Diabetes Voice by International Diabetes Federation

Global perspectives on diabetes

Volume 58 â&#x20AC;&#x201C; June 2013

Staying healthy in todayâ&#x20AC;&#x2122;s world

50 DiabetesVoice

Contents

Diabetes Views

News in Brief

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

T H E G LOBAL CA M PAI G N The IDF perspective: reforming the global food system to tackle diabetes and obesity

This publication is also available in French and Spanish.

The International Diabetes Federation

Understanding the complex nature of diabetes

Diversity, debate and new directions

Jonathan Shaw

Mark Cooper and Sophia Zoungas

Breaking down barriers and living your dreams…with diabetes

João Valente Nabais

Why health matters to human development

Health Cities report

Helen Clark

h e a lt h d e l i v e r y Good things come in pairs: the Cambodia-Korea Twinning Project

Bong Yun Cha and Touch Khun

Gestational diabetes – an update from India

Arivudainambi Kayal, Ranjit Mohan Anjana and Viswanathan Mohan

CLINICAL CARE Guidelines for type 2 diabetes - designed to help newly diagnosed children and adolescents

W.A.S.H. away the world’s dietary salt

Warren Lee and Stuart Brink

Elizabeth Snouffer

Debate: how low can you go? The low-down on the low carbohydrate debate in type 1 diabetes nutrition

Anthropometric indicators of obesity for identifying cardiometabolic risks in a rural Bangladeshi population – Chandra Diabetes Study

Akhtar Hussain, A K Azad Khan and Bishwajit Bhowmik

DIABETES IN SOCIETY Voices of type 1 diabetes: doing my best each and every day

June 2013 • Volume 58 • Issue 2

International Diabetes Federation Promoting diabetes care, prevention and a cure worldwide

Editor-in-Chief: Rhys Williams, UK Managing Editor: Isabella Platon, isabella.platon@idf.org Editor: Elizabeth Snouffer Advisory group: Pablo Aschner (Colombia), Ruth Colagiuri (Australia), Patricia Fokumlah (Cameroon), Attila József (Hungary), Viswanathan Mohan (India). Layout and printing: 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 – isabella.platon@idf.org

© International Diabetes Federation, 2013 – All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permission of the International Diabetes Federation (IDF). Requests to reproduce or translate IDF publications should be addressed to the IDF Communications Unit, Chaussée de La Hulpe 166, B-1170 Brussels, by fax +32-2-5385114, or by e-mail at communications@idf.org.

The information in this magazine is for information purposes only. IDF makes no representations or warranties about the accuracy and reliability of any content in the magazine. Any opinions expressed are those of their authors, and do not necessarily represent the views of IDF. IDF shall not be liable for any loss or damage in connection with your use of this magazine. Through this magazine, you may link to third-party websites, which are not under IDF’s control. The inclusion of such links does not imply a recommendation or an endorsement by IDF of any material, information, products and services advertised on third-party websites, and IDF disclaims any liability with regard to your access of such linked websites and use of any products or services advertised there. While some information in Diabetes Voice is about medical issues, it is not medical advice and should not be construed as such.

ISSN: 1437-4064 Cover photo : © YinYang | istockphoto.com

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Diabetes views

From words to action

The work of our Federation depends crucially upon our volunteers who give unstintingly of their time and expert knowledge, serving the cause of diabetes selflessly, whether in Member Associations, or IDF’s Board, Task Forces, Consultative Sections and expert working groups. Their contribution is hugely appreciated and will never be taken for granted.

As the authentic global voice of diabetes, the International Diabetes Federation (IDF) has achieved much in fixing diabetes firmly on the international political agenda. Diabetes and other Non-communicable Diseases (NCDs) are now recognised as leading threats to development in the 21st century and to the success of the United Nations’ ambition to eradicate poverty. But our work is very far from over. We showed determination in securing the UN Resolution on Diabetes, we were resolute in our campaigning for the UN High Level Meeting on Non-Communicable Diseases. Now we must remain determined to ensure that political promises turn into practical action on the ground to help people living with or under the threat of diabetes.

At the World Health Assembly in Geneva last month, the world’s governments agreed a framework of time-bound targets for NCDs, including a breakthrough for IDF: the commitment to halt the rise in diabetes. I am not alone in considering this target to be the other side of ambitious. With literally hundreds of millions with IGT or early evidence of the metabolic syndrome, the conveyor belt of new cases of diabetes will grind on relentlessly. Better care and treatment should mean that people with diabetes live longer, thus increasing the total number of those with the disease. Halting the rise in diabetes will be a colossal challenge, and will require huge commitment by governments in effective primary prevention measures.

One such magnificent volunteer was Professor Harry Keen who died in April. His illustrious career is briefly summarised in an obituary in News in Brief. A fellow trustee of Diabetes UK, I learned much from Harry, especially how much the committed volunteer could achieve for people with diabetes. He embodied all the virtues of the volunteer for diabetes, and we will miss his influence and passion, as well as his undiminished wit and wisdom. Diabetes Voice is the collaborative work of all its expert volunteers and local champions. On behalf of the board of IDF, I thank our network of tireless contributors who are at the core of this magazine’s success. In welcoming Elizabeth Snouffer as editor, I also thank Tim Nolan for his outstanding contribution over eleven years. Finally, I’d like to remind our readers about the World Diabetes Congress in Melbourne from 2-6 December 2013. Professor Paul Zimmet has assembled a brilliant international faculty, with new Streams, and important announcements will be made in Melbourne. The Convention Centre is outstanding, and in addition to the thousands of clinicians, healthcare professionals and representatives of Member Associations, we shall be joined by a new cohort of Young Leaders in Diabetes and Parliamentary Champions for Diabetes. It may be quite a long way to travel, but the Congress will certainly be worth attending! I’ll look forward to seeing you there.

IDF is currently working on a powerful tool to help our Member Associations in every region monitor the progress of their governments against their promises made in Geneva. The Diabetes Scorecard will be launched later this year. The Board of IDF and I are passionate about strengthening our regions and providing member associations with the tools to do ever more for people with diabetes. So I am delighted that IDF’s regional focus will be reflected in Diabetes Voice which is a powerful channel for linking and learning about the challenges we face and the successes we achieve nationally across all IDF regions. IDF’s number one publication also ensures the experience of living with diabetes cannot be ignored. Diabetes Voice will report on news and information from all parts of the world, and will discuss IDF’s progress and challenges related to the disease burden. Diabetes Voice will continue to inform members about key diabetes issues related to advocacy, society, technology and clinical development. Most significantly it will focus on the delivery of critical services for people affected with diabetes regardless of where they may live in the world. My hope is that there will be an abundance of success and trailblazing efforts to report in this triennium, 2013-2015.

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Michael Hirst President, International Diabetes Federation

June 2013 • Volume 58 • Issue 2

Diabetes views

Welcome to this, the second issue of Diabetes Voice for 2013. It has some new features. Let me tell you about some of them.

In this issue …

First, in News in Brief, we have a section entitled On the bookshelf. Here we will be listing, in each issue from now on, some recent or forthcoming publications which you may like to take a look at as items for your diabetes bookshelf, real or virtual. A plethora of diabetes publications appear constantly and we cannot hope to update you on more than a fraction of them but we will select a few that have caught our eye. All of them will be new and some will pertain specifically to the content of the issue. Also mentioned in News in Brief are pointers to some articles from the official journal of IDF, Diabetes Research and Clinical Practice (DRCP). From now on we will be featuring a selection of recent DRCP content. The articles selected will almost always be from the ‘Free Featured Articles’ section of the DRCP website (www.diabetesresearchclinicalpractice.com) and are, therefore, accessible to all in their fully published form. An exception to this, in this issue, is the article on gestational diabetes which is featured because of particular relevance to our article on that subject from India. Further on in this issue you’ll find a debate. We have invited two individuals from the diabetes world each to set out succinctly and in plain language, either the ‘pro’ or the ‘con’ argument for a given topic, in this case the option of the low carbohydrate diet in the management of type 1 diabetes. The aim here is to present and clarify both sides of this important issue. As time goes on we will be interested in how successful or otherwise we have been in this ‘head to head’ debate approach. Your comments on this and future debates can be sent to: diabetesvoice@idf.org. We now have a new member of the Diabetes Voice Editorial Team – Elizabeth Snouffer. Elizabeth is a freelance journalist and consultant based in Singapore. Among many other activities, she has created and is the main contributor to www.diabetes24-7.com - a website ‘dedicated to global news and information for people living with T1 and T2 diabetes’. Check it out for yourselves! Her insight into the day to day issues of living with diabetes is based on personal experience. She has herself been living with type 1 diabetes for 36 years. Welcome to the Team, Elizabeth! This issue continues to feature information about the forthcoming World Diabetes Congress in Melbourne. At Melbourne the sixth edition of the IDF Diabetes Atlas will be launched. In addition to updates of diabetes prevalence and mortality statistics, and much more, this edition will include, for the first time, estimates of the global occurrence of gestational diabetes mellitus (GDM). The current burden of this form of diabetes in India and, in particular, in Tamil Nadu is reviewed in this issue in an article from our Chennai colleagues. Despite considerable recent work on GDM including the revision of authoritative guidelines, there is still no clear global consensus on the best methods of definition and early detection of the condition. As our Chennai colleagues report, the situation on the ground is by no means totally satisfactory in terms of prevention, detection, management and continued surveillance of GDM – to the detriment of the health of both mothers and their babies.

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The article by Akhtar Hussain and colleagues is also from the South East Asia Region of IDF. Its message, however, like that of the GDM article, is applicable on a global scale. Hussain et al’s message might be summed up by that old adage 'to all questions there is a simple answer and that simple answer is usually wrong'. For us to adopt the same anthropometric cut-off points for obesity and other conditions vitally connected with diabetes would be a mistake. It is clear that, as previously thought, we need different cut-off points for different ethnic groups but, not only that, different anthropometric measures have different relationships to different cardiometabolic risk measures – type 2 diabetes, hypertension, dyslipidemia and the metabolic syndrome. A topic which would benefit from a higher profile in the world of diabetes is that of dietary salt. We take in much more NaCl (sodium chloride) than we need. How strong is the evidence that it is harmful to our blood pressure? How strong is the evidence that, if we reduce this intake, we will benefit in relation to the prevention of hypertension and to the treatment of established hypertension? Reducing salt intake is not just a simple matter of not adding it at the table. Much of our intake is already wrapped up in our foods, particularly processed foods. World Action on Salt and Health (W.A.S.H.), chaired by Professor Graham MacGregor, aims to bring these issues to our attention and reduce our intake of salt. These and other important topics are featured in this Diabetes Voice issue. Please read on and, should you wish to bring any comments on current or future Diabetes Voice content to our notice, then email us at diabetesvoice@idf.org.

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

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News in brief

World Diabetes Day 2013

Diabetes: protect our future

Activities will be organised to strengthen public awareness about diabetes as a serious health threat. The campaign will also reinforce how even small and simple actions can make a difference and help to achieve meaningful outcomes for people with diabetes and those at risk.

IDF will be encouraging everyone to Take a Step for Diabetes, thereby engaging people in the diabetes community to make a symbolic donation of steps accrued through various activities. A step is considered to be any activity that helps promote diabetes awareness, improve the lives of people with diabetes, promote healthy lifestyles or reduce individual risk of developing diabetes. All steps are submitted on a custom online platform where the total number of steps will be counted and targeted toward support of the 371 million people currently living with diabetes. The initiative is open to all, and will officially end at the World Diabetes Congress in Melbourne, December 2013.

The key messages of the campaign are: ■ World's most populated countries: 1.China 2.India 3.DIABETES 4.USA 5.Brazil ■ 1 in 2 people with diabetes don't know they have it: Are you at risk? ■ Diabetes: know the complications – Amputation, Blindness, Heart Attack, Kidney Failure ■ People with diabetes are just like you and me: Don't discriminate

Find out more about the campaign at www.worlddiabetesday.org.

World Diabetes Day 2013 marks the fifth and final year of the 2009-2013 campaign on diabetes education and prevention. Under the proclamation ‘Diabetes: protect our future’, the campaign aims to inspire and engage local communities to promote and disseminate simple education and prevention messages.

Professor Harry Keen,

one of IDF’s Honorary Presidents passed away last April Harry was the Professor Emeritus at Guy’s Hospital Campus of the King’s College London School of Medicine. During his highly distinguished career, he led or was associated with many of the important research or clinical advances in diabetes. He inspired a generation of today’s leading diabetologists who worked with him. He was one of the principal architects of the St Vincent Declaration which was the catalyst of many of the National Diabetes Plans in European countries, and he oversaw the vital work of the WHO Collaborating Centre for the Study and Control of Long-Term Complications in Diabetes. His eminence in the field of diabetes was recognised in the many awards and distinctions which he received, among them Honorary President of IDF, Honorary Member of EASD and Vice President of Diabetes UK.

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June 2013 • Volume 58 • Issue 2

News in brief

The 66th World Health Assembly The 66 th World Health Assembly (WHA) set in Geneva last month was host to Ministers of Health from governments worldwide. This authoritative decision-making forum of the World Health Organization is responsible for determining world health policy every year. In 2013, WHA included a resolution with the potential to change the reality of how public health policy controls the diabetes epidemic today. The resolution marks the achievement of IDF’s campaigning since the landmark United Nations Summit on Non-Communicable Diseases (NCDs) in September 2011. Ministers of Health confirmed how the UN Political Declaration adopted at the Summit will translate into action. This year, all stakeholders agreed to a Global NCD Action Plan for 2013-2020 as an im-

plementation guide for the Political Declaration. In addition, the Assembly has adopted a global monitoring framework, including targets, to measure progress and ensure accountability on commitments to improve prevention, treatment and care. WHA is committed to the reduction of preventable mortality from NCDs by 25% by 2025 and to the fulfilment of landmark targets on essential medicines and treatment for diabetes. For the first time, governments, UN agencies, civil society and the private sector will formally begin collaboration in a global multisectoral response to the NCD epidemic, which will be realised through the creation of a Global Coordination Mechanism for NCDs. Such an effort will be a significant breakthrough for the prevention

of diabetes – the causes and consequences of which go beyond the health sector and require concerted action in diverse areas including urban design, food systems, workplaces, sport, trade and finance. The ambitious resolution not only affirms diabetes as a global health threat requiring immediate attention, but also establishes the ‘what’ and ‘how’ of government action to ensure progress. WHA is set to be another milestone in the political response to diabetes.

WORLD HEALTH ASSEMBLY

INTERPRET-DD In March 2013, the Dialogue on Diabetes and Depression (http://diabetesanddepres sion.org/) brought together leaders from centres of diabetes care and psychiatry from 15 countries (Argentina, Brazil, China, Thailand, India, Pakistan, Bangladesh, Kenya, Ethiopia, Poland, Russia, Serbia, Ukraine, Italy and Germany) for the launch of the International Prevalence and Treatment of Depression and Diabetes (INTERPRETDD) study. Commencing in September 2013, this study will examine the pathways of care for people with co-morbid diabetes and depression. This study, the largest of its kind, provides us with a unique opportunity to examine the relationship between type 2 diabetes and depression in individuals being treated in a diverse range of health care systems across the world.

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DiabetesVoice

News in brief

Currently,

in Diabetes Research and Clinical Practice

On the Bookshelf

DRCP is the official journal of IDF. The following articles have recently appeared or are about to appear in that journal. Access information can be found in the QR code. Results that matter: Structured vs. unstructured self-monitoring of blood glucose in type 2 diabetes Parkin CG, Buskirk A, Hinnen DA, et al. Diabetes Res Clin Pract 2012; 97: 6-15. ‘This article reviews recent studies that appropriately utilized structured SMBG as an integral component of comprehensive diabetes management and discusses how their findings support the IDF recommendations.’

MY BELOVED WORLD By Sonia Sotomayor Illustrated. 315 pages. Alfred A. Knopf (January 15, 2013) Sonia Maria Sotomayor is an Associate Justice of the Supreme Court of the United States, serving since August 2009. Diagnosed at age 7 with Type 1 diabetes, she recounts her survival in a Bronx housing project and how she rose to become the first Hispanic appointed to the United States Supreme Court.

in type 2 diabetes: Is the debate

MEDICAL MANAGEMENT of PREGNANCY COMPLICATED by DIABETES

(finally) ending?

By Donald R. Coustan (Editor), Abbot R. Laptook (Contributor), Carol

Ceriello A. Diabetes Res Clin Pract 2012; 97: 1-2.

J. Homko (Contributor), Susan Biastre (Contributor), Julie M. Daley

Self-monitoring of blood glucose

‘ … structured SMBG is a valid tool for the better management of type 2 diabetes not on insulin therapy, but only

(Contributor) 184 pages, American Diabetes Association; Fifth Edition (September 10, 2013)

if both patients and health care professionals are trained

Pregnancy complicated by pre-existing diabetes can be managed through ex-

on how to respond to the data for SMBG to be effective.’

pert protocols and patient partnerships. Based on the new American Diabetes Association recommendations, this revised edition widely expands on the

Universal screening to identify gestational diabetes: A multi-centre study in the North of England

fourth edition. Topics include: pre-pregnancy counselling, contraception, psychological impact, morning sickness, nutritional management, insulin, diagnostic testing and surveillance, gestational diabetes, neonatal care of infants, and postpartum follow-up.

Hayes L, Bilous R, Brandon H et al. Diabetes Res Clin Pract 2013 (In Press). ‘ … an audit of treatment and outcomes in 116 women with gestational diabetes. These women received intense monitoring and high levels of medical and obstetric intervention. 24% would not have been identified by risk factor based screening. Cost effective strategies to identify all women with gestational diabetes are needed.

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SALT SUGAR FAT: HOW THE FOOD GIANTS HOOKED US By Michael Moss 480 pages. Random House (February 26, 2013) From a Pulitzer Prize–winning reporter, Moss reveals the story behind the rise of the processed food industry and its link to the emerging obesity epidemic. www.idf.org/diabetesvoice

June 2013 • Volume 58 • Issue 2

the global campaign

The IDF Perspective: reforming the global food system to tackle diabetes and obesity The International Diabetes Federation

The role and responsibilities of the private sector in global health and development have evolved in recent decades. The view that the only responsibility of business is to return a profit to stakeholders is being weakened by the dawn of corporate shared values and a mushrooming of public-private partnerships, both of which have resulted in the leveraging of resources and expertise of the private sector to bear on many contemporary global health challenges.

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At the same time, deep mistrust and scepticism remain within some camps of the health community towards increasing this private sector involvement. And nowhere is this more apparent than in relation to diabetes and other noncommunicable diseases (NCDs).

More than 371 million people are living with diabetes today, a number that is expected to rise to 552 million in less than 20 years’ time. We at the International Diabetes Federation (IDF) know all too well that we are facing a diabetes and NCD crisis. The numbers are bleak, and are becoming worse: more than 371 million people

are living with diabetes today, a number that is expected to rise to 552 million in less than 20 years’ time. While previously considered a disease of the rich, diabetes disproportionately impacts on the poor and vulnerable. Today nearly two-thirds of people with diabetes live in low- and middle-income countries. Diabetes and NCDs are multi-sectoral issues. While these diseases come to monopolise the health system, they are fuelled by rapid urbanization, globalization, economic development, and a deeply dysfunctional global food system. Current food systems are simultaneously delivering under- and over-nutrition, resulting in one billion people hungry and two billion people overweight. Both ends of this malnutrition spectrum are fuelling the epidemic

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The global campaign

of type 2 diabetes. The links between overweight and obesity and type 2 diabetes are well documented, but what is less known is that undernourished mothers give birth to babies who are at a higher propensity to develop type 2 diabetes and obesity later in life. The sheer scale and complexity of diabetes mean that no single actor or sector can solve the epidemic alone. A truly society-wide approach is required – including UN agencies, government, NGOs and the private sector. IDF has long been pioneering what we

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call ‘Triple P Partnerships’ – combining public, private and people. In 2011, governments signed up to this approach when they adopted the UN Political Declaration on NCD Prevention and Control which has multi-sectoral action at its core and a set of commitments dedicated entirely to the private sector. Even with this, actually ‘walking the talk’ of multi-sectoral action still remains hotly contested and debated in public health. Partnership with the food industry in particular has become a dirty word. Ever since IDF entered into a corporate

partnership with Nestlé last year, we have been at the centre of a discourse on conflict of interest. However, we feel it would be abrogating our responsibility to stop talking to the food industry. Underlying both over- and under-nutrition is a common factor: global food systems are not driven to deliver optimal and sustainable nutrition, but to maximize profits. It is a systemic problem that often works against, rather than facilitates healthier choices. To remedy this global challenge, global food systems must be oriented to ensuring

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the global campaign

the most remote regions where we still fail to deliver lifesaving medicines and technologies. If we can get these global corporations on board, harness their unique expertise, and get them to make significant improvements to their product portfolio, we will catalyse change at the scale that is urgently required - change we have been unable to accomplish in our own silos. Rather than acting independently, IDF believes that working with the private sector will lead to greater success in urging industry to be more responsible, act with integrity and adopt the mantra ‘do no harm’. Our critics feel that it is either/or: either you are in partnership with the food industry or you are in favour of regulating that industry. This is not the case. We believe it will take a broad mixture of policies, including industry regulation and fiscal measures, in addition to industry-led voluntary efforts, to reverse the global diabetes and NCDs epidemic. We support and push for industry regulation where it is needed, particularly around marketing to children and food labelling, as self-regulation to date has been vague in its design and limited in its reach.

universal access to ‘sustainable diets’ – and for this shift to happen, the participation and co-operation of major food companies is vital.

The food industry is beginning to provide ‘healthier’ options but the progress to date has not yet been good enough. Food companies deliver billions of products each and every day and access even

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Multinational food companies are not going away. Food companies have made major advances in increasing the availability and accessibility of food throughout the 21st Century – now the challenge is to align this progress with public health goals. Watchdogs from all sectors are needed to march forward, with governments leading the way through policies and recommendations. The food industry is beginning to provide ‘healthier’ options, but these are the first steps of a long journey and progress to date has not yet been good enough. For example, the International Food and

Beverage Association (IFBA) has made five commitments to improve nutrition, including those around product reformulation. But who is ensuring accountability? Who is making sure that their commitments are measurable and represent biologically significant improvements? For IDF and Nestlé, partnership means taking a harder look at what more needs to be done. NGOs need to be encouraging private sector to do better, but we also can’t let them off the hook if they haven’t done well enough.

Diabetes and NCDs are everyone’s business and all sectors have a shared incentive and responsibility to act. Whether it is engagement with or without funding, political mandates and common sense agree that working with the food industry is a necessary part of tackling the diabetes and NCD epidemics crippling our world. Diabetes and NCDs are everyone’s business and all sectors have a shared incentive and responsibility to act. As the world’s governments start to take diabetes and NCDs more seriously, we urge them not to forget this and to establish a truly multi-sectoral, a ‘whole of society’ response that will drive progress.

The International Diabetes Federation The International Diabetes Federation promotes diabetes care, prevention and cure worldwide. www.idf.org

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The global campaign

A look 'upstream' to Melbourne

Understanding the complex nature of diabetes Jonathan Shaw

Incidence. Prevalence. Risk factors. Outcomes. We hear these words frequently in relation to diabetes and their impact on our world, but are we learning how certain patterns, and trends are associated with the global diabetes epidemic? Are we able to see the big picture, which now totals more than 371 million people living with diabetes worldwide? This is not an easy task given that every nation in the world, regardless of geography or race, is confounded by the rising tide. Professor Jonathan Shaw, Associate Director of Baker IDI Heart and Diabetes Institute, talks about the upcoming Public Health and Epidemiology Stream in Melbourne 2013, and how the programme will provide attendees with a greater understanding of the social, ethnic and geographic complexity of diabetes.

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The Public Health and Epidemiology Stream aims to provide up to date information on the relationship of diabetes to population health. Broadly, this type of research involves tracking and mapping the trends of diabetes and its complications over time; examining the impact of treatments and interventions on populations; and attempting to identify new risk factors for diabetes, and complications of diabetes. The programme will cover type 1, type 2 diabetes and gestational diabetes.

Many parts of the world struggle to afford basic care. Importantly, this Stream will provide insights and data on how large populations are affected by diabetes. What’s crucial to the success of studies contributing to epidemiology and public health is the scientific aim to include all members of a given population. If this is achieved, the bias of the enthusiastic volunteer for a study is minimized, and scientists are able to see a more realistic ‘warts

and all’ picture of the patterns, such as improvements, or problems. Understanding the complex nature of diabetes as it plays out in a wide range of social, ethnic and geographic settings is a challenge we hope the Public Health and Epidemiology Stream will advance. Whereas populations in the richer developed countries have resources to provide complex and expensive treatments, many other parts of the world struggle to afford basic care. However, this division of rich versus poor countries is an over-simplification. Wealth and poverty exist side-by-side in nearly every country, teaching us that every section of society is challenged by the indiscriminate nature of diabetes. Whilst wealth provides opportunity, it also leads to excesses and many unhealthy lifestyle choices, while poverty limits education, access to healthcare, and often combines emerging Non-communicable Diseases (NCDs) with nutritional deficiencies or communicable diseases. The Public Health and Epidemiology Stream will attempt to unravel the interplay of social,

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source? Unfortunately, accurate and reliable data are not available for large parts of the worldâ&#x20AC;&#x2122;s population, making various modelling techniques indispensable to fill in gaps. How effective this process is, and what alternative methods should be considered will be discussed. Supplementing the programme of invited speakers will be presentations, including the latest research presented as orals and posters from around the world. This will include updates on the prevalence and incidence of diabetes from diverse populations, examinations of well-established cohort studies for new clues about the causes of diabetes, reports of the impact of diabetes on health systems, economies and on communities, as well as information on the rapidly changing picture of type 1 and type 2 diabetes in children.

ethnic and biological factors responsible for the rise in diabetes prevalence and incidence today. One particular focus of the invited lectures will be on disadvantaged populations. This will include the challenges of delivering care for people with diabetes, developing programmes for the prevention of diabetes, the supply of costly drugs and devices and the social and environmental factors that increase the risk of developing diabetes. There will also be a close examination of how some of the most important measurements are made in epidemiological studies of diabetes. In addition to the

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announcement of the latest estimates for the numbers of people with diabetes in every country, there will be a discussion of how these are compiled.

The IDF Diabetes Atlas has become a cornerstone of planning, tracking and campaigning for diabetes. The regular updates on diabetes numbers within the IDF Diabetes Atlas have become a cornerstone of planning, tracking and campaigning for diabetes, but we also need to ask - how accurate is the

Jonathan Shaw Jonathan Shaw is leader of the Public Health and Epidemiology Stream of the IDF World Diabetes Congress in Melbourne, 2013.

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The global campaign

A look 'upstream' to Melbourne

Diversity, debate an Mark Cooper and Sophia Zoungas

Targeting today’s most contemporary issues, the Basic and Clinical Science Stream may provide this year’s Congress with the biggest buzz, especially in areas of obesity, diabetes complications and new treatment strategies. A range of provocative topics including debates about driving type 2 diabetes prevention and bariatric surgery will be presented. Noteworthy speakers will discuss new treatment options for both types of diabetes and present the latest results of clinical trials. Mark Cooper and Sophia Zoungas talk about the exciting programme this year.

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nd new directions The Basic and Clinical Science Stream is a major component of the World Diabetes Congress to be held in Melbourne in December 2013. This Stream encompasses major advances and updates in basic, preclinical and clinical aspects of both type 1 and type 2 diabetes and their complications. With a full programme of symposia, ‘meet the professor’ sessions, debates and plenary lectures the meeting and this Stream in particular plans to review important advances in the field of diabetes and looks to setting the agenda for new directions and research opportunities in diabetes care. Building on a new initiative established two years ago at the congress held in Dubai, there will be two IDF award lectures in Melbourne: one in clinical science by Professor Stephen O’Rahilly, Cambridge, UK; and one in basic science by Professor Michael Brownlee, New York, USA. Each lecture will address contemporary issues in obesity and diabetic complications respectively and promise to be major highlights of this Stream. A new initiative is a planned symposium co-sponsored with the prestigious journal, The Lancet. Entitled 'Managing diabetes in the 21st Century,’ this symposium will include four eminent international speakers: Professors Paul Zimmet, Australia; Steven Kahn, USA; Leif Groop, Sweden; and Tadeshi Kadowaki, Japan. In this symposium the speakers will address the epidemiology of diabetes, the interface between type 1 and type 2 diabetes, pathophysiological advances in the area of type 2 diabetes and new treatment directions in diabetes care. In addition, speakers from diverse fields outside of diabetes have been invited to present their work with the idea that our Melbourne registrants have an opportunity to adapt or translate original research from these other fields to some of the more intractable problems in the field of diabetes. On the last day of the meeting, we are also fortunate to have a session dedicated to late breaking clinical trials on the relationship between new glucose lowering agents and mortality

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and cardiovascular disease in diabetes. It is anticipated that results of the first of a series of these trials, the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR) trial, will be announced. The latest findings and a discussion on the implications of this trial will be a major attraction of the Congress programme. Other sessions which will be of particular interest to registrants include symposia on bariatric surgery; technical advances in type 1 diabetes including an update on the artificial pancreas; new directions in stem cell biology as it pertains to the beta cell and a review of the current pipeline of new drugs for the management of type 2 diabetes. In addition, with the ongoing development of new pharmacological strategies for glucose lowering agents, there will be important updates on the role of GLP-1 agonists, DPP-IV inhibitors and SGLT-2 inhibitors in the management of diabetes.

We are sure that the impressive array of topics to be addressed will more than meet the expectations of all those attending this meeting. We encourage registrants to take a look at the detailed final programme which will soon be available on the Congress website. We are sure that the impressive array of topics to be addressed will more than meet the expectations of all those attending this meeting.

Mark Cooper and Sophia Zoungas Mark Cooper leads the Stream of the Basic and Clinical Science at the IDF World Diabetes Congress in Melbourne, 2013. Sophia Zoungas is Associate Professor at Monash University, Melbourne, Australia and member of the Basic and Clinical Science Stream at the IDF World Diabetes Congress in Melbourne.

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The global campaign

A look 'upstream' to Melbourne

Breaking down barriers and living your dreams… with diabetes João Valente Nabais

João Valente Nabais, President of the IDF European Region and development lead for the Living with Diabetes Stream, is passionate about the 2013 Melbourne programme. Living with type 1 diabetes since 1981, João has been an active diabetes advocate ever since his youth. This year, Living with Diabetes (LWD) delivers a unique opportunity for people to become inspired and work on realising dreams. Highlights include Olympic gold medallist, Cathy Freeman, speaking in a programme entitled ‘Living your Dreams’ and ‘Diabetes and Professional Sports,’ and meeting one exceptional person who has lived with diabetes for more than 75 years.

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The Living with Diabetes Stream (LWD) for the Melbourne World Diabetes Congress 2013 is meant to inspire and help all people living with diabetes build on success, get informed and believe in the promise of a healthy future. Our programme offers something for everyone who manages diabetes, including healthcare professionals, people with type 1 or type 2 diabetes and finally families, especially parents caring for children with diabetes. Topics include patient motivation and self-management, patient-provider communication strategies, and the evolution of diabetes health delivery through advances in technology. Many LWD presentations will reflect how ambition, persistence and clear thinking can lead to the realisation of dreams, crushing the façade of diabetes barriers.

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important tools for many people, and we will address the impact of sharing information among virtual communities. During this segment of the Stream we will have the opportunity to hear shared experiences of summer camp and the importance of peer support.

Two LWD events, ‘Living your Dreams’ and ‘Diabetes and Professional Sports,’ offer a spectacular roster of celebrity speakers including: Olympic gold medallist, Cathy Freeman; elite marathon runner, Missy Foy; and volleyball champion, Bas van de Goor. In further support of our breaking down barriers theme, LWD will showcase the extraordinary journey of a Mount Everest expedition, and separately, a celebration of one exceptional person who, at 84-years, has lived with type 1 diabetes since the age of seven. In ‘Living your Dreams’ our stance will be ‘diabetes is not a barrier’. If barriers exist they are there to be overcome. Everything should be possible for people with diabetes. A significant goal for our programme in 2013 is to emphasise the importance of the diabetes partnership. Stream lectures such as, ‘Building Effective Relationships with Healthcare Practitioners,’ and

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topics on science and research should provide meaningful discussions in a format that is open and understandable for all participants. We hope to satisfy the expectations and needs of many patients with a variety of topics including ‘Where are we with the Type 1 Cure?’ and ‘Technology and Diabetes’.

If barriers exist they are there to be overcome. Everything should be possible for people with diabetes. The LWD Stream will also look at practical issues such as complications related to managing planned pregnancy, and the pitfalls of drugs and alcohol. Stress associated with diabetes and the demands of modern life will also be examined. Social media and the advent of various digital communication channels have become

Even in the 21st century there is an urgent call to change the continuing injustice of diabetes discrimination. Discrimination and worldwide protection of the rights of people living with diabetes will be covered in two instalments, ‘Diabetes and Public Awareness’ and ‘Fighting Diabetes Discrimination.’ Even in the 21st century there is an urgent call to change the continuing injustice of diabetes discrimination. We look forward to seeing you there!

João Valente Nabais João Valente Nabais leads the Living with Diabetes Stream at the IDF World Diabetes Congress in Melbourne, 2013.

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Diabetes in Indigenous Peoples Diabetes Research in the 20th Century

www.worlddiabetescongress.org

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Why health matters to human development Helen Clark

Helen Clark, Administrator of the UN Development Programme, reflects on the development agenda post-2015 and explains how better prevention and care of Non-communicable Diseases fit into her vision for a broader development goal thereby decreasing the threat NCDs pose to progress.

The preamble to the Constitution of the World Health Organization, agreed in 1946, defined health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’. That definition stands to this day. It reminds us that good health is built on broad foundations, and is about rather more than the absence of illness. The United Nations Development Programme (UNDP), the organization I head, is not a specialized health agency. Yet, our core mandate of helping countries to tackle poverty, promote gender equality, and achieve sustainable human development is highly relevant to lifting health status. In that sense, it can complement the work of the World Health Organization (WHO) and other specialized global health agencies. There can be no doubt that poverty impacts adversely on health, as do both inequality in general and gender inequality. To lift health status and make the right to health a reality, it is vital to

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tackle poverty and inequality in all their dimensions. That too places health at the centre of the development agenda. The Alma Ata Declaration of WHO’s 1978 International Conference on Primary Health Care proclaimed that: ‘the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector’. As head of UNDP, the Alma Ata Declaration helps me place health status in that broader developmental context. UNDP’s own strategy for tackling HIV, ‘HIV, Health, and Development,’ is based on our understanding that ‘just as health shapes development, development shapes health’. It is therefore vital to tackle health challenges on a cross-sectoral basis. Action in the health sector alone will not produce the gains in health status and development we all want to see. The final report of the Commission on Social Determinants of Health, established by WHO in 2005,

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reinforces the importance of crosssectoral strategies and action. In September 2011, the UN General Assembly held its first ever High Level Meeting on NCDs, bringing together world leaders, ministers, and other stakeholders within and beyond the health sector. The meeting issued a Political Declaration recognizing NCDs as not only a global health concern, but also as a threat to social and economic development. The UN Conference on Sustainable Development in Rio de Janeiro in June 2012 weighed in along similar lines, stating in its outcome document that ‘health is a precondition for and an outcome of all three dimensions of sustainable development’ – the economic, social, and environmental.

child mortality; increase access to education, clean water, and sanitation; protect the environment; and forge strong global partnerships for development. NCDs were not covered in the MDGs, but are increasingly recognised as a very significant health problem in developing countries. Indeed, nearly 80% of global NCD deaths are estimated to occur in developing countries. NCDs have striking socio-economic impacts: at the macro level, morbidity and mortality related to NCDs sap productivity among working age populations. China, India and Russia were estimated to lose USD 23-53 billion per year between 2005 and 2015 because of heart disease, stroke, and diabetes alone. For low-income countries, managing NCDs can be very expensive, and puts a severe strain on already overburdened health

systems. At the household level, NCDs can push families into poverty when adequate social protection measures, such as health and disability cover and access to services, are not available. Evidence suggests that policies, which directly target the use of tobacco, alcohol, and obesogenic food and drinks, through taxation, production, and advertising restrictions, can have a positive effect on NCD prevention and control. The UN has been supporting Ministries of Trade and Health in the South Pacific to review import tariffs on unhealthy foods, because we believe that reforming such laws and policies can help reduce the incidence of NCDs. Public policy in other areas as wide ranging as sport and recreation, transport, urban planning, the environment, access to clean energy, and more could also help tackle the NCD burden.

Health and the MDGs Health was placed at the very centre of the development agenda in the Millennium Development Goals (MDGs) promulgated by UN SecretaryGeneral Kofi Annan in 2000. The MDGs focus on basic benchmarks of progress in human development. They set out to: reduce poverty and hunger; empower women and girls; reduce the incidence of specified diseases and maternal and

Nearly 80% of global NCD deaths are estimated to occur in developing countries. 20

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The question now is: can the time bound, measurable, and easily communicated approach of the MDGs be brought to bear in the post-2015 development agenda on the threat posed to global health by the NCDs? UNDP is not a specialist health agency. We are a general development agency working within the human development paradigm. Our work is a natural complement to that of WHO and other specialized global health agencies.

Action on a much broader front is needed, including on tackling the socio-economic determinants of health Sustainable development calls for integrated policy-making across the economic, social, and environmental spheres – an approach highly consistent with the multisectoral approach required to address NCDs. One of the challenges in this approach, and in designing sustainable development goals, is to ensure that economic and social development and environment actors work together. So what could the unifying concepts for a global health goal be? There is strong advocacy for a focus on universal health coverage, and also some opposition. The UN General Assembly passed a resolution last December, recommending that: ‘consideration be given to including universal health coverage in the discussions on the post-2015 development agenda in the context of global health challenges’, and asserting that ‘the provision of universal health coverage is mutually reinforcing with the implementation of the Political Declaration on the Prevention and Control of NCDs’.

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The concept of universal health coverage should be seen as covering preventive and long term care services as well as acute illness services. The concept is a departure from the element of verticality inherent in the current health-related MDGs, and, to some extent it addresses concerns of equity and inclusion, particularly for those who are financially excluded from accessing healthcare. Given the persistent, and likely growing, inequities in NCD burdens within countries, universal health coverage could offer a means of ensuring that everyone affected by them has access to the services they need, especially to essential medicines for NCDs - and is not impoverished as a result. Universal health coverage, however, desirable as it is, will not in itself deliver higher health status. Action on a much broader front is needed, including on tackling the socio-economic determinants of health. That is because various forms of stigma, discrimination, and marginalization, rooted in laws, policies, and economic, social, cultural, and other factors, have profound impacts on health status, and on whether people will access health services even when they are readily available.

saturated fats, and processed sugars – are influenced by underlying policy choices which span the areas of, for example, agriculture, trade, intellectual property and trade law, tax policies, and attitudes to regulation. Similarly, preventive behaviours, such as physical activity, can be impacted by public policy in areas as wide ranging as sport and recreation, transport, and urban planning. A broader chapeau for a health goal could therefore be envisaged – possibly around ‘universal health’ – as in the Almaty Declaration’s ‘Health for All’ – or maximizing ‘healthy life’, beneath which specific targets could be set; for example, for progress towards universal health coverage and on tackling the drivers of ill health. Such a goal could encourage multisectoral action on social determinants of health, embrace WHO’s agreed goal of a 25% reduction in premature mortality from NCDs by 2025, and adopt targets for tackling major drivers of NCDs as agreed by the WHO Executive Board last month. A key lesson from the experience of working with the MDGs is the need for focus on a small set of clear targets.

At UNDP we know this well from our work with the Global Commission on HIV and the Law. Its report shows how discriminatory laws and stigma can prevent people seeking HIV services – even where the services are available. Indeed such discrimination can also be a constraint on MDG progress in general. Moreover, social determinants shape not only access to and the use of services, but also the pattern of the underlying risks themselves. Risk factors for NCDs – such as tobacco and harmful alcohol use, and consumption of foods high in salt,

Helen Clark Helen Clark is the Administrator of the United Nations Development Programme and the Former Prime Minister of New Zealand.

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Healthy Cities In our first Healthy Cities report, Diabetes Voice highlights municipal and national governing policies that are trailblazing new directions for human health. Mayor Michael Bloomberg has dominated his mayoral terms with strong government leadership providing unconventional initiatives for New York City’s public health problem. His controversial policies have gained worldwide acknowl-

edgement and support from a distinguished list of international leaders and influential scholars. We briefly review his extraordinary final term and present supporting words from another New York City resident, Marion Nestle, Professor of Nutrition, Food Studies, and Public Health at New York University. Winds of change and fresh air are also moving across other regions in North America. In an interview with members of Mexico’s Health Secretariat, we learn about the city’s

The new health revolution: New York City Elizabeth Snouffer

A healthy city is one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and developing to their maximum potential.

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WHO, Health Promotion Glossary (1998): WHOs Healthy Cities programme is a long-term international development initiative that places public health ‘high on the agendas of decision makers in order to promote comprehensive local strategies for health protection and sustainable development’. Focussing on cities that represent the best of community participation and empowerment, and intersectoral partnerships creating a health-supportive environment, in our

first ‘healthy cities’ instalment, we praise the efforts of Mayor Michael Bloomberg of New York City, who has forced change on issues related to public health, including tobacco cessation, and campaigned in support of healthy nutrition. The world is watching Mayor Bloomberg’s new health revolution. Will his initiatives control the obesity and diabetes epidemic in New York? Only time will tell. Mayor Michael Bloomberg, Chief Executive of New York City since 2002,

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report anti-smoking policies, and new educational campaigns for the prevention of obesity and diabetes. Once the world’s most polluted urban centre, Mexico City now seems intent on transforming its public health environment to the highest possible standard. In our final segment, Pilar Garcia Crespo sheds some light on why Spain has been ranked as one of the healthiest countries in the world. Surprisingly or not, people residing in the birthplace of the heart-healthy Mediterranean

has taken on the forces of Big Tobacco and the food and beverage industry, and succeeded in making change and reform in ways no one could have imagined. In his quest to reclaim the vibrancy of the Big Apple and wipe out poverty, unproductivity, and disease, what has been most visible in his relentless campaign for public reform are enforceable restrictions of sugar, saturated fats and smoking all in the name of health.

In a city where 800 languages are spoken, more than 22% of adult New York City residents are obese. Across the United States, obesity and diabetes exist as two of the most serious threats to the total population and

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diet also require government interventions targeting nutrition, physical activity and obesity. These thought leaders, health ministries and governments have all prioritised the escalating public health burden related to Non-communicable Diseases (NCDs). Although unique, all of these individual or regional voices believe in the power of policy to encourage and provide greater opportunities for the future of human health.

the privatized health care system. New York State has the fourth largest number of people living with diabetes, behind California, Florida and Texas respectively, and in a city where 800 languages are spoken, more than 22% of adult New York City residents are obese. Health disparities are traceable in part to fundamental social and environmental problems. According to Scott Stringer, Manhattan Borough President, ‘the scarcity of fresh foods and produce prevalent in low-income neighbourhoods and communities of colour, contribute to the disproportionate disease burden carried by the city's minority populations’. In one study conducted from 2002 to 2004, New York City’s rates of obesity and diagnosed diabetes both increased by 17% and researchers concluded that during that time the adult population had gained ten million pounds in weight.1,2

The researchers also concluded that the over-consumption of sugary drinks was to blame. Sadly 45% of all newly diagnosed cases of type 2 diabetes for New York State occur in children.3 Age, black race, Hispanic ethnicity, elevated body mass index, and low educational attainment have all been cited as the most predominant features for diabetes risk in New York City.4 The economic burden is hard to ignore. According to the New York City Department of Health, obesity related healthcare problems, including diabetes, account for USD 4 billion a year. For every person diagnosed with type 2 diabetes, the estimated cost to the New York Health and Hospitals Corporation is USD 400,000. New Health Revolution In an effort to transform the impaired public health status of his city, Mayor

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Liberty from Big Soda Marion Nestle

Bloomberg decided to take charge; determining average New York citizens don’t know what’s best for them. He has likened his municipal restrictions to outlawing drunk driving or protecting citizens from potential terrorists. The Mayor’s most controversial initiatives include: the ban of trans fat in cooking oils for the city's 24,000 food establishments; an ordinance requiring chain restaurants in the city to display calorie information on menus and menu boards; and illegalizing smoking in the city’s parks, beaches, marinas, boardwalks and pedestrian plazas. According to Dr. Susan Kansagra, an assistant commissioner at the New York City Department of Health and Mental Hygiene, since Bloomberg took office, New York City’s smoking rate has dropped from 22% to just above 14%.

Since Bloomberg took office, New York City’s smoking rate has dropped from 22% to just above 14%. To date, the most provoking initiative has been the Bloomberg ‘Soda Ban’,

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which was set to take effect on 12 March 2013. Most of all stakeholders involved in helping New York’s obesity problem, including public health officials, scientists, nutritionists and medical professionals, believe curtailing the consumption of sugar-sweetened beverages is a significant step in the effort to reduce obesity and to promote citizens’ general health and wellness. (Please see Marion Nestle’s article, Liberty from Big Soda.) The Mayor’s third and final term in office ends this year, and while his Soda Ban was invalidated the day it was to take effect, one thing is clear: in the effort to minimize the risks associated with the exposed and unstable health status of New York, the Mayor has provided unprecedented awareness to the 21 st century health epidemic for Non-communicable Diseases — chiefly obesity and type 2 diabetes.

While some people believe that Mayor Bloomberg’s soda regulations go too far, Marion Nestle, a professor of nutrition at New York University, believes that they may not go far enough. Mayor Bloomberg’s 16 ounce cap on sugary sodas that should have gone in effect on 12 March 2013, would have prohibited restaurants, movie theatres, sports venues and food carts from selling extra-large portions of sugar-packed drinks. Stay calm. This does not signal the end of democracy in America. If we want Americans to be healthy, we are going to have to take actions like this – and many more – and do so soon. It’s long past time to tax sugar soda, crack down further on what gets sold in our schools, tackle abusive marketing practices, demand a redesign of labels – and extend the soda cap, no matter how controversial it may seem.

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This must be the beginning, not the end, of efforts toward a healthier America. In short, we need a series of serious changes to make the healthy choice the easy choice. The soda size cap is a nudge in that direction. You will still be able to drink all the soda, and down all the sugar, that you want. The cap on soda size makes it just a tiny bit harder for you to do so. That ‘tiny bit harder’ is its point. If you have to order two sodas instead of one, maybe you won’t. If you have to add sugar to your coffee drink yourself, maybe you will only add one or two teaspoons instead of the ten or more someone else put in there for you. For a public health nutritionist like me, the soda size cap is a terrific idea. Unlike other foods, sodas are a unique target for intervention. They contain sugars – and sugar calories – but nothing else of nutritional value. They are candy in liquid form. Candy has a place in healthy diets, but a small one. So it should be for sodas. It’s no surprise that people who drink large amounts of liquid candy have worse diets, are heavier, and have more health problems than those who do not. And it looks like the body doesn’t compute the calories from liquid sugars as accurately as it does for sugars in foods. On top of that, big sizes make the problems worse. To state the obvious, larger portions have more calories.

health-speak – and are content with that amount. So a reasonable goal of public health intervention is to change the default drink to a smaller size. Hence: Bloomberg’s 16 ounce size cap.

only puts ‘better-for-you’ drinks in school vending machines, but sugarfilled sports drinks are still liquid candy. And kids should not have to pay for water in schools.

From my nutritionist’s perspective, a 16 ounce soda is still generous. Just one contains the equivalent of 12 packets of sugar. Just one provides 10% of the daily calorie needs of someone who typically eats 2,000 calories a day. Just one contains the upper limit of sugar intake that health officials recommend for an entire day. Once you down a 16 ounce soda, it’s best to stop right there.

■ Restrict marketing of sodas to children. Soda companies market extensively to children and adolescents, especially those in low-income neighborhoods. We already have restrictions on cigarette and alcohol marketing to kids. It breaks no new ground to add sodas to the list.

City officials concerned about the health of their citizens, as those in New York most definitely are, want to do everything they can to prevent obesity and the illnesses that go with it. Their rationale is humanitarian, but also fiscal. Poor health is expensive for both individuals and society. We can thank Big Soda – Coca-Cola, Pepsi and their trade association, the American Beverage Association – for the contribution of big sodas to weight gain. The soda industry may profess to care more about your well-being these days, but it ultimately will not do anything to promote health if doing so harms sales. Here are some additional actions New York City should take, if only it were allowed to:

But big sizes also have other effects. They induce people to eat and drink more than they would if given smaller portions. Big sizes confuse people into underestimating the number of calories consumed.

■T ax sodas. Raising the price of sodas would discourage sales, especially among young people most susceptible to marketing efforts and most vulnerable to weight gain.

Most people eat whatever size is in front of them – the ‘default,’ in public

■ Remove vending machines from schools. Yes, the Beverage Association

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■ Show full calories on the front of containers. The current way calories are tallied, in a measure called ‘caloriesper-serving,’ is confusing because the servings are unrealistically small and people don’t do the math. Actions like these will evoke ferocious opposition from the soda industry, and it will spare no expense to make sure such things never happen. Polls say that many New Yorkers oppose the 16 ounce cap and would oppose measures like this, too. But I can’t tell whether the opposition comes from genuine concern about limits on personal choice or because soda companies have spent millions of dollars to protect their interests and gin up histrionic, misinformed opposition. The 16 ounce soda is the new default size in New York City. While waiting for the court decision and for politics to play out, why not give it a chance? Maybe it will help you live a healthier and longer life.

Excerpt from the NEW YORK DAILY NEWS, 8 March 2013

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Health snapshot: Mexico City

Spanish steps to Pilar García Crespo

Interview with Armando Ahued Ortega, Rafael Alvarez Cordero and Mónica Hurtado Gonzalez Do you believe Mayor Bloomberg’s initiatives would work in Mexico City? Mexico Federal District in 2004 adopted a policy for Health Protection of Non Smokers which prohibits smoking in public indoor spaces. Policies have also been put in place requiring producers to include information of food products. However, we need to educate people on how to read labels and how to use this information. At the Health Secretariat we have worked towards empowering people through training and lectures to provide tools that will allow them to choose healthier options and combinations. The Health Secretariat’s efforts have been acknowledged through the Bloomberg Award*. What public health policies has Mexico City established? Since 2009 Mexico City has opened centres for the management of obesity. We recently opened a Specialized Centre on Diabetes Management, which provides diabetes education and treatment of complications, including sections focused on nutrition and sports. With the creation of the Council for the Prevention and Comprehensive Care for Obesity and Eating Disorders we intend to improve the relation between the public and private sectors. This action will

result in improved collaboration with the Health Secretariat at the Legislative Assembly responsible for formulating policies and reforms. Name a few activities that promote healthier lifestyles. In 2008 the Health Secretariat of Mexico implemented the on-going campaign ‘Muévete y Métete en Cintura’ (Move and change your habits) which promotes the concept that a combination of a healthy diet, physical activity and healthy choices creates a healthier society. We are also promoting a culture of self-management, wherein the individual is educated to make healthy choices.

In 2011, according to the National Statistics Institute, in Spain the life expectancy at birth was 82.1 years for both sexes (84.9 years for women and 79.1 for men). In Madrid it is 83.6 years for both sexes (86.1 for women and 80.7 for men).

How many people are diagnosed with diabetes? In 2012, 582 new cases of type 1 diabetes were diagnosed and 28,297 cases of type 2 diabetes. In a screening programme, 290,754 people were tested and just under 20% were found to be positive and required further investigation.

* In 2009, The Union Mexico Office developed the first case study for smoke-free environments, focusing on Mexico City. The successful implementation of the 100% smoke-free city law led Michael Bloomberg to award a 2009 Bloomberg Award for Global Tobacco Control to the Mexico City Secretary of Health.

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a healthy city

Elizabeth Snouffer, Marion Nestle, Armando Ahued Ortega, Rafael Alvarez Cordero, Mónica Hurtado Gonzalez and Pilar García Crespo Elizabeth Snouffer is Editor of Diabetes Voice. Marion Nestle is Paulette Goddard Professor in the Department of Nutrition, Food Studies, and Public Health at New York University. She is author of three prize-winning books including her most recent: Why Calories Count: From Science to Politics (2012). (www. foodpolitics.com, twitter @marionnestle)

The significant development in the last decades of the general socioeconomic status, the development of the health and education systems - both free and universal - and the pension and retirement programmes have contributed to a healthier Spain. The main success factors of the Spanish healthcare system can be attributed to the development of the 1986 Health Act: universal healthcare, the new model of primary care, the development of public health policies, the implementation of a single system with a national test for accessing training for intern and residents doctors, the implementation of administrative systems for the provision of technology to health centres and the salary system was not very high for all public health professionals.

Activity and Obesity Prevention) with the aim of raising awareness among the population on the problem obesity poses to health. This programme promoted initiatives that enabled the public, especially children and adolescents to adopt healthy lifestyles through a healthy diet and regular physical activity. NAOS aims to continue to provide a platform for any action that will help meet this goal. It integrates the efforts of all stakeholders: public, government, experts, private sector. This way, the sectors of action influenced by the NAOS strategy are multiple: family, school environment, businesses and health systems. The Strategy received an award from WHO European Regional Office at the Ministerial Conference in Istanbul in November 2006.

In 2005, the Ministry of Health, through the Spanish Agency for Food Safety and Nutrition, launched NAOS (Strategy for Nutrition Physical

Madrid has adapted the NAOS strategy into their ‘Gente Saludable’ (Healthy people) programme ALAS (diet, physical activity and health).

Armando Ahued Ortega is Health Secretary and Council Vice-president, Council for the Prevention and Comprehensive Care for Obesity and Eating Disorders in Mexico FD, Health Secretariat Mexico Federal District. Rafael Alvarez Cordero is Obesity Programme Responsible of Council for the Prevention and Comprehensive Care for Obesity and Eating Disorders in Mexico FD, Health Secretariat Mexico Federal District. Mónica Hurtado Gonzalez, is the Technical Secretary for the Council for the Prevention and Comprehensive Care for Obesity and Eating Disorders in Mexico FD, Health Secretariat Mexico Federal District. Pilar García Crespo is responsible for the ALAS Programme, Madrid, Spain.

References 1. Obesity and Diabetes in New York City, 2002 and 2004: http://www.cdc.gov/pcd/issues/2008/ apr/07_0053.htm?s_cid=pcd52a48_e 2. R ehm CD, Matte TD, Van Wye G, et al. Demographic and behavioral factors associated with daily sugar-sweetened soda consumption in New York City adults. Journal of Urban Health 2008; 85(3): 375-85. 3. New York Diabetes Coalition. New York Focus on Diabetes: New York State Facts and Figures. www.nydc.or/ny_focus.php 4. Tabaei BP, Chamany S, Driver et al. Incidence of self-reported diabetes in new york city, 2002, 2004, and 2008. Prev Chronic Dis 2012: 110320.

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Health Delivery

Good things come in the Cambodia-Korea Bong Yun Cha and Touch Khun

Professor Bong Yun Cha, Chairman of the Korean Diabetes Association and Dr. Touch Khun, Chief of Diabetology at the Preah Kossamak Hospital in Phnom Penh, Cambodia report on the exciting partnership reflected in the IDF’s Association Twinning Initiative. Learn how people living with diabetes in Cambodia are getting extra help for better care by virtue of the first and more significantly, the second, Cambodia-Korea Twinning Project.

One of the main objectives of the Korean Diabetes Association (KDA) is to increase accessibility to diabetes supplies in many countries around the world where resources are lacking and to better educate general physicians who are not familiar with diabetes. To contribute towards achieving these aims, an IDF Task Force has developed the Association Twinning Initiative (ATI) and KDA was invited to participate. The twinning initiative aims to encourage IDF Member Associations in developed countries to implement projects that will improve access to insulin and diabetes supplies by 'twinning' or partnering with a select number of associations in developing countries. In March 2011, the first Cambodia-Korea Twinning Project was established with support from the KDA and Jeremiah’s Hope Korea for the Preah Kossamak Hospital in Phnom Penh, Cambodia. In total, 1901 patients participated in

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the project along with the assistance of volunteer medical students and doctors. Aspects of the second Cambodia-Korea Twinning Project included professional volunteer care, professional education and distribution of essential diabetes supplies. To begin with, KDA and the Korea Diabetes Research Foundation held a medical volunteering service and medical educational programme in midDecember, 2012 for the Preah Kossamack Hospital. Here, a group of 60 medical staff, including doctors, nurses, and pharmaceutical experts, cared for a total of 1,300 patients and donated 200 million Korean Won (approximately USD 200,000) worth of medical equipment and drugs benefitting the Hospital and the surrounding impoverished neighbourhood. This year's programme also included 12 educational sessions targeted to local medical staff and medical students who will ultimately oversee the treatment of diabetes in Cambodia.

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pairs: Twinning Project

The results of the second CambodiaKorea Twinning Project include: improved access to diabetes treatment and care; improved awareness among diabetes patients; better glycaemic control; better collaboration for new diabetic patients and improved care for people living with diabetes below the poverty line. In addition, effective teamwork has been observed between Cambodian and Korean teams with the diabetes knowledge of hospital staff strengthened by this educational programme. We consider this to be an excellent model for subsequent ‘Twinning Projects’. Additionally, a ground-breaking ceremony for the first Cambodian National Diabetes Centre, sponsored by LG Life Sciences (Seoul, Korea) was celebrated by the Twinning Project. The Centre is scheduled to open by December 2013. It will become the cornerstone of care for Cambodian people living with diabetes. In addition to support offered through

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medical treatment, equipment such as devices, and essential diabetes supplies, the Centre is also expected to establish a Korea-Cambodia reciprocating educational and development programme for medical professionals and students.

Bong Yun Cha and Touch Khun Bong Yun Cha is Chairman of the Board of Directors, Korean Diabetes Association. Touch Khun is Chief of Diabetology Unit, Preah Kossamak Hospital, Phnom Penh, Cambodia.

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Gestational diabetes – an update from India Arivudainambi Kayal, Ranjit Mohan Anjana and Viswanathan Mohan

In recent decades, more women of a reproductive age have diabetes, and more pregnancies are complicated by pre-existing diabetes especially in low- and middle-income countries (LMICs). Also of concern is gestational diabetes mellitus (GDM) - the type of diabetes that is first recognized during pregnancy and affects up to 15% of women worldwide.

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Health Delivery

Gestational diabetes mellitus (GDM) refers to any degree of glucose intolerance with onset or first recognition during pregnancy. Uncontrolled GDM increases the risk of complications both in the mother and baby. Moreover, women with GDM are seven times more likely to develop type 2 diabetes in later life compared to women who have not had GDM.

Approximately 15% of all pregnant women worldwide develop GDM. As a result of the global trend of increased maternal obesity, it is estimated that approximately 15% of all pregnant women worldwide develop GDM.1 Comprising around 90% of all cases of diabetes in pregnancy, GDM left undetected or uncontrolled is a formidable threat to the health of the mother and her unborn child. In low- and middle-income countries (LMICs), where maternal and child mortality are highest, GDM is likely to go undetected and undiagnosed because of poor screening standards and resources. Infants born to mothers with GDM are often characterised as large-for-gestational-age (LGA), a condition that includes greater risk for problems during delivery and a higher risk of future obesity and type 2 diabetes for the child, thus perpetuating the cycle of diabetes for another generation. Most tragically, perinatal mortality is increased around four-times by complications of GDM. International agreement on the clinical criteria and method of detection of GDM has been elusive. In 2009, the results of a multinational study designed to clarify risks of adverse outcome associated with less severe glucose intolerance during pregnancy – the HAPO (Hyperglycaemia and Adverse Outcomes in Pregnancy) study - made it clear that a change in policy was needed in order to save lives.2 Today some guidelines for diagnosing GDM recommend screening for previously undiagnosed type 2 diabetes at the first prenatal visit in women with observable risk factors, and using a 75 g OGTT at 24–28 weeks of gestation for all women not known to have prior diabetes.3 GDM can be managed with oral drugs as well as insulin if required, but Medical Nutrition Therapy is an essential component of the treatment plan for GDM. Best prescribed by a qualified nutritionist or dietician, food plans should be culturally relevant, and propose lifestyle interventions tailored to meet the needs of the patient in order to achieve glycaemic control.4 It is critical that pregnant women who develop GDM

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sustain normoglycemia in order to minimize complications. Irrespective of treatment, blood glucose usually returns to normal after delivery but the risk of developing diabetes in the future should prompt continued surveillance. GDM in India – a country with a heavy diabetes burden India has the second largest number of people with diabetes in the world – currently estimated at 63 million. Not surprisingly therefore, the prevalence of GDM in India is also alarmingly high. Indian women are more likely to develop GDM compared to Caucasian women.5 Estimates of the prevalence for GDM in India vary greatly; from low figures in the northern region of Jammu,6 to higher figures reported in the southern state of Tamil Nadu.7 These widely ranging statistics may reflect a true variation in GDM prevalence throughout the subcontinent, but may also be partially accounted for by discrepancies in protocols for screening and diagnosis, and access to care or changes in risk factors in different geographic regions. Although India offers many central government sponsored vertical national health programmes implemented by the state government through the primary health system, the Government spends only 1.2% of GDP on healthcare. Hence, ‘out of pocket’ spending on health in India is about four times greater than government contributions.8 Health service in the government sector is delivered as a three tier system: primary health care centres (PHCs), and community health care centres (CHCs) are the first points of access for care. District hospitals are the next level and the medical college hospitals are tertiary referral centres. In most cases, district level hospitals manage all health needs. However, a vast majority of individuals utilize services in the private sector where diagnostic and treatment modalities vary considerably.

The prevalence of GDM: 16.2 % in urban areas and 9.9% in rural areas. Tamil Nadu – a state with a plan for GDM Tamil Nadu is one of the southern states of India and also one of the best performing states in terms of health indicators. It has a well-structured public health care system and a dedicated professional cadre to deliver the services with good public–private partnerships. Diabetes is one of the health burdens receiving increased recognition in recent years. The seminal work of Dr. V. Seshiah and colleagues has

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health delivery

Photo taken in one of the primary health centres in rural Tamil Nadu.

revealed the prevalence of GDM to be 16.2 % in urban areas and 9.9% in rural areas.9 Responding to these results, Tamil Nadu adopted the universal screening of all pregnant women for gestational diabetes from 2008.10 Though this policy is a major step towards prevention of GDM related complications, issues remain relating to its implementation at the point of health delivery. A milestone was achieved in 2011 when the Indian Ministry of Health introduced free screening for GDM among the five services offered to pregnant women below the poverty line in the National Rural Health Mission (NRHM) program.

Awareness and knowledge about GDM is very poor even among health care professionals. Nevertheless, many challenges remain Unfortunately problems arise at the outset for maternal health. There is insufficient focus on prevention, and a lack of preconception planning for mothers who are at risk of GDM. Despite the adoption of the government screening policy by public health centres, there is a lack of uniformity in screening criteria, diagnosis and management of GDM in private hospitals and clinics, leading to discrepancies in the care offered by different providers.11 In addition, there is a lack of interdisciplinary coordination at the health system

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level. More generally, awareness and knowledge about GDM is very poor even among health care professionals. Though trained in nutrition during pregnancy, they have no specific training in GDM nutritional management. Barriers of care for the women themselves are mainly related to cost and lifestyle. Cost of treatment, particularly insulin, and general care are both high and unaffordable for the majority of those who need it, leading to limited access for mothers diagnosed as having GDM. Furthermore, advocating dietary modification for pregnant women is not always culturally accepted. Most often, it is the woman who cooks for the whole family and the following of dietary advice specifically tailored to her needs is often not feasible. With regard to postnatal care, the fact that women often deliver in centres near their homes before returning to their families after delivery renders continuing contact after birth difficult if not impossible. Care is further complicated by the fact that a very limited number of primary health centres are equipped to be able to offer insulin treatment. Therefore, many of these cases are referred to higher centres. The woman continues her pregnancy at these higher centres and is not followed up after delivery. In cities, support from the family for the pregnant women is often limited. These factors often result in a lack of long term monitoring of both mother and child.

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Health Delivery

How to improve care for GDM in India A multi-pronged approach is needed to improve GDM care in India. As GDM is a ‘silent’ disease, universal screening of pregnant women should be carried out. While the International Association of Diabetes in Pregnancy Study Group’s (IADPSG) criteria for diagnosis of GDM have been validated in many populations, obtaining three blood samples as required by these criteria might pose a huge challenge in rural areas of India. Hence although the IADPSG criteria may be useful in urban areas and in bigger hospitals, in rural areas and PHCs or CHCs, the older WHO criteria (which require only a single 2 hr post glucose load value of 140 mg/ dl (7.8 mmol/l) or more for diagnosis of GDM) may be appropriate. This has also been recently validated against the IADPSG criteria.11 Improved care of GDM will necessitate large scale training of health care providers, doctors, nurses and village health workers. Also, wherever indicated insulin should be made available free or at subsidized rates so that good control of GDM can be achieved. What are the best strategies for the future? While GDM is a formidable threat to both maternal and child health, and is therefore a barrier to the realization of Millennium Development Goals four and five, it is potentially preventable. The following are some of the key targets in combating GDM: ■ the development of evidence based, simple, cost effective and accessible models of care for women diagnosed with GDM to prevent short and long term complications in the mother as well as the newborn; ■ the integration of these models of care into the existing maternal and child health services both in state and private health centres; ■ increasing the capacity of health care professionals for screening, diagnosis and management of GDM and its complications; ■ improving the awareness and knowledge of health care professionals and expectant mothers about preventing and recognizing GDM and its complications. To achieve these objectives, the identification of a point of entry to the system is crucial to integrate a unified, feasible and effective GDM model of care into existing services. Logically, such an entry point should be the primary health centre. Also, Village Health Nurses, Accredited Social Health Activists and other volunteer groups in the rural area should be targeted for training on nutritional education and awareness activities. In the state of Tamil Nadu, occasions such as maternity picnics

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and bangle ceremonies conducted at primary health centres could be utilized for group counselling and other educational activities on GDM for pregnant mothers.

Arivudainambi Kayal, Ranjit Mohan Anjana and Viswanathan Mohan Arivudainambi Kayal is Project Coordinator based at Madras Diabetes Research Foundation, Chennai, India. Ranjit Mohan Anjana is Joint Managing Director and Consultant Diabetologist of Dr. Mohan's Diabetes Specialities Centre, and Vice President of Madras Diabetes Research Foundation, Chennai, India. Viswanathan Mohan is Chairman and Chief Diabetologist of Dr.Mohan's Diabetes Specialities Centre, and President and Chief of Diabetes Research of Madras Diabetes Research Foundation, Chennai, India.

References 1. International Diabetes Federation. Policy Briefing. Diabetes in Pregnancy: Protecting Maternal Health. IDF. Brussels, 2011. http://www.idf.org/diabetes-pregnancy-protecting-maternal-health 2. Metzger BE, Lowe LP, Dyer AR, et al. HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008; 358: 1991-2002. 3. Metzger BE, Gabbe SG, Persson B, et al. International Association of Diabetes and Pregnancy Study Groups consensus panel. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010; 33: 676-82. 4. Reader DM. Medical nutrition therapy and lifestyle interventions. Diabetes Care 2007; 30: S188-93. 5. Dornhost A, Paterson CM, Nicholls, JS, et al. High prevalence of GDM in women from ethnic minority groups. Diabetic Med 1992; 9:820-2. 6. Wahi P, Dogra V, Jandial K, et al. Prevalence of gestational diabetes mellitus (GDM) and its outcomes in Jammu Region. J Assoc Physicians India 2011; 59: 227-30. 7. Seshiah V, Balaji V, Balaji MS, et al. Pregnancy and diabetes scenario around the world: India. Int J Gynaecol Obste 2009; 104: S35-8. 8. M ohanty SK, Srivastava A. Out-of-pocket expenditure on institutional delivery in India. Health Policy Plan. 2012. doi: 10.1093/heapol/czs057 9. S eshiah V, Balaji V, Balaji MS, et al. Prevalence of gestational diabetes mellitus in South India (Tamil Nadu) - a community based study. J Assoc Physicians India 2008; 56: 329-33. 10. Madhab A, Prasad VM, Kapur A. Gestational diabetes mellitus: advocating for policy change in India. Int J Gynaecol Obstet 2011; 115: S41-4. 11. Nallaperumal S, Bhavadharini B, Mahalakshmi MM, et al. Comparison of the WHO and the IADPSG criteria in diagnosing gestational diabetes mellitus in South Indians. Indian Journal of Endocrinology and Metabolism 2013; (In press).

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Guidelines for type 2 diabetes - designed to help newly diagnosed children and adolescents Warren Lee and Stuart Brink

The prevalence of childhood obesity has increased dramatically worldwide with potentially dire consequences to the health of children and to their future. Drs. Warren Lee of Singapore and Stuart Brink of the USA introduce the new American Academy of Pediatrics guidelines for newly diagnosed type 2 diabetes in children and adolescents, explaining how the evidence-based recommendations are essential for all physicians involved in the care of children.

Type 2 diabetes, which previously was not typically seen until much later in life, accounts for 8% to 45% of new childhood diabetes in the USA according to the TODAY study,1 with a disproportionate representation in ethnic minorities and occurring most commonly among those

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between 10 and 19 years of age. This trend is also occurring internationally. The American Academy of Pediatrics (AAP), an organisation representing the interests of general pediatrician and pediatric subspecialists in the

USA, has recently published a set of guidelines on the treatment of type 2 diabetes in children and adolescents (28 Jan 2013) in cooperation with the Pediatric Endocrine Society and the American Diabetes Association.2 The AAP guidelines recognise how the diagnosis of type 2 diabetes in children and adolescents has become a threat in many communities and because the problem is too formidable for pediatric endocrinologists to address alone, the guidelines call for general pediatric treatment and care. With considerable weight, the guidelines advise: 窶連t any point at which a clinician feels he or she is not adequately trained or is uncertain about treatment, a referral to a

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Clinical care

pediatric medical subspecialist should be made. If a diagnosis of type 2 diabetes is made by a pediatric medical subspecialist, the primary care clinician should develop a comanagement strategy with the subspecialist to ensure that the child continues to receive appropriate care consistent with a medical home model in which the pediatric partners with parents to ensure that all health needs are met.’

The AAP guidelines recognise how the diagnosis of type 2 diabetes in children and adolescents has become a threat in many communities. Features of childhood type 2 diabetes Consider type 2 diabetes diagnosis in a child who presents with the following features: ■ overweight or obese (BMI ≥85th–94th and >95th percentile for age and gender); ■ strong family history of type 2 diabetes e.g., parent or grandparent with type 2 diabetes, gestational diabetes mellitus (GDM); ■ substantial residual insulin secretory capacity at diagnosis of hyperglycaemia (e.g., normal or elevated insulin and C-peptide concentrations) even with ketoacidosis at presentation; ■ insidious onset of disease; ■ demonstrates insulin resistance (including clinical evidence of polycystic ovarian syndrome or acanthosis nigricans); ■ lacks evidence for diabetic autoimmunity (negative for autoantibodies typically associated with type 1 diabetes); ■ more likely to have hypertension and dyslipidaemia than those with type 1 diabetes

The new guidelines include a series of six action statements and a paper outlining the decision making criteria and process. These are useful and timely. The full guidelines and an accompanying technical paper available for download here at http://pediatrics.aappublications.org/content/early/2013/01/23/peds.2012-3494 The ISPAD Guidelines on Diabetes in Childhood which also covers Type 2 diabetes in Childhood and Adolescence) and the Global ISPAD – IDF guidelines are both available at www.ispad.org

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The AAP guidelines have undergone extensive peer review by the American Diabetes Association (ADA), Pediatric Endocrine Society (PES), American Academy of Family Physicians (AAFP), and the Academy of Nutrition and Dietetics. The evidence-based approach to guideline development requires that the evidence in support of each key action statement be identified, appraised, and summarized and that an explicit link between evidence and recommendations be defined. The new guidelines emphasize that insulin should be started when the distinction between type 1 and type 2 diabetes is in doubt and when the initial blood glucose is >250 mg/dl (>13.9 mmol/l) or when the HbA1c at presentation is >9%. This allows for quicker restoration of glycaemic control and, theoretically, may allow islet β cells to ‘rest and recover’. The use of HbA1c >6.5% as well as conventional blood glucose criteria (fasting glucose >126 mg/dl (>7.0 mmol/l), post prandial >11.0 mmol/l

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(>198 mg/dl) or 2 hr glucose >11 mmol/l (>198 mg/dl) is useful in certain instances when an HbA1c is more practical and/ or less expensive than a full 2 hr OGTT. The use of medications (metformin and or insulin) is recommended as an initial and concurrent treatment together with lifestyle changes, namely diet and exercise. However, diet and exercise alone are effective for metabolic control in less than 10% of youths with type 2 diabetes, significantly fewer than in a comparable adult type 2 diabetes cohort, prompting the need for oral medication or insulin. Metformin is an oral medication approved for use in some children in many parts of the world and has a long safety profile compared to many newer, but more expensive, type 2 diabetes oral medications available. The guidelines recommend starting metformin at a low dose of 500 mg daily, increasing by 500 mg every 1 to 2 weeks, up to an ideal and maximum dose of 2000 mg daily in divided doses. Starting at a low dosage helps minimize the frequent nausea side effects of metformin. Moving towards a long-acting metformin also helps prevent nausea and then a slow stepup from 500 mg once-a-day to 500 mg twice-a-day and then 750 mg + 500 mg per day, then 750 mg twice-a-day, and finally 1000 mg long-acting metformin twice-a-day over several weeks allows the metformin to be better tolerated for most patients. Liquid metformin is also available for those unable to swallow tablets. Because metformin's maximum effect may be delayed as much as four weeks, patients with substantial ketosis, ketoacidosis, or markedly elevated blood glucose levels initially should be treated with insulin. In adolescents in whom type 2 diabetes is subsequently diagnosed, 5% to 25% present with ketoacidosis, and

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many also have very low serum insulin and C-peptide levels at presentation. Importantly, these guidelines give practical, worked examples of how to initiate and titrate insulin doses in youngsters with type 2 diabetes, an area with which many family physicians and pediatricians may not be familiar. Although insulin is recommended, a dose range was omitted in the guidelines. The typical insulin requirement in young people with type 2 diabetes may be higher than in typical type 1 diabetes patients of the same age and pubertal staging; insulin requirement of 1-2.5 u/kg/day are often seen, as compared to the 0.5-1.0 u/kg/day requirements in type 1 diabetes. For pediatricians in less resourced settings, it would be useful if the AAP guidelines provided instructions on the importance of blood glucose home monitoring and HbA1c results although these tools need to be modified to suit local needs, including issues regarding availability or affordability and how often such blood glucose monitoring should be done. For example, more monitoring is required at diagnosis and in subsequent weeks when dose decisions are being made, less often for long-term follow-up. While the AAP guidelines address treatment needs of those with diagnosed type 2 diabetes, they do not offer advice about identifying pre-diabetes states such as impaired glucose tolerance and impaired fasting glucose. It is important for experts and professional organisations to also address the issues of how one can improve case finding, the effectiveness of interventions and treatment thus hopefully delaying or preventing type 2 diabetes in childhood and adolescence. Nevertheless, the provision

of links to several web based articles on practical issues like management of hyperlipidaemia is extremely useful. Dr Francine Kaufman, former President of the ADA in commenting on the new guidelines, noted that ‘increasing numbers of paediatricians and primary care providers are doing more around identifying childhood obesity and understanding the risk of type 2 diabetes. The new guidelines on type 2 diabetes treatment essentially say to use metformin and insulin and lifestyle. There is still not much on the other medications used in type 2 in adults. More real studies need to be done.’

Warren Lee and Stuart Brink Warren Lee is Senior Consultant, Endocrinology Service, Department of Paediatric Medicine, KKH Singapore and a former IDF Vice-President. Stuart Brink, MD is Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC) and Associate Clinical Professor, Tufts University School of Medicine, USA.

References 1. Peterson K, Silverstein J, Kaufman F, et al. Management of type 2 diabetes in youth: an update; Am Fam Physician 2007; 76: 658-64. 2. C opeland K, Silverstein J, Moore K, et al. Clinical practice guideline: management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics peds; published ahead of print January 28, 2013, 2012-3494.

http://bit.ly/114QJtS

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W.A.S.H. away the world’s dietary salt Elizabeth Snouffer

The world’s current dietary salt consumption, more than twice the daily amount recommended, is rubbing the wound of declining public health. Increasing evidence suggests that a high salt intake may directly increase the risk of heart disease, stroke, obesity through soft drink consumption, and many other preventable diseases, including cancers. Restricting dietary salt is even more critical for high-risk populations, such as diabetes. In this report we review the serious health consequences associated with high dietary salt intake and speak to Professor Graham MacGregor, Chairman of the World Action on Health and Salt, which has successfully pursued the food industry and campaigned for better consumer awareness. It’s time to expose the facts and refuse that pinch of salt.

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Today, the link between sugar, obesity and disease is largely accepted, but one other common food additive is successfully getting away with murder. It is prominent in popcorn and pizza and people all over the world use the kitchen cupboard version to season gravy or sauce, unaware of the potential consequences. Salt, sodium chloride or table salt is the offending agent, and over-consumption is estimated to cause nearly 2.3 million heart-related deaths worldwide in a single year.1

In 2010, 75% of the world’s population consumed nearly twice the daily recommended amount of salt. A high dietary intake of salt is linked to elevated blood pressure (hypertension), severely increasing the risk of cardiovascular disease, the number

one cause of premature death in the world. Hypertension is also connected to kidney disease. A high salt intake has been linked to osteoporosis and stomach cancer in adults and it has been suggested as an indirect cause of obesity, particularly in children, given that salty foods create a thirst which is often quenched with high calorie soft drinks. In the US, where salt consumption is high, 97% of children and adolescents eat too much salt, increasing their risk for cardiovascular disease later in life.2 In late March this year, the American Heart Association (AHA) reported that, in 2010, 75% of the world’s population consumed nearly twice (4000 mg/day) the daily recommended amount of salt and suggested that 2.3 million lives were lost as a result in that year. Unsurprisingly, most of these deaths occurred in lowand middle-income countries (LMICs). The AHA also reported that 99% of the world’s population exceeds the

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out 1 04/02/2013 12:53 Page 2

According to the World Heart Federation, there are at least 970 million people worldwide who have elevated blood pressure, and 640 million of these individuals live in the developing world. The world’s desire for salt has huge implications for public health in every country today, and indisputable evidence points to the high intake of dietary salt as one of the causes of hypertension. Millions of premature deaths worldwide are attributable to hypertension and the problem is growing worse. By 2025, there will be an estimated 1.56 billion adults living with high blood pressure. As mentioned previously, high salt diets put today’s children at risk for serious long-term health problems, including risk for high blood pressure later in life, but high salt intake is also likely to be contributing to increased rates of childhood obesity and to the development of type 2 diabetes in younger and younger individuals. In 2005, a group of global hypertension experts, nutritionists and cardiovascular

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LOWER

= BLOOD

PRESSURE

LESS

OF = RISK STROKE stroke, Salt raises blood pressure, increasing the risk of . one of the biggest causes of death and disability

WASH

World Action on Salt & Health

World Salt Awareness Week 26th March - 1st April 2012 To learn more visit www.worldactiononsalt.com

Eating too much salt dama health advocates formed ges our health. Salt is also called sodium chloride; it is the sodium in salt that can be bad for our health. an alliance to tackle Ask for less salt please! the worldwide dietary World Salt salt problem. World Awareness Week Action on Health and 11th - 17th March 2013 To learn more visit World Action on Salt & Health Salt (WASH) was eswww.worldactiononsal t.com tablished to encourage populations across the globe to achieve a reduction in dietary salt intake. WASH’s primary for Disease Control and Prevention achievement so far has been to exert (CDC) recommends that high risk poppressure on multi-national food com- ulations limit daily intake to 1500 mg.5 panies for a reduction of salt in food Included in the high risk population products, especially in the United are people over age 40, people already Kingdom. Professor Graham MacGregor, diagnosed with high blood pressure, WASH Chairman and Professor of people of black African descent and Cardiovascular Medicine at the Wolfson people living with diabetes. Institute, London, UK, believes: ‘It is much easier to pursue the food indusThe most responsible try than to depend on public health thing for doctors to campaigns directed at individuals for do when they treat change in individual salt intake’. WASH counts 85 countries as members and people with diabetes recent public health initiatives aimed at is to treat them as salt reduction strategies are taking shape if they have already in Australia, Brazil and South Africa.

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By 2025, there will be an estimated 1.56 billion adults living with high blood pressure.

“Waiter !- there’s soup in my salt !”

WASH

A high risk population: those living with diabetes Currently, WHO recommends that healthy adults limit daily salt consumption to 2000 mg/day, and the US Centers

Charity registration number:

The danger of salt Human beings are genetically engineered to consume less than 250 mg of salt per day,4 and yet, the worldwide average for daily dietary salt intake is as much as 16 times that amount, often more. Consumers all over the world have become both addicted to and comfortably tolerant of the taste of ready meals and salted snacks, soft drinks, and bread, and it isn’t good for us.

LESS SALT

Charity registration number: 1098818

World Health Organization (WHO) recommended limit of 2000 mg/day for healthy adults.3

15:04 Page 1 WASH Stroke poster final AW_Layout 1 22/12/2011

had a heart attack, and go from there.

Tight control of blood pressure in patients with diabetes lowers the already elevated risk of stroke, and heart attack

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Salty Six Foods that can quickly contribute to a sodium overload Breads and rolls:

Cold cuts, cured meats:

Pizza:

Although many breads do not taste salty, one piece can have as much as 230 milligrams of sodium.

Deli and pre-packaged meats can contain as much as 1,050 milligrams of sodium, and sodium is added to most cooked meats to prevent spoilage.

One slice of pizza can contain as much as 760 milligrams of sodium; just two slices will reach the recommended daily salt limit.

Poultry:

Soup:

Sandwiches:

Sodium levels in chicken vary based on how it’s prepared. Just three ounces of frozen breaded chicken nuggets can have 600 milligrams of sodium, while grilled and skinless preparations may have much less.

One cup of canned chicken noodle soup can have up to 940 milligrams of sodium.

This food item combines two of the salty six, cold cuts and bread, with sodium-rich condiments, such as ketchup and mustard. Altogether, a single sandwich can easily surpass the recommended daily sodium limit.

y and Mortality Weekly Report Credit for Salty Six: Centers for Disease Control and Prevention, Morbidit tion– (MMWR), Vital Signs: Food Categories Contributing the Most to Sodium Consump United States, 2007–2008, February 10, 2012 / 61(05);92-98.

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and slows the progression of diabetic kidney disease. Although there is no consensus in restricting salt intake in diabetic patients, Professor Macgregor believes (as do many) that doctors must be as serious about hypertension as they are about blood glucose control and that dietary salt reduction is an important strategy to assist in blood pressure reduction: ‘Since people living with diabetes die of cardiovascular disease more than anything else, the most responsible thing for doctors to do when they treat people with diabetes is to treat them as if they have already had a heart attack, and go from there’.

reflected in the success of the soft drinks industry where salt is a significant determinant of thirst. One sugary, salty drink easily leads a child to drink one more. Strategies utilized by the food industry have been likened to the techniques used by the tobacco industry, and the problem isn’t going away on its own.

Because diabetes and high blood pressure increase the risk of heart attack, stroke and kidney disease, it is important that all people with diabetes maintain a healthy lifestyle by, amongst other things, eating a diet rich in vegetables and whole-grains, limiting processed foods and restricting table salt.

The United Kingdom has been very successful in pressuring food manufacturers to reduce salt, and serves as a role model for the rest of the world. In 2004, Consensus Action on Salt and Health (CASH) conducted a public health campaign to encourage the UK food industry to reduce the salt added to food. This effort resulted in an initiative to label salt content of all packaged foods with a simple colour coded system making it easy for consumers to understand how much salt is in a product at the point of sale. Professor MacGregor believes the cost-effectiveness of salt-reduction strategies have been very worthwhile, ‘A 15% reduction in the UK population’s salt intake has saved a minimum of 9000 stroke and heart attacks every year, and these efforts are saving the UK 2 billion US dollars annually’.

Change of seasoning Approximately 80% of all salt consumed is added at the stage of manufacturing, which makes it very difficult for consumers to control.4 If a reduction in salt intake is to occur worldwide, the food industry must reduce the amount of salt added to food. The problem: industry opposition is a formidable barrier because salt is regarded as an important part of commercial success. Salt makes cheap, unpalatable food market-ready and saleable, and salt increases the amount of water in foods like processed meat, making products heavier by as much as 20%. Some of the largest multi-national food companies in the world market snacks and soft drinks - two of the biggest salt offenders today. The habituation or taste for salty food increases tolerance and desire for more. This scenario is most clearly

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A 15% reduction in the UK population’s salt intake has saved a minimum of 9000 stroke and heart attacks every year.

Unfortunately, the global burden of hypertension-related disease finds its home primarily in LMICs. Tragically, there is little incentive for these governments to develop dietary guidelines or educate their populations about the risk of high dietary salt intake. Although eating too much salt has traditionally been blamed on the use of table salt in

cooking and in preserving foods, this landscape is changing as the food industry targets populations in LMICs with inexpensive high fat, high salt and high sugar foods. Dietary salt reduction needs to be taken seriously for the world’s health future, along with other lifestyle changes, such as increasing physical activity, eating a diet rich in whole grains and vegetables, reducing fat and sugar intake and stopping smoking. National health measures and global public campaigns will save millions of lives.

Elizabeth Snouffer Elizabeth Snouffer is Editor of Diabetes Voice.

References 1. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012; 380: 2224-60. 2. M endis S, Puska P, Norrving B. Global Atlas on Cardiovascular Disease and Prevention and Control. World Health Organisation, Geneva 2011. 3. A merican Heart Association Meeting Report, March 21, 2013. http://newsroom.heart.org/ news/adults-worldwide-eat-almost-doubledaily-aha-recommended-amount-of-sodium 4. H e FJ, MacGregor GA. Reducing population salt intake worldwide: from evidence to implementation. Progress in Cardiovascular Diseases 2010; 52: 263-383. 5. W HO issues new guidance on dietary salt and potassium. Geneva. http://www. who.int/mediacentre/news/notes/2013/ salt_potassium_20130131/en/

www.worldactiononsalt.com

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Debate: how low can you go? The low-down on the low carbohydrate debate in type 1 diabetes nutrition

As a means of representing relevant issues to the diabetes community, Diabetes Voice will be providing a forum in which experts can examine controversial issues and provide an argument supporting their point of view. The low carbohydrate debate marks the first in a series of many more to come. Since the advocacy of intensive insulin therapy following the Diabetes Control and Complications Trial, people living with type 1 diabetes have been subjected to broad nutrition and dietary advice, with varying opinions on the recommended total daily intake of carbohydrate. Current American Diabetes Association (ADA) guidelines suggest a flexible range of carbohydrate, protein, and fat tailored to meet individual preferences, emphasizing the need to monitor

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and match insulin to carbohydrate intake as a means for achieving glycaemic control below or around an HbA1c of 7%. More rigorous goals (<6.5%) are recommended for healthy younger people who have been recently diagnosed. While low carbohydrate diets are recommended for weight loss as an effective short-term (up to two years) measure, there is less clarity regarding the utilization of very low (>30 g/day), or low carbohydrate (30-105 g/day) intake on a permanent basis. According to the ADA guidelines, the moderately low recommended daily allowance (RDA) for carbohydrate intake (130 g/day) is ‘an average minimum requirement’. Many people complain that maintaining even a moderately low carbohydrate diet is counterproductive, making glycaemic

control difficult to achieve, especially when considering the targets for postprandial excursion (1h post meal: ≤140 mg/dl (7.8 mmol/l) or 2h post meal: ≤120 mg/dl (6.7 mmol/l)). Many people with type 1 diabetes, especially those on insulin pump therapy, have opted out of a diet based on 50%-60% carbohydrate intake, and an ‘underground movement’ has prompted some endocrinologists with large numbers of type 1 patients to support their efforts. We have asked two experts with opposing views to weigh in and answer the question: Can a nutritional regimen based on low carbohydrate intake provide safe and more effective glycaemic control for healthy type 1 diabetes glycaemic management?

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clinical care

YES Franziska Spritzler

The optimal carbohydrate intake for nutritional management of diabetes is a hotly debated topic among healthcare professionals and people with diabetes, including those with type 1. Severe carbohydrate restriction was prescribed for this population until

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1922, when the discovery of exogenous insulin made possible the consumption of carbohydrate-containing foods, although often with less than ideal glycemic control. While carbohydrates are the only macronutrient with any discernible impact on blood glucose levels, carbohydrate restriction is currently not considered an acceptable long-term option for diabetes management by most clinicians. The American Diabetes Association has stated that there is no one diet that suits every person, but the majority of dietitians and other healthcare professionals continue to recommend a moderateto-high-carbohydrate, low-fat diet for people with diabetes. Arguments

against carbohydrate restriction include the following: low-carbohydrate diets lack fibre and various micronutrients; diets high in fat, particularly saturated fat, increase the risk of heart disease; and eating fewer than 130 g of carbohydrate per day is unhealthy because this does not meet the glucose needs of the central nervous system (CNS). However, these claims need to be examined. Fibre and all micronutrient needs can be met on a well-formulated low-carbohydrate diet without supplementation. Despite the oft-repeated message that saturated fat increases heart attack risk, this has never been proven; on the contrary, a recent meta-analysis of 21 studies of saturated fat and heart

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disease led researchers to conclude that there is a lack of evidence to support an association between the two.1 Consuming fewer than 130 g of carbohydrate daily poses no risk to health because most of the CNS and the body’s other organs can safely use ketone bodies as a fuel source.2 The few structures requiring glucose can meet needs via gluconeogenesis even with limited carbohydrate intake. An inability to accurately estimate the amount of carbohydrate consumed coupled with varying rates of insulin absorption results in difficulty matching carbohydrate intake to insulin dosage. By reducing the carbohydrate content of meals significantly, there is less potential for inaccuracy, and blood glucose response becomes more predictable. For instance, dosing mealtime insulin for a vegetable omelet calculated at 10 g of carbohydrate rather than its actual value of 13 g carries considerably less chance of postprandial excursion than dosing for a meal of whole grain pasta, chicken, and vegetables estimated at 45 g that actually contains 70 g. Overestimating the amount of carbohydrate in the pasta meal and bolusing a larger dose of insulin places a person at high risk for hypoglycemia, a more urgent concern. Research on low carbohydrate diets in type 1 patients is limited, but what exists is encouraging. Recent studies from Sweden in which individuals were instructed to consume 70-90 g of carbohydrates per day for up to four years found a significant decrease in HbA1c, dramatic reduction in hypoglycemic episodes, and improvement in lipid profiles in those with good adherence.3,4 For the motivated patient,

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following a similar eating pattern or one containing even fewer carbohydrates could result in finally achieving healthy blood glucose levels, thereby reducing risk for microvascular and macrovascular damage. A frequent criticism of carbohydrate restriction is that it is unsustainable long term. The number of people with type 1 diabetes who currently follow a low-carbohydrate diet is unknown, but data from online diabetes communities and anecdotal reports suggest it is fairly large and that the majority find it pleasurable, easy to follow, and practical. One well-known proponent, Dr. Richard K. Bernstein, has been consuming a very-low-carbohydrate diet (30 g/day) for more than 40 years. Still practicing medicine at age 78, he maintains normal blood glucose, HbA1c, and lipid values and has virtually no diabetes-related complications. A well-balanced low-carbohydrate diet – one containing 30-100 g of carbohydrate and a balance of protein, fat, and plants – can be a safe and effective method of attaining desirable blood glucose control and should be offered as an option for people with type 1 diabetes. Although not every person will want to limit carbohydrates in this way, dietitians and other healthcare professionals should support the efforts of those who do rather than try to discourage them. Of course, being followed and monitored by a physician, Certified Diabetes Educator, or other healthcare practitioner well-versed in carbohydrate restriction would be an important component of diabetes management. My hope is that in the near future, all people with diabetes will be afforded this opportunity.

NO Carolyn Robertson

Ignoring the possible threat of weight gain or cardiovascular risk factors for the type 1 diabetes patient, the negative consequences of maintaining a low carbohydrate diet are evident when you review normal physiology. A number of tissues—mainly the brain, red blood cells and nerves – depend solely on glucose as fuel. These tissues cannot synthesize glucose, store more than a few minutes’ supply, or concentrate glucose from circulation. When additional glucose is required, glycogen stores are utilized. However, this supply is limited by the daily intake of carbohydrate and by a limited capacity to store glycogen. The brain requires about 100 g of glucose daily and will typically deplete the liver’s supply of glycogen by the end of an overnight fast.5 Gluconeogenesis functions as the secondary system to assure a continued supply of glucose. The liver’s glucose contribution assures that the brain can function regardless of the dietary actions of the individual. A low carbohydrate diet (less than 100 g/day) forces the system to use proteins and fats to create less efficient alternative fuels and potentially toxic by-products called ketoacids. This creates a situation where the body is releasing glucose into the blood stream in a totally unpredictable manner. Without predictability, the blood glucose control of a person who depends on insulin becomes unstable.

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clinical care

Without endogenous insulin, individuals with type 1 diabetes must calculate the time and the amount of insulin required to accommodate the differing sources of glucose. By using specific information the amount, type and quality of carbohydrate; the blood glucose of the moment; the level of activity and the presence of confounding variables (amount of sleep, stress, infection, hormones etc.) - it is possible to determine how much exogenous insulin is needed.6,7,8 Though challenging, the required insulin dose can be estimated to achieve near normal glucose levels after a meal. Non-dietary (i.e. endogenous) sources of glucose create an insulin-dosing problem since it is near impossible to predict when or how much glucose the liver will release. The person taking insulin is forced to either take insulin proactively and risk a low blood glucose level if the liver does not make its contribution or wait until the blood glucose rises before taking additional insulin. In both cases, blood glucose control is likely to be erratic. Assume three different daily carbohydrate intakes for a person dependent upon insulin: more than 100 g/day; less than 30 g/day; and something in between 30 and 99 g/day. When the intake is over 130 g/day, the glycogen stored by the liver is sufficient to meet the needs of the brain for fuel. Gluconeogenesis, the production of glucose by the liver into systemic circulation, occurs but mostly at night or if there is an unexpected need for glucose (activity, stress for example). With low carbohydrate intake, gluconeogenesis must supply the short fall. If the actual daily intake is less than 20 to 30 g/day of carbohydrate, gluconeogenesis is activated continuously and the liver releases a consistent amount of glucose. The insulin dose required to manage this glucose is mostly basal

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and only small amounts are needed at meal times. However, this degree of carbohydrate restriction is extremely difficult to follow 100% of the time. Most people with diabetes cannot manage this tight regime, and their blood glucose control suffers. A meal plan with a dietary carbohydrate intake between 30 g but less than 100 g/day is even more difficult to manage for a person dependent on insulin. The liver’s contribution to the blood glucose pool is mixed and occurs from both glycogenolysis, glycogen release by the liver, and gluconeogenesis. Since there is no way to predict the liver’s contribution, there is no way to anticipate the dose of insulin needed to prevent elevations and to avoid an excessive fall of glucose. The person with type 1 diabetes is forced to react after the blood glucose levels have changed. Instances of hypoglycaemia and hyperglycaemia occur unrelated to food or fasting. To summarize, a meal plan that consists of less than 100 g/day will result in blood glucose patterns that are erratic. It is almost impossible to design an effective insulin plan that anticipates the peaks and valleys of the resulting blood glucose levels. A low carbohydrate plan is not a good strategy for people with type 1 diabetes largely because they lack effective biological feedback, or the capacity to recognise a change in the liver’s rate of glucose secretion. Low carbohydrate plans for the dietary management of type 1 diabetes lead to erratic blood glucose control frustrating both the person living with diabetes and the diabetes team.

Franziska Spritzler and Carolyn Robertson Franziska Spritzler is Clinical Dietitian at Department of Veterans Affairs and Certified Diabetes Educator, Los Angeles, USA. Carolyn Robertson is a Clinical Nurse Specialist who is certified as a diabetes educator (CDE) as well as board certified in Advanced Diabetes Management.

References 1. Siri-Tarino PW, Sun Q, Hu FB, Krauss RM et al. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr 2010; 91: 535-46. 2. W estman EC, Feinman RD, Mavropolous JC, et al. Low carbohydrate nutrition and metabolism. Am J Clin Nutr 2007; 86: 276-84. 3. N ielsen JV, Joensson EA, Ivarsson A. A low carbohydrate diet in type 1 diabetes: clinical experience – a brief report. Upsala J Med Sci 2005; 110: 267-73. 4. N ielson JV, Gando C, Joensson EA, Paulsson C et al. Low carbohydrate diet in type 1 diabetes, long-term improvement and adherence: a clinical audit. Diabetol Metab Syndr 2012; 4: 23. 5. C hiasson JL, Atkinson RL, Cherrington AD, et al. Effects of fasting on gluconeogenesis from alanine in nondiabetic man. Diabetes 1979; 28: 56-60. 6. D AFNE Study Group; Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomized controlled trial. BMJ 2002; 325: 746-9. 7. R abasa-Lhoret R, Garon J, Langelier H, et al. Effects of meal carbohydrate content on insulin requirements in type 1 diabetic patients treated intensively with the basal-bolus (ultralente-regular) insulin regimen. Diabetes Care 1999; 22: 667-73. 8. S heard N, Clark NG, Brand-Miller JC. et al. Dietary carbohydrate (amount and type) in the prevention and management of diabetes: a statement by the American diabetes association. Diabetes Care 2004; 27: 2266-71.

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Anthropometric indicators of obesity for identifying cardiometabolic risks in a rural Bangladeshi population – Chandra Diabetes Study Akhtar Hussain, A K Azad Khan and Bishwajit Bhowmik

Professor Akhtar Hussain’s aim of studying anthropometric indicators of obesity was to evaluate the predictive ability of body mass index, waist circumference, waist-to-hip ratio, waist-to-height ratio and body fat percentages for the presence of cardiometabolic risks – namely type 2 diabetes, hypertension, dyslipidemia and the metabolic syndrome. Professor Hussain’s research confirms that indices of central obesity better predict cardiometabolic risk factors than general obesity defined by BMI for both men and women and, moreover, that lower cut-off points are needed for people of South Asian origin. If accepted, a positive change in uncovering cardiovascular and metabolic disease earlier would mean an increased opportunity for better outcomes in South Asian populations. Once considered a problem only for affluent countries, obesity has now emerged as an important clinical and public health problem worldwide including middle- and low-income countries. In 2013, the World Health Organisation (WHO) reported that 1.4 billion adults aged ≥20 were overweight, and of these, over 200 million men and nearly 300 million women were obese.1 Epidemiological studies have shown overweight and obesity as an independent risk factor of type 2 diabetes, hypertension (HTN), dyslipidaemia and cardiovascular disease

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(CVD). Central obesity, which suggests excessive deposition of intra-abdominal fat, is also found to be an important predictor of cardiometabolic risk. Furthermore, central obesity is assumed to play a pivotal role in the development of the ‘metabolic syndrome’ (MS), a term given to the clustering of CVD risk factors. Although there are several instruments to measure total body fat and its distribution there is still no ideal method for the measurement of adiposity (diagnostic definitions) or cut-off points that should satisfy the criteria of being

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accurate, precise, accessible and acceptable worldwide.

South Asians have higher body fat percentage than white Caucasians. The concept of different cut-offs for different ethnic groups has been proposed by WHO, because it has become accepted that ethnicity plays a role in the risk for CVD and metabolic disease at lower body mass index (BMI). This might be because of differences in body shape and fat distribution. Studies have shown that for the same age, sex and BMI, south Asians have higher body fat percentage (BF %) than white Caucasians. In Caucasian men, a BMI

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of 30 kg/m2 corresponds to 25% body fat, whereas in South Asian men, a BMI of less than 25 kg/m2 corresponds to 33% body fat.2 Anthropometric measurements still play an important role in clinical practice and epidemiological surveys. BMI is often used to reflect total body fat amounts, whereas the waist circumference (WC), waist-to-hip ratio (WHR) and waist-toheight ratio (WHtR) are used as surrogates for intra-abdominal adiposity. The International Association for the Study of Obesity and the International Obesity Task Force have suggested lower BMI cutoff values for the definitions of overweight (23.0–24.9 kg/m2) and obesity (≥25.0 kg/ m2) in South Asian populations because of the observed differences between popula-

tions.3 However, there are few reports and only a few small studies in the South Asian region based on these cut-off values. To define and compare the cut-off values of BMI, WC, WHR, WHtR and BF% for several cardiometabolic risk factors including type 2 diabetes, HTN, dyslipidemia and MS in a rural Bangladeshi population a cross-sectional study was carried out from March through December 2009 in Chandra, a rural community, 40 km north of the capital city of Bangladesh, Dhaka. It should be noted that the vast majority (72%) of the Bangladeshi population live in rural areas. A total of 2293 subjects aged ≥20 years from rural Bangladesh were randomly selected in a population-based, cross-sectional survey. The association of anthropometric indicators with cardiometabolic risk conditions was assessed

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by using receiver operating characteristic curve analysis and adjusted odds ratios (ORs) for type 2 diabetes, HTN, dyslipidemia and MS. The optimal cut-off values for BMI ranged between 21.2 kg/m2 and 23.6 kg/m2 for men, and 21.8 kg/m2 and 22.8 kg/m2 for women to indicate risk for type 2 diabetes. These values were apparently lower than the values for the Western population (BMI ≥25 kg/m2 for overweight and BMI ≥30 kg/m2 for obesity) and for the Asia-Pacific population (BMI ≥23 kg/m2 for overweight and BMI ≥25 kg/m2 for obesity) that have been previously recommended.3 Optimal values of WC fell into a wide range of 79-90 cm for men and 80-82 cm for women. The optimal WC cut-off values of 90 cm for men and 80 cm for women for MS were similar to the cutoff levels recommended by IDF for the Asian population.4 However, IDF values remained lower than optimal WHR values of 0.93 for men and 0.87-0.89 for women in the present study. Optimal WHtR levels of 0.51-0.53 for men and 0.53-0.54 for women were higher than the present standard for WHtR of ≥0.50 for both sexes and the optimum level of BF% 21.1-21.4% for men were lower than the standard level of ≥25% for men, but the optimal cut-off values of 32.134.9 for women were higher than the standard level of ≥30% for women.5 In the present analysis, more women had central obesity than men, as defined by WHO for the Asian population. This might be a consequence of the division of labour by gender in this culture. Study findings support the contention that central obesity is an important indicator for predicting cardiometabolic risk compared with general obesity as measured by BMI in the South Asian population. Moreover, indices have different

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sensitivities for the prediction of different measures of cardiometabolic risk. In the present study, the most sensitive indices were WHR for type 2 diabetes, BF% for HTN and WC for MS for both sexes; whereas WHtR for men and WC for women were most sensitive for dyslipidaemia. Study findings support that central obesity is an important indicator for predicting cardiometabolic risk compared with general obesity as measured by BMI in the South Asian population a finding which has been verified by a number of other studies as well as pathophysiological mechanisms.

Indices of central obesity better predicted cardiometabolic risk factors than general obesity defined by BMI for both men and women. In conclusion, we projected various anthropometric indices of obesity associated with the risk related to cardiometabolic threats. It should be noted that the risk factors themselves are based on arbitrary cut-offs, and do not necessarily indicate a clinical condition, especially like type 2 diabetes, hypertension, dyslipidemia and MS. Thus, the recommended cut-off values show levels of the anthropometric indices above which the population are screened for cardiometabolic risk. The present data suggested that a BMI of 22 kg/m2 for men and 22.8 kg/m2 for women; a WC of 82 cm for men and 81 cm for women, except for MS which were 90 cm for men and 80 cm for women; a WHR of 0.93 for men and 0.87 for women; a WHtR of 0.52 for men and 0.54 for women; and 21.4% for men and 32.4% for women were optimal cut-offs for defining general and

central adiposity in the adult population of Bangladesh. The present study finding proposed that indices of central obesity predicted better cardiometabolic risk factors than general obesity defined by BMI for both men and women. We therefore recommend that the cut-off values in use for defining obesity as a risk indicator should be readjusted for the population in question.

Akhtar Hussain, A K Azad Khan and Bishwajit Bhowmik Akhtar Hussain is Professor of Chronic Disease – Diabetes, Department of Community Medicine, Institute of Health and Society, University of Oslo and a Vice President of International Diabetes Federation. A K Azad Khan is President, Diabetic Association of Bangladesh and Professor, Department of Public Health, Bangladesh University of Health Sciences, Dhaka, Bangladesh. Bishwajit Bhowmik is a PhD Student, Department of Community Medicine, Institute of Health and Society, University of Oslo.

References 1. World Health Organization. Factsheet No. 311 – ‘Obesity and Overweight’. WHO. Geneva, September 2013. 2. B anerji MA, Faridi N, Atluri R, et al. Body composition, visceral fat, leptin, and insulin resistance in Asian Indian men. J Clin Endocrinol Metab 1999; 84: 137-44. 3. W orld Health Organization Western Pacific Region, The International Association for the Study of Obesity and the International Obesity Task Force. The Asia–Pacific Perspective: Redefining Obesity and its Treatment. Health Communications Australia Pty Limited, Sydney, Australia, 2000. 4. Alberti KG, Zimmet P, Shaw J, IDF Epidemiology Task Force Consensus Group. The Metabolic Syndrome: a New Worldwide Definition. The Lancet 2005; 366: 1059-62. 5. H ortobagyi T, Israel RG, O’Brien KF. Sensitivity and specificity of the Quetelet index to assess obesity in men and women. Eur J Clin Nutr 1994; 48: 769-75.

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Siemens DCA HbA1c Results: A Convenient Aid to Diagnose Diabetes and Pre-Diabetes New clinical guidelines to aid healthcare professionals in diagnosis and treatment Summary: In 2009, an International Expert Committee comprised of representatives from American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) recommended the use of Hemoglobin A1c tests to diagnose diabetes.1

Why measure HbA1c?

Choose a system for accuracy and more

HbA1c measurements represent the degree of glucose exposure over a three-month period and are more useful than relying upon a single or episodic measurement of glucose levels to guide patient management and therapy adjustment.2 Unlike the traditional protocols, HbA1c testing does not require a patient to fast, drink glucose beverages, or be subjected to serial venous blood draws over a three-hour period. It is standardized and aligned to the Diabetes Control and Complications trial and UK Prospective Diabetes study, exhibits less biologic variability and preanalytic instabilty, and is relatively unaffected by acute (e.g., stress or illness related) fluctuations in glucose levels.3

Independently recognized as one of only two methods that meet the accuracy and precision required for in-office testing4, DCA™ analyzers are used by three out of four physicians who perform HbA1c testing in the office.5 They offer: • Simplicity: requires 1 µl sample of capillary or venous blood, no reagent preparation, and 6 minutes to results. • Decision-support tools including A1c trend graphs, estimated average glucose*, albumin-to-creatinine ratio test for early kidney disease detection, and on-board GFR calculator. • Proven DCA technology has been in use for more than two decades with performance documented in more than 140 independent clinical studies. • Precision necessary for tracking HbA1c levels over time: <2.5% co-efficient of variation at clinically significant levels.6 • Good correlation with lab methods: in-house study with 127 patients showed correlation co-effcient of 0.9912 vs. Tosoh.6 • A continuous track record of annual IFCC and NGSP certifications. 2012 CAP proficiency survey results published at www.ngsp.org demonstrate the instrument's precision and accuracy based on results reported by more than 300 DCA system users.

What are the accepted clinical guidelines?3 • An HbA1c level above 6.5% (48 mmol/mol) is an indicator of diabetes. • Diabetic patients should keep HbA1c levels below 7% to minimize the risk of diabetes complications. • Levels between 5.7% and 6.4% (39 mmol/mol to 46 mmol/mol) may indicate pre-diabetes. • Pre-diabetic or at-risk patients should make lifestyle changes or explore pharmacologic treatment. • Measuring HbA1c levels every 3 months is a useful tool for monitoring glycemic control.

Siemens DCA® HbA1c test kit 7 can now be used as an aid to diagnose diabetes and identify patients at risk for developing the disease. Learn more at www.siemens.com/dcadx

References 1. Diabetes Care, Volume 35, Supplement 1, January 2012. 2. Standards of Medical Care in Diabetes - Diabetes Care, Volume 35, Supplement 1, January 2012. 3. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2012;35(Suppl 1):S64–S71. 4. Six of Eight Hemoglobin A1c Point-of-Care Instruments Do Not Meet the General Accepted Analytical Performance Criteria, Erna Lenters-Westral, et al., Clinical Chemistry January 2010 vol. 56 no. 1 44-52. 5. GHX Market Intelligence, market data report. Q4 2012 Report. 6. DCA Systems Hemoglobin A1c Addendum to Instructions for Use. 10698776 Rev A, 2012-08. 7. Not all product offerings are available in all countries. Not available for sale in the U.S. Kit#10698915. *Not available in the U.S.

For additional information visit www.siemens.com/dcadx Not all product offerings are available in all countries. Not available for sale in the U.S./Kit#10698915.

Diabetes in society

Voices of type 1 diabetes: doing my best each and every day

Voices of type 1 diabetes is a new Diabetes Voice instalment reflecting the personal burden of diabetes in society. This new series will present individual stories from all over the world and provide an opportunity to appreciate different perspectives about life with type 1 or type 2 diabetes. In this first edition, voices from the type 1 diabetes community share their thoughts about every day life beyond diagnosis.

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People living with type 1 diabetes, an incurable, auto-immune form of the condition, must be vigilant about blood glucose levels and disciplined about diet, exercise and keeping healthy – 24 hours a day, 7 days a week. Children and adults living with type 1 diabetes often express that the worst thing about diabetes is its relentless nature; there is no vacation from endless testing and daily injections. Type 1 diabetes insulin therapy necessitates a keen mind for trouble-shooting, and an uncanny knowledge for nutrition and carbohydrate quantities if complications are to be kept at bay.

Often misunderstood in some communities, diabetes can be invisible to others. If recognised and unfairly judged, discrimination may follow. People living with type 1 diabetes must often overcome prejudice and learn how to live a functioning life regardless of difficulty. It’s a full-time job. We asked four exceptional people living with type 1 diabetes at different stages in life and in different areas of the world – Austria, Tanzania, United Arab Emirates and India – to describe their daily routine or any challenges they might face at present. Here’s what they had to say:

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Diabetes in society

Mohammed Hamoud, Life for a Child Programme recipient crying too much and urinating a lot. My dad always gave me some soda so I would stop crying, because he didn’t know what to do or what was wrong with me. Finally, he took me to the Mnazi Mmoja Hospital and told the doctor I needed help. The medical staff saw that my blood glucose was high and told my dad it was diabetes. My dad thanked God, because some people told my dad he should go to the witch doctor as I might have a ghost. Then my dad took me to Dar es Salaam where we met my doctor. We were very lucky to have met this doctor because he gave me insulin and saved my life. Since I was diagnosed so young, I have grown up living with diabetes. I feel OK about that.

‘I am 19 years old and I am from Tanzania. I was diagnosed with diabetes when I was just two years old. I was the first child in Zanzibar to be diagnosed with type 1 diabetes. The story of my diagnosis is important to me, and something I still think about today. When I was two years old, I was

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Now I am attending college, and I feel like a normal person. No one mistreats me and my friends help me when I need assistance. I love sports and I play football, swim and try to do like 100-150 push-ups a day because exercise helps me better control my diabetes. I take fruit to school in case of low blood sugars, and eat healthy every day. I usually check my blood glucose twice a day, but supplies in our hospital are low just now so it is three times a week at present. Most of the time I am between 5 and 8 mmol/l (90 -144 mg/dl). That's how I manage my diabetes.’

Maria Hillinger is 25 years old and was diagnosed with type 1 diabetes in 2004. She lives in Austria and is studying at Linz on a degree programme in social economics. Maria has been an IDF Young Leader since 2011.

‘I open my eyes and look at the clock. It’s 5 am. No, that’s not my usual time for waking up in the morning. I normally wake up when I am not feeling well, so I test my blood sugar because it might be too high or too low. I look down at the blood glucose meter result, which says 180 mg/dl. There is no reason for a number like 180 and I try to figure out the cause for my elevated blood sugar. Did I miscalculate my carbohydrates? Did I forget to check my blood sugar before I fell asleep? My life is like this a lot. When I see a high or low blood sugar on my glucose meter, I wonder what I could have done wrong. Perhaps this is not the best way to cope with my diabetes, but I believe many people like me do the exact same thing. I use an insulin pump to manage insulin therapy and it’s easy to correct a mild “high” like 180 mg/dl. I give myself a correction bolus of insulin with the push of a button. I am still in bed and fall back asleep very quickly. High blood sugars have a way of making me feel exhausted.

http://www.idf.org/lifeforachild

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Ahmed Hussein and Rasha Noureldin are a married couple who live in the United Arab Emirates. Ahmed is 34 years old has been living with type 1 diabetes for more than 16 years. He is an Egyptian civil construction engineer and she is a pharmacist. Ahmed depends on Rasha to help him care for his diabetes, and calls her his ‘maestro’. Below Ahmed discusses how important it was when he finally met someone who accepted his diabetes, and Rasha discusses how she helps Ahmed care for his type 1 diabetes.

‘The ups and downs are a part of my life. I stay positive.’

At 9 am, the alarm goes off and I wake up again, but this time my blood sugar is 95 mg/dl, which is very good. Unfortunately, I’m not hungry because if my sugar was elevated the entire night, it can suppress my appetite. Nevertheless, I have to eat something before going to the fitness centre. I eat one banana or a cereal bar and reduce the basal rate on my insulin pump to 80% in order not to have hypoglycaemia or a low blood sugar while I work out. As a precaution, I carry glucose tablets and my glucose meter with me to the gym. After I exercise, I check my blood sugar and use my insulin pump again for another bolus of insulin otherwise I might get another high blood sugar later.

DiabetesVoice

For lunch, I decide to have noodles with sauce – pretty typical for a student – but I have to weigh the noodles first, because it’s impossible to estimate by sight how many grams of carbohydrate are in a handful. I start calculating and figure I need one unit of insulin for 12 g of carbohydrate. After lunch, I work on my thesis, which is a diabetes related topic. Two hours after having food I am checking my blood sugar again. I have a bit of a headache and I am feeling tired again. The result of my blood glucose test is 220 mg/ dl. What can I say? The ups and downs are a part of my life. I stay positive and try to look forward to a stable blood sugar for the rest of my day.’

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Diabetes in society

Ahmed: ‘Before I met Rasha, I wandered between Egypt and UAE for a couple of years, searching for my soul mate. I often bumped into people who did not accept the idea of partnering with me because of my diabetes. Last year, my heart fell into the hands of Rasha, who accepted my diabetes and believes that people living with diabetes have the same rights as healthy individuals to live, love, and build a family. Since we married, my life has become warmer and rosier and today, we are living every moment anticipating the arrival of our first child in four months!' Rasha: ‘Even though I am a trained pharmacist, the skills I learned did not include a complete understanding on how to properly manage type 1 diabetes. When I met Ahmed, I realised I was too uninformed about his diabetes, and I read all I could to learn about the dietary requirements for Ahmed, including cooking foods low in fat and sugar as well as

‘When diabetes is a part of family life, it is very important that everyone in the family understands all the diabetes requirements and helps their loved one try to live a stable life.’ paying attention to dietary proteins and whole grains. I also started accepting the idea that eating whole grain carbohydrates would even improve my health and lifestyle. On a daily basis, I ensure that Ahmed's meals are taken on time and in an organised manner. Every morning, I wake up early and prepare his meals so he will avoid eating junk food, which hurt him in the long run. Since blood glucose testing technology has vastly improved over the years, the new smaller sized blood glucose meters

make it very easy to monitor Ahmed’s blood glucose levels frequently. I make sure Ahmed takes his blood glucose meter with him everywhere he goes and I find it very easy for him to test especially when I insist that he tests frequently! In terms of troubleshooting, I always keep sweets in Ahmed's pocket so that if he suddenly feels hypoglycaemia or a low blood sugar, he immediately takes sugar or glucose. He keeps sweets at his work desk, in his car, at home, and in his pocket. When diabetes is a part of family life, it is very important that everyone in the family understands all the diabetes requirements and helps their loved one try to live a stable life. One of the reasons Ahmed and I do so well is because we are so very cooperative with each other. We do our best to understand all the requirements. Ahmed’s engineering studies have made him extremely good at planning and organising and we have a good team of doctors amicably assisting and helping us out whenever the need arises.’

Postscript: After dealing with the shock of his type 1 diabetes diagnosis, Ahmed founded a non-profit organisation called Diabetic Youth Care Association (DYCA) at www.diabetes-egypt.com. The mission of the organisation is to help people avoid live healthier and avoid diabetes complications.

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Saranya is a 24 years old woman living with type 1 diabetes in Chennai, India. In less than a month, Saranya will give birth to her first child. She is looking forward to motherhood and has generously agreed to discuss her life with type 1 diabetes and pregnancy. ‘I was diagnosed with type 1 diabetes when I was 12 years old. I was in 7th grade, and before diabetes, I was a happygo-lucky girl. I was active, and did well in school and sports. After my diagnosis, I took my diet very seriously but in truth, I hated the painful injections I was required to take each day. I worked hard on overcoming social fears, keeping appointments with my doctor, checking blood sugars regularly and eating well. Fortunately, when I graduated from university and began working, I understood the importance of informing friends, and office co-workers about my condition, especially about the risk of hypoglycemia and what happens to me during low blood sugar episodes. I dislike pity and my co-workers understood this about my nature and supported me. Perhaps

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this is why I met my future husband at work. We discussed the risks associated with diabetes complications and our life ahead, including having a child and the difficulties associated with diabetes and pregnancy. Our families were concerned with our decision at first, but have since become supportive of our decision to have a child.

‘ My pregnancy has been a big challenge for me, but I am excited for motherhood.’ When I became pregnant, I stopped working so I could take better care of myself. One of the hardest things about pregnancy was a change in my appetite and the development of food cravings. There are meal-planning guides for diabetes

in India, but I couldn’t find a guide for diabetes and pregnancy, and neither the doctor nor the dietician helped me much. Because of the lack of information, I had quite a few severe low blood sugars early in my pregnancy because my insulin doses were too high and my diet wasn’t adequate. Now that I am in my 9th month, things have improved. Another challenge was my lack of understanding with healthy weight gain and pregnancy. None of the health professionals caring for me could assist me with my concerns related to weight management. Instead, I turned to the Internet as my only resource for information, which was helpful. My doctor also told me how I should use my own judgment to modify my diet according to my insulin doses, but I found this very difficult to do successfully. My pregnancy has been a big challenge for me, but I am excited for motherhood. My husband and the entire family are waiting for our new arrival with a lot of enthusiasm. I worry because I want to do the best I can for the baby. I don’t want our child to suffer with diabetes like me.’

June 2013 • Volume 58 • Issue 2

TAKE A STEP FOR DIABETES watch our motivational video # 24 in groups

DIABETES ADVOCATES

India 350,000 STEPS

taken so far

Took 1,500 steps on March 15, 2013 Their total number of steps as of today is 3,500.

MARIA from Portugal took 3,500 steps in total

Help us reach 371,000,000 STEPS

http://steps.worlddiabetesday.org

Did you know?

Elsevier also publishes Diabetes Research & Clinical Practice together with its A1chieve Resource Center. Visit www.A1chieve.com for more information.

Presenting The Lancet Diabetes & Endocrinology, the latest title in The Lancet portfolio dedicated to covering diabetes, endocrinology, and metabolism. Following in the The Lancet tradition, each monthly issue will include original research, expert reviews, informative commentary, and breaking news — all of which will provide a clear, independent perspective and keep you well-informed about the clinical advancements and practice-changing research shaping your specialty. Why not acquaint yourself with the journal today? ■

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Browse a selection of freely available papers published online in advance of our first issue, which will be published August 2013. Read more about the scope and aim of the journal and consider us for publication of your original research, review, or personal view. Stay informed about the journal’s developments in the lead up to launch by registering for email alerts of newly published articles and other relevant freely available online content.

Learn more at www.thelancet.com/diabetes-endocrinology, or submit a manuscript at http://ees.elsevier.com/thelancetde.

in delivering science for better health