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17 September 2012
The real tragedy concerning the introduction to insulin therapy for type 2 diabetes (T2DM) is they will have to follow a healthy regime, which had they followed on first recognition of pre-diabetes/diabetes may well have prevented or delayed the progression of this disorder and its complications.
The sheer scale of the T2DM problem means seeing an expert who can give meaningful care is a rarity. Hence the major problems experienced in diabetes care as honestly described by diabetologists Kilvert and Rayman recently published in the BMJ (1)
The misinformation and misconceptions surrounding diabetes still continue unabated. Much of the public health information for diabetes is produced by commercial interests such as the drug and food industry, surely an unacceptable situation?
Whilst the diabetes crisis deepens in the developed world, the situation in the developing world is dire. Rapid uncontrolled urbanisation and major changes in lifestyle is thought to be driving this epidemic (2)
The current problems of unaffordable insulin experienced in many countries were recently highlighted in 2011 by an article by Deborah Cohen in the BMJ. (3) The supply of insulin to those with T2DM in the UK is in stark contrast to children suffering from type 1 diabetes (T1DM) in the developing world. Unavailability of insulin is immediately life threatening. The life expectancy of a child with newly diagnosed T1DM in much of sub-Saharan Africa varies between 7 months and 7 years, depending on the country. (4) Type 1 diabetes cannot be prevented.
The availability of insulin has the added problems of: refrigeration, regular distribution, a regular food supply, needles, blood testing equipment and education on diabetes management for the basics of continuous care.
The developing world does not have the facilities or the financial resources to overcome the problems of diabetes (both types). On average, there are 15 times the numbers of doctors and 8 times the number of nurses in Europe compared to Africa. (5) The World Health Organization estimates that the global shortage of trained health care staff exceeds four million. (6) Malawi, for example, has just one doctor per 50,000 people compared to the United States with one per 390 people. (7) The age of onset of T2DM is said to be decreasing in countries such as Sub-Saharan Africa (8) where the peak occurrence of T2DM is between the ages of 20 and 44, (encompassing the reproductive age group) already 40 years lower than the peak age of occurrence in high income countries, the highest diabetes (T2DM) prevalence is in people of Indian origin, followed by native Africans. (9)(10)(11)(12)
With the age of (T2DM) affecting increasingly younger people prevention of the disorder should be the highest priority. Education and public policies need to be addressed. Professor Gale, a diabetes specialist, describes the progression to insulin use in uncontrolled type 2 diabetes (T2DM)(13). However (T2DM) in the UK is treated within primary care (without diabetes specialist expertise). This represents a serious cause for concern. Are we also to assume that progression to insulin therapy should be the norm for both the developed and the developing world?
(1) Kilvert A Rayman D The crisis in diabetes care in England BMJ 2012;345:e5446
(2) Diabetes in sub-Saharan Africa. The Lancet, Volume 375, Issue 9733, Pages 2254 - 2266, 26 June 2010. Prof Jean Claude N Mbanya MD, Prof Ayesha A Motala MD, Eugene Sobngwi MD, Felix K Assah MD, Sostanie T Enoru MD.
(3) Deborah Cohen. Non-communicable Diseases. The prickly problem of access to insulin. BMJ 2011; 343:d5782
(4) Beran D, Yudkin JS. Diabetes care in sub-Saharan Africa. Lancet2006;368:1689-95.
(5) World Health Organization (2007), 'World Health Statistics 2007'
(6) WHO (2010) 'HIV/AIDS Programme Highlights 2008-09'
(7) UNAIDS (2008) 'Report on the global AIDS epidemic(
(8) Alberti KG, Zimmet P & Shaw J. International Diabetes Federation:A consensus on type 2 diabetes prevention. Diabetic Medicine. 24,451–463. 2007
(9) Levitt NS, Steyn K, Lambert EV, et al. Modifiable risk factors for type 2
Diabetes mellitus in a peri-urban community in South Africa. Diabetic
Medicine. 16, 946–50. 1999
(10) Omar MA, Seedat MA, Dyer RB, et al. South African Indians show
A high prevalence of NIDDM and bimodality in plasma glucose
distribution patterns. Diabetes Care. 17, 70–74. 1994
(11) Ramaiya KL, Swai ABM, McLarty DG, et al. Impaired glucose tolerance and diabetes mellitus in Hindu Indian immigrants in Dar es Salaam. Diabetic Medicine. 8, 738–44. 1991
(12) McLarty DG, Swai AB, Kitange HM, et al. Prevalence of diabetes
and impaired glucose tolerance in rural Tanzania. The Lancet. Volume 335, Issue 8690, Pages 661 – 662 (1990)
(13) Newer insulins in type 2 diabetes. BMJ 2012;345:e4611. Edwin A M Gale.
Competing interests: None declared
Independant, Penrhyn Close, Kenilworth Warks
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