Monday, 5 July 2010

Type 2 Diabetes—Time to Change Approach

Type 2 Diabetes—Time to Change Approach

Four Articles add precision to cardiovascular risk in people with type 2 diabetes, or describe new strategies in pharmacological pathways, dosing, and delivery. More studies will be published online during the meeting to coincide with a Lancet/ADA symposium. They will consider the treatment of women with diabetes during pregnancy, therapeutic comparisons in type 2 diabetes, and further results from the ACCORD study. Two Seminars examine diabetes mechanisms and epidemiology. In their totality, these publications represent great progress in the understanding of diabetes and the ability to lower concentrations of blood glucose. But there is a glaring absence: no research on lifestyle interventions to prevent or reverse diabetes. In this respect, medicine might be winning the battle of glucose control, but is losing the war against diabetes.

Since 2000, the number of people with diabetes has more than doubled to 285 million. An increasing majority, over 200 million people, live in low-income and middle-income countries where few will benefit from the advances in today's issue. In developed countries, the link between diabetes and social disadvantage can also preclude access to advanced treatment. But, even if care was widely accessible, increasing evidence suggests that glucocentric treatment might not result in better overall outcomes. Clearly, different strategies are needed to reach a wider population and deliver better results.

Because type 2 diabetes, which accounts for 90% of diabetes, is largely rooted in reversible social and lifestyle factors, a medical approach alone is unlikely to be the solution. Moreover, medicalisation disempowers individuals and excludes communities, schools, and urban planners who have the potential to reduce diabetes incidence. Following the example of Andrew Renehan and colleagues' Comment in The Lancet today, health professionals who care for people with diabetes have an enormous opportunity to build collaborations with different agencies that seek similar outcomes. A collective approach provides predisposed individuals with better protection from the environmental hazard of decreased opportunities for physical exercise and the abundance of energy-dense food.

To lessen the burden of diabetes requires a substantial change in diet and routine, such as that advocated by Michelle Obama's Let's Move campaign. Her approach involves three components: nutrition, activity, and children. Too many Americans, and others, consume a diet of excessive solid fats and added sugar. To help Americans make better choices more easily, the US Department of Agriculture released updated dietary guidelines on June 15 that aim to shift consumption towards more plant-based foods. By contrast, on the same day in Brussels (and amid intense lobbying by multinational food corporations), the European Parliament rejected plans to aid consumers by labelling food with a health traffic-light system. Physical activity is as important as diet, and like a healthy diet has systemic benefits beyond weight control. Creating opportunities for physical activity within the built environment is the greatest—and most urgent—challenge, because of large migrations from rural areas to urban centres in Asia and sub-Saharan Africa. Urban recreation must be readily accessible, affordable, and include safe areas for youngsters, whose requirement for exercise is greater than that of adults. The focus on youth in a disorder that is age-related might seem paradoxical; but the age of diabetes onset is falling and it is in young people that diet and exercise habits are formed. It is also at a young age that the seeds of diabetes are sown—one in three children over the age of 2 years in the USA is overweight and one in six adolescents is obese. For those who are obese in childhood, type 2 diabetes in adolescence and premature mortality in later life are more common.

Diabetes need not be an inevitable consequence of urbanisation or social inequity, nor should future generations be condemned to perpetuate diabetogenic lifestyles. The fact that type 2 diabetes, a largely preventable disorder, has reached epidemic proportion is a public health humiliation. A strong, integrated, and imaginative response is required, in which the limits of drug treatment and the opportunities of civil society are recognised. The ADA meeting offers world leaders in diabetes an opportunity to reflect on the above challenges and initiate debate on a more inclusive and effective strategy to control diabetes.

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