Lancet Panel Calls for Urgent Global Action to Combat Diabetes

Miriam E. Tucker

November 13, 2020

A panel convened by The Lancet has published a comprehensive report calling for major initiatives to improve diabetes prevention and care around the world.  

The article, entitled, The Lancet Commission on Diabetes: Using Data to Transform Diabetes Care and Patient Lives, was published online November 12, just ahead of World Diabetes Day.

Of the 463 million people with diabetes worldwide in 2019, 80% live in low- and middle-income countries. The condition reduces life expectancy in middle-aged adults by 4 to 10 years, including increasing the risk of death from cardiovascular disease, kidney disease, and cancer by up to threefold. It is also a leading cause of nontraumatic amputation and blindness.

Use of evidence-based interventions, if implemented and managed properly, could prevent thousands of deaths globally every day, stress the Commission.

"There is an enormous amount of knowledge that we have amassed over the years. We need good preventive care and we need to ensure that diabetes patients, once diagnosed, have good continuous care. There is an urgent need for decision-makers, policymakers, and payers to make things happen," the leader of the multidisciplinary commission, Juliana C.N. Chan, MBChB, MD, told Medscape Medical News.

And now diabetes has emerged as a major risk factor for death from COVID-19, particularly in the setting of inadequate glycemic control. 

"COVID-19 has exposed the vulnerability of individuals with diabetes," said Chan, of the Hong Kong Institute of Diabetes and Obesity.

"We should use the pandemic as an opportunity to implement solutions."

Physician Education Key, Trickling Down to Field Workers and Patients 

First on the agenda, she says, should be "physician education. There are many primary care providers and internal medicine physicians whose knowledge needs to be updated."

"Then doctors need to transfer this information to other people, such as nurses and community field workers. We cannot just rely on doctors; we need to train nonmedics" so that knowledge about how to prevent, treat, and manage diabetes long-term is communicated right down the healthcare chain, she explained.

"They need to know how to look at people's eyes and feet, how to do blood and urine tests, and how to collect data. Then they need to educate patients on what they should be doing, on how to practice self-care," she added.

"We need to change our way of thinking, redesign clinic flow and how you build a team. And those care teams need to know how to collect data, and then use that data to monitor patients and to stratify individual risk, to ensure that what has been said has been done, as well as to inform practice and policies," through, for example, the establishment of diabetes registers.

The focus needs to be on "lifelong integrated care, the right treatment at the right time," she emphasized. History-taking, clinical and laboratory assessments, as well as monitoring of macrovascular and microvascular complications, comorbidities, and medications are all key.

Just a few simple things, if properly implemented, could make a big difference, Chan stressed.

For example, implementing a structured lifestyle intervention and use of metformin can each prevent or delay type 2 diabetes in individuals with impaired glucose tolerance by 30%-50%, and sustained weight reduction in patients with obesity by 15 kg (33 lb) or more can induce remission of type 2 diabetes for up to 2 years.

And there are plenty of medications that are "very affordable even in low- and middle-income countries" to treat diabetes and associated risk factors, including metformin, "statins, and RAS inhibitors," she noted.

For instance, the 10 low- and middle-income countries with the greatest burden of diabetes (China, India, Brazil, Mexico, Indonesia, Egypt, Pakistan, Bangladesh, Turkey, Thailand) account for 217 million cases of type 2 diabetes, representing nearly 50% of all diabetes cases.

The Commission estimates that 3.2 million of these individuals would die in 3 years if not treated, with 1.3 million of these deaths due to cardiovascular disease.

By reducing A1c, blood pressure, and LDL-cholesterol through achieving a diagnosis rate of 50%, ensuring access to essential medicines in at least 70% of patients, and with a support system to sustain reductions in these risk factors over 3 years, up to 800,000 premature deaths could be avoided.

People With Type 1 Diabetes Dying; WHO Launches Initiative  

In an accompanying commentary, Katie Dain, chief executive officer of the Noncommunicable Diseases (NCD) Alliance, points out that only half of people living with diabetes around the world — and just one in seven in Africa — have reliable access to insulin.

"Lots of people with type 1 diabetes are still dying due to lack of insulin," Chan told Medscape Medical News. "We need to elevate basic care to intermediate and ensure that basal-bolus insulin and glucose-monitoring tools are available and that patients are trained in self-care. In that way, 80% of type 1 diabetes deaths could be prevented."

Dain agrees, stressing, "Political rhetoric and commitments have yet to translate into sufficient and sustainable action for people living with diabetes worldwide, and particularly for those in [low- and middle-income countries]."

The Lancet Commission document also emphasizes the importance of support for pregnant women with diabetes and attention to the psychosocial needs of people with diabetes.  

And it stresses "society, population, and community-based strategies" for type 2 diabetes prevention including health awareness programs, food policies, and broad use of nonphysician personnel to deliver diabetes prevention efforts.

In tandem with World Diabetes Day, the World Health Organization (WHO) will announce the development of the WHO Global Diabetes Compact, which will be launched in April 2021.

This will aim to implement the Commission's recommendations through partnerships with governments, care providers, patient advocates, and nongovernmental organizations.

Together, they will "support countries to mobilize resources and accelerate structural transformations, which will enable the scale-up of access to essential diabetes medicines and technologies, inclusion of diagnosis and treatment of diabetes in primary health care and universal health coverage packages, and reduction of major population-level diabetes risk factors such as obesity," according to another Lancet editorial accompanying the report.

"The evidence-base for improving diabetes prevention and care is strong. The question now for diabetes advocates is how to achieve the comprehensive, systems-level change needed to translate this evidence into action." 

Chan has reported receiving grants from AstraZeneca, Lilly, Lee Powder, Hua Medicine, and Qualigenics; and grants and personal fees from Bayer, Boehringer Ingelheim, Sanofi, Novartis, Merck, and MSD outside the submitted work. She has reported being the chief executive officer (pro bono) of the Asia Diabetes Foundation and a cofounder of GemVCare. She also holds a patent for genetic markers for diabetes and its complications. Dain has reported no relevant financial relationships.

Lancet. Published online November 12, 2020. Full text, Editorial

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