Diabetes is a chronic, and largely preventable, disease that can lead to cardiovascular disease, blindness, kidney failure, loss of limbs and loss of life. It causes suffering and hardship for the approximately 60 million people in the European Region currently living with the disease, while also straining the Region’s economies and health systems.
Prevalence of diabetes is increasing in the European Region, already reaching rates of 10-12% of the population in some Member States. This increase is strongly associated with increasing trends towards overweight and obesity, unhealthy diets, physical inactivity and socioeconomic disadvantage. These risk factors also contribute to the development of the other three noncommunicable diseases (NCDs) that have become international public health priorities (cardiovascular disease, chronic respiratory diseases and cancer), making it imperative that the prevention of diabetes be integrated into population approaches to prevent NCDs as a group.
What is diabetes?
Type 1 diabetes
Type 1 diabetes is characterized by deficient insulin production and requires daily administration of insulin. Type 1 diabetes is not preventable with current knowledge.
Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly, and the disease may present as an acute condition.
Type 2 diabetes
Type 2 diabetes results from the body’s ineffective use of insulin (insulin resistance). It accounts for 90% of people with diabetes around the world and is largely preventable. Excess body weight - especially around the waist, physical inactivity and a high intake of saturated fatty acids all independently increase the risk of insulin resistance. This risk is heightened even with modest weight increases within the normal range (Body Mass Index under 25). Development of type 2 diabetes has also been associated with other factors, such as ethnic group, experiences and influences in early life, and socioeconomic factors.
Symptoms may be similar to those of type 1 diabetes, but are often less marked. As a result, the disease may be diagnosed several years after onset, once complications have already arisen.
Type 2 diabetes was until recently seen as a disease of middle-aged and elderly people, but its frequency has escalated in all age groups and the condition is now increasingly seen in adolescence and childhood.
Impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to type 2 diabetes, although this is not inevitable.
Gestational diabetes
Gestational diabetes is hyperglycaemia with onset or first recognition during pregnancy.
Symptoms of gestational diabetes are similar to type 2 diabetes. Gestational diabetes is most often diagnosed through prenatal screening, rather than reported symptoms. It is generally temporary, but women with gestational diabetes may develop type 2 later in life.
Risk factors
Patterns of disease differ by ethnic group: type 2 diabetes is up to six times more common in people of South Asian descent and up to three times more common among those of African and African-Caribbean origin.
Diet: Eating high levels of refined carbohydrates and saturated fat and not enough fruits and vegetables contributes to weight gain, thereby increasing the risk of diabetes.
Physical inactivity: Studies have shown that just 30 minutes of moderate exercise a day, five days a week is enough to promote good health and reduce the chance of developing type 2 diabetes.
Overweight and obesity (BMI over 25 kg/m2) have been estimated to account for about 65–80% of new cases of type 2 diabetes. The risk is a function of the age of onset and the duration of obesity, and weight gain during adult life. Overweight people run a lower relative risk than obese people, however the fraction of disease attributable to overweight may be as high as, if not higher than, that due to obesity. This demonstrates the importance of preventing weight gain in all ranges.
Low birth weight is associated with increased risk of developing type 2 diabetes.
Age: The older a person is, the greater their risk of diabetes. However, type 2 diabetes is increasing in all age groups and is now also reported among children and adolescents.
Gestational diabetes: Women who have had gestational diabetes (GDM) have an increased risk of developing type 2 diabetes in later years. GDM is also associated with increased risk of obesity and abnormal glucose metabolism during childhood and adult life in the offspring.
People with a family history of type 2 diabetes are at greatly increased risk of developing the disease.
Socioeconomic disadvantage contributes to the development of diabetes and its complications through inequitable access to quality treatment and environmental conditions that promote unhealthy choices.
Studies of the diabetes epidemic suggest that modifiable risk factors explain about 80% of the increase in prevalence.
Socioeconomic determinants: Almost 80% of diabetes cases occur in low- and middle-income countries. However, high rates of diabetes are also found among the lower-income groups in many middle- and high-income countries. For example, morbidity from diabetes complications is three and a half times higher among the poorest people in the United Kingdom than the richest.
Though type 2 diabetes is largely preventable, it is unfair to believe that people have only themselves and their lifestyle to blame. Individual responsibility is important, but governments and societies must also play a part. In general, energy-dense, nutrient-poor foods, such as refined grains, added sugar and fats are not only convenient and tasty but also less expensive than nutrient-dense lean meats, fish, fresh vegetables and fruit. Healthy choices are easier when the policy environment nudges people in that direction or when the environment makes them the automatic choices.
Common consequences
If diabetes is not managed correctly, sufferers are likely to become progressively ill and debilitated. Over time, diabetes can damage the heart, blood vessels, kidneys, eyes and nerves.
50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke), and 10-20% of people with diabetes die of kidney failure.
Long-term accumulated damage to the small blood vessels in the eye leads to diabetic retinopathy, an important cause of blindness. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment.
Damage to the nerves (diabetic neuropathy) affects up to 50% of people with diabetes. Although many different problems can occur as a result of diabetic neuropathy, common symptoms are tingling, pain, numbness, or weakness in the feet and hands. Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation.
The overall risk of dying among people with diabetes is at least double the risk of their peers without diabetes.
Prevention
Many of the health risks associated with increasing body weight first appear in children and young people.
To help prevent type 2 diabetes and its complications, people of all ages should achieve and maintain healthy body weight; be physically active, eat a healthy diet and avoid tobacco use (smoking increases the risk of cardiovascular diseases).
Individuals with impaired glucose tolerance (IGT) or impaired fasting glycaemia (IFG) are in the intermediate stage between normality and diabetes and are at high risk of developing type 2 diabetes. This risk can be drastically reduced through intensive lifestyle modification and pharmacological intervention.
The public and private sectors also have an important role to play in developing and implementing policies and programmes that increase knowledge about diabetes, its prevalence and consequences, encourage and provide greater opportunities for greater physical activity, and improve the availability and accessibility of healthy foods.
Diagnosis and treatment
Type 2 diabetes can be diagnosed at an early stage through relatively inexpensive blood testing. However, 50% of people with diabetes may be undiagnosed.
Treatment of diabetes involves lowering blood glucose and the levels of other known risk factors that damage blood vessels. People with type 1 diabetes require insulin; people with type 2 diabetes can be treated with oral medication, but may also require insulin. Other important measures include control of blood pressure and cholesterol level, foot care, and regular screening for retinopathy and early signs of diabetes-related kidney disease. Treatment should be supported by a healthy diet, regular physical activity, maintaining a healthy body weight and avoiding tobacco use.
Training for self-management strategies in people with type 2 diabetes is effective in improving fasting blood glucose levels, glycated haemoglobin and diabetes knowledge and in reducing systolic blood pressure levels, body weight and the requirement for diabetes medication.