Diabetes and under-resourced populations: European and Asian perspectives
In the second part of our series on diabetes and under-resourced populations, Dr Susan Aldridge reports on two presentations from the EASD 2022 conference, which explored the particular challenges and solutions prevailing in Europe and Asia.
Europe: Challenges beyond access
Dr Tsvetalina Tankova, Professor of Endocrinology, Medical University, Sofia, reviewed some of the diabetes figures for Europe, with the highest prevalence being in Germany at 15.3% and the lowest in Ireland at 4.4%. Europe also has the highest number of children and adolescents with type 1 diabetes at 300,000 as well as the highest estimate of new onset cases. When it comes to outcomes, 1.1 million people in Europe died of diabetes or its complications in 2021, which accounts for 8.5% of all-cause mortality. “What’s very important is that diabetes and its complications account for 7.7% of all-cause mortality of people under 60,” Dr Tankova said. So, Europe is facing a diabetes pandemic similar to the rest of the world, despite favourable outcomes of prevention studies there.
“Europe is an example of unity in diversity with its different cultures, healthcare systems and levels of resources. There are economic and regional inequalities in access to specialist care, medications and technology,” she said.
She outlined some of the challenges Europe faces. For instance, data is important to ensure people have access to equitable, affordable high-quality diabetes care. National registries are crucial to improving diabetes care in Europe – yet several countries still don’t have one. “Without data it is hard to build accountability and ensure diabetes is diagnosed, treated and controlled,” Dr Tankova warned.
And when it comes to medication, insulin availability is not a problem in Europe, as it is in some other parts of the world. The barriers are of distribution, re-export, tendering and government policies, rather than affordability or accessibility.
For other medications, once they are approved, they are used in a different manner in different countries. In Bulgaria, all new drugs approved by the European Medicines Agency (EMA) immediately go on the ‘positive prescription list’, are 100% reimbursed and are handled by specialist endocrinologists. There are similar variations between countries in use of diabetes technology. These differences arise from cost, disparities in access and psychosocial problems.
Clinical inertia in Europe
Frequent updates in guidelines can be challenging to keep up with and there is a clear discordance between fast-evolving evidence and everyday clinical practice. “Clinical inertia is preventing patients from getting life-saving treatments. That’s why it has to be overcome,” Dr Tankova observed. She gave an example from the Danish diabetes registry on trends in prescriptions of SGLT-2 inhibitors and GLP-1 receptor agonists in people with atherosclerotic cardiovascular disease and obesity, and noted there was no change even after the “amazing” results of recent clinical trials and this was not because of cost, given that the price of DPP-4 inhibitors and GLP-1 receptor agonists is about the same.
“We need to bridge the gaps between available scientific evidence and clinical practice in Europe at the level of the healthcare system, healthcare professionals and people with diabetes,” she added. She has worked with a group of experts from central and Eastern Europe, looking at the drivers of clinical inertia and they have produced a clinical manifesto called ABCDEFG (https://doi.org/10.1186/s12933-020-01154-w) “With this manifesto we aim to change minds with regard to clinical inertia. We need to increase awareness of the benefits of the new medications.”
Ending on a positive note, Dr Tankova pointed to the EU’s ‘Healthier together’ initiative on non-communicable diseases initiative. Diabetes is one of five strands and aims to decrease the burden of diabetes and its complications with a focus on data, primary and integrated care and health inequality.
Asia: the diabetes capital of the world
Dr Somia Iqtadar, Associate Professor of Medicine at King Edward Medical University Lahore said. “In Asia, most countries are struggling with GDP growth, a huge economic gap with the rest of the world, besides being affected by climate change at a very rapid pace. But there’s one thing, unfortunately, in which we are leading the world and that is diabetes.”
For Asia has the world’s highest prevalence of diabetes, with figures being particularly high in China, India, Pakistan, Indonesia and Bangladesh. The Asian diabetes phenotype, with its low lean mass and tendency to accumulate visceral fat, is perhaps the most significant cause of diabetes here.
There is also concern over suboptimal maternal health and uterine programming, which lead to a higher risk of type 2 diabetes and heart disease in the child. And, unfortunately, gestational diabetes and childhood obesity are also on the increase.
“These are things that cannot be controlled overnight – but what we can control is our unhealthy lifestyle, with a lot of carbs and unhealthy fats,” Dr Iqtadar said. “And with globalisation and urbanisation, we now have junk food – all this on top of a body which is prone to accumulating fat. Although Asians tend to have a low body mass, many are now obese. It’s often said that ‘Genetics loads the gun and lifestyle pulls the trigger’.”
Then there are the environmental factors – urbanisation, smoking and pollution, all of which are strongly associated with diabetes. Air pollution is perhaps the unexplored pathway to type 2 diabetes, but is now becoming a topic of interest. And finally, there are social factors, including poor access to healthcare, low literacy, low adherence to treatment and clinical inertia.
The way forward in Asia.
“Let’s not lose hope,” Dr Iqtadar said. “There is so much that we can do. We believe that with our actions we can bend the curve and save 111 million cases of diabetes through prevention and control.” This means four levels of prevention: at the population level, for those who are at high risk, then good control among those who already have diabetes and, finally, prevention of complications.
“Every level of prevention is important to bring the figures down. We need government leadership and multisectorial intervention on strategies, action plans, guidelines, taxes on unhealthy foods and promotion of physical activity,” said Dr Iqtadar.
A focus on maternal and child health is crucial with the message that ‘What you do and eat in the first 1000 days makes a difference for the rest of your life.’ To this end, work on gestational diabetes in India, mentioned in discussion, will be a game changer, but working on the health of mothers will improve that of the next generation.
“We are in this together and will get through this together,” Dr Iqtadar concluded. “Because if not now, when?”
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Any opinions expressed in this article are those of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.