30% of total calories, this is routinely exceeded by at least 10%.2
Schools should develop strategies to encourage children to participate in standardized meal programmes. However, on the positive side, most studies have shown that students participating in the school lunch programme consume a more nutritious lunch than those who either bring lunch from home or buy lunch from the school snack bar. 2 Therefore, schools should develop strategies to encourage children to participate in standardized meal programmes. Improving the physical characteristics of the cafeteria and how the food is presented, reducing the time waiting in queues and giving students the opportunity to participate in decisions about meals have all been assessed and have shown promise as strategies to enhance participation in the federal food programmes.
to ban the sale of soft drinks in 20022003.3 The main barrier to the initial adoption was the concern on the part
not significant. When a controlled study demonstrated the effectiveness of reducing the consumption of soft drinks as a means of controlling the rate of weight gain in children,4 almost all schools in the USA banned the sale of sugar-added soft drinks. In addition, many schools have expanded this ban to include all junk foods, including sweets and chocolate and fried chips.
Recommendations now exist for increased physical activity every year, throughout the year.
Prohibiting of the sale of sugar-added soft drinks was perhaps one of the most successful strategies used to reduce empty calories in schools. The Los Angeles Unified School District, which has over 800,000 students, was one of the first large school systems
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of schools that they would lose money because selling soft drinks had become a revenue-generating option. There was also the issue of removing choice for children. However, thanks to the bold steps taken by the Los Angeles Unified School Board and the Superintendent of Schools, it was shown that the reduction in revenue from banning soft-drink sales was
Increasing physical activity in school is likely to be as important as reducing calorie consumption. This is particularly important given that during the period between 1980 and 2000, adolescents in the USA reduced their level of physical activity by 13%.5 A few years ago, only 8% of
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elementary schools and 6% of middle and high schools provided physical education for the entire school year.5 Recommendations now exist for increased amounts of physical education and physical activity every year and throughout the school year, and to develop physical education and after school programmes designed not to train students to be future athletes, but to motivate children to be fit and active for life. Reversing the trends in physical inactivity and unhealthy eating requires the coordinated efforts of school administrators, policy makers, teachers, parents and students. The basic principles – some proven, some intuitive – include the following: apply the principles outlined in the US Dietary Guidelines for Healthy Eating (www.health.gov/dietaryguidelines) i ncrease offerings of fruits, vegetables and salad bars, consider school gardens and farm-to-school programmes increase offerings of whole grains and fibre avoid offering beverages with calories – including sugar-added soft drinks, sugar-added sports drinks and juices
o ffer only low-fat or non-fat dairy products o ffer healthy snacks and avoid excessive portions schedule physically activity, recess or physical education for every student, every day, every year – 150 minutes of physical education per week and recess up to 20 minutes per day for elementary school encourage children to reduce the amount of time spent in sedentary activities, such as watching television or playing video games, to less than two hours per day d evelop safe ways for children to walk to school through supervision, designated drop-off areas and creating ‘walking school buses’ (simply a group of children walking to school with one or more adults) e ncourage school personnel to be good role models for children p rovide a safe environment for children and their friends to play actively after school and have this as a component of school-sponsored child care a void the use of food as a reward and never withhold food as punishment do not use the sale of junk food, including sweets and chocolate and soft drinks, for school fundraising.
Francine Kaufman Francine Kaufman is Distinguished Professor Emerita of Pediatrics and Communications at The Keck School of Medicine and the Annenberg School of Communication. She is Chief of the University of Southern California and Childrens Hospital Los Angeles and Medical Officer, VP of Global Medical, Clinical and Health Affairs, Medtronic Diabetes.
References 1 T urner L, Chaloupka FJ, Chriqui JF, Sandoval A. School policies and practices to improve health and prevent obesity: National elementary school survey results: School years 2006-07 and 2007-08. Vol 1. Bridging the Gap Program, Health Policy Center, Institute for Health Research and Policy. University of Illinois at Chicago. Chicago, 2010. www.bridgingthegapresearch.org 2 K oplan JP, CT Liverman CT, Kraak VA, eds. Preventing Childhood Obesity: Health in the Balance. Institute of Medicine. Washington DC, 2005: 237-84. 3 K aufman FR. Diabesity. Bantam Dell. New York, 2005. 4 J ames J, Thomas P, Cravan D, Kerr D. Preventing an increase in childhood obesity by reducing consumption of carbonated soda: cluster randomised controlled trial. BMJ 2004; 328: 1237. 5 A ugust G, Fennoy I, Kaufman FR, et al. Prevention and treatment of pediatric obesity: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2008; 93: 4576-99.
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East meets west in st 21 Century Arabia – welcome to Dubai! Dubai is all set to welcome the International Diabetes Federation World Diabetes Congress in December 2011. The emirate is looking forward to the opportunity to demonstrate its credentials as an excellent congress location that offers the very best of facilities, easy access, a state-of-the-art expansive infrastructure and, above all, a culture of hospitality that will provide a memorable congress experience to delegates and exhibitors alike.
Located between Europe and Asia Pacific, Dubai really is the meeting point between east and west. Dubai is one of seven emirates that make up the federation known as the United Arab Emirates (UAE). It is home to a third of the UAE population – 1.8 million people and growing. Safety first Dubai has been rated by Interpol as one of the safest cities in the world. The Dubai police have a department dedicated to ensuring tourist safety. The majority of travellers are not impacted by any crime. Congress delegates will have access to state-of-the-art health facilities and, should the need arise, paramedics are on duty in most hotels. Tolerant and welcoming The UAE’s national language is Arabic. However, English is widely spoken throughout Dubai, and appears on all street signs, so delegates should have no problems travelling around the city. The UAE is tolerant and welcoming; foreigners are free to practise their own religion. Alcohol may be consumed at home, in hotels and on
licensed club premises. The dress code is generally conservative, however: beachwear and warm-weather attire is permitted only in appropriate areas. Simply be aware of those around you and dress accordingly – as you would in any other country. Heritage and tradition Dubai’s culture is rooted in the Islamic traditions of Arabia. The UAE’s rulers are committed to safeguarding their heritage against the cultural erosion associated with rapid socio-economic development. We are keen to promote cultural activities that are representative of our traditions, including falconry, camel racing and dhow sailing. Arabic poetry, dancing, songs and traditional art are all encouraged. Travelling to Dubai Dubai is easily accessible by several airlines – primarily through the expanded services of Emirates Airlines. Dubai International Airport offers flights to more than 200 destinations on over 120 airlines, with new routes being launched throughout 2011. Flights, hotels, meeting venues and local
culture are at the core of any successful international congress. In Dubai we deliver all of these and more – and we pride ourselves on the additional infrastructure that brings all of this together. The new metro system offers speedy, affordable, hassle-free access from Dubai International Airport to more than 10,000 hotel rooms and, of course, the Dubai International Convention and Exhibition Centre, the World Diabetes Congress venue. Everyone travelling to the UAE must have a passport valid for at least six months from the date of entry. There are several country residents who do not require visas to enter the UAE. For a complete up-to-date list and for further information, please visit www. dnrd.gov.ae.
rward Dubai is looking fo to a successful ress. World Diabetes Cong r! See you in Decembe
early Register t from to benefi fees reduced ential r e f e r p d an es. hotel rat
Don’t miss the chance to help shape the future of diabetes. February 2011
Opening of online abstract submission/grant application
20 April 2011
Deadline of online abstract submission/grant application
17 June 2011
Deadline early registration www.worlddiabetescongress.org