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Problemas globales de salud de impacto local II. The economic and social consequences
of type 2 diabetes
University of Sydney, The Children’s Hospital at Westmead, Sydney, Australia. Recibido en su versión modificada: 16 de julio de 2009 La diabetes tipo 2 involucra la interacción de genes y del ambiente, Type 2 diabetes involves the interplay of multiple genes and the y está ocurriendo en grupos de edad más jóvenes. El tamizaje environment and is currently observed among younger age groups.
universal no es costo-efectivo y es preferible identificar a las Universal screening is not a cost-effective strategy since it is preferable personas en riesgo según una escala de riesgo. La diabetes ha to identify at risk groups based on at risk scores. Diabetes is now an alcanzado proporciones epidémicas, con una prevalencia global epidemic with an estimated 2007 global prevalence among adults of estimada en 2007 de 246 millones de adultos; para 2025 se 246 million; by 2025 it will increase to 380 million. For Mexico the incrementará a 380 millones. En México, la apreciación para 2007 2007 estimated prevalence among adults was 6.1 million and the en adultos fue de 6.1 millones y la proyección para 2025 fue de 10.8 2025 projections will be of 10.8 million.
millones. La diabetes es responsable mundialmente de 3.8 millones Diabetes is globally responsible for 3.8 million deaths, which de muertes, que excede las atribuidas a VIH/sida y paludismo exceeds those attributed to HIV/AIDS and malaria combined and juntos, y de 55.6 millones de años de vida perdidos. Los costos for 55.6 million life years lost. The direct health care costs of people directos de atención médica de las personas con diabetes son with diabetes are generally 2-3 fold greater than for those without generalmente dos a tres veces más que para aquellas sin diabetes, the disease and 4-8 fold more if diabetes complications are present.
y cuatro a ocho más si hay complicaciones. Entre 2003 y 2005, la The impact of diabetes on Mexico illustrates an increase of 26% in diabetes en México muestra un aumento de 26 % en costos de health care expenditures between the years 2003 -2005. Many of atención médica. El financiamiento internacional para la acción these costs were out-of-pocket expenses. International funding for global en enfermedades no transmisibles continúa siendo bajo y es global action on non-communicable diseases remains very low; in casi inexistente en países en desarrollo. La diabetes es una de las the developing world it is virtually non-existent. Diabetes is one of causas más importantes en el mundo de gastos en atención médica, the world’s most important causes of health-care expenditure, mortalidad, morbilidad y pérdida de desarrollo económico, con mortality, morbidity and lost economic growth with profound implicaciones sociales y económicas graves.
Diabetes tipo 2, impacto económico, impacto social, Type 2 diabetes, economic consequences, social Type 1 diabetes
The term diabetes mellitus encompasses a group of Type 1 diabetes is the predominant form of diabetes affecting disorders which are all marked by a raised blood glucose childhood.1 It does occur in adulthood but less so and the level.1 Whilst the diagnosis is based on the elevated glucose evidence is that the age of onset is decreasing. It is marked level, diabetes is complex and involves changes in the body’s by a deficiency of insulin, the pancreatic hormone needed to metabolism not only of glucose but also of fat and protein. The control glucose metabolism. In children this form of diabetes 3 main types of diabetes are type 1, type 2 and gestational is increasing at the rate of 3 % per annum, with a greater rise diabetes (GDM) and these account for over 95 % of diabetes.1 in those under the age of 6.1 The aetiology of type 1 diabetes All three forms of diabetes are increasing but the greatest rise is still not fully understood but it involves interplay between is in type 2 diabetes which has now reached epidemic genetic risk factors, mainly affecting the immune system, and environmental triggers. A simplistic explanation is that * Correspondencia y solicitud de sobretiros: Dr. Martin Silink. Institute of Endocrinology and Diabetes, University of Sydney. The Children´s Hospitalat Westmead, Locked Bag 4001, Westmead, NSW,2145, Australia. Tel. 00 (612) 9845-3172. Correo electrónico [email protected] / [email protected] Gac Méd Méx Vol. 145 No. 4, 2009
an environmental trigger (for example a virus or chemical in (healthy diet, loss of weight in those overweight, increased the food) is perceived as foreign in an individual having the physical activity) but failing that, oral medication to reduce genetic predisposition and results in an unfocused immune insulin resistance (eg metformin) or increase insulin secretion response which, by mistake, is also directed at the insulin (eg sulphonamides) are introduced to control the disease.4 producing cells of the pancreas, destroying them and resulting Newer drugs are being developed (eg incretin therapy to in insulin deficiency. Type 1 diabetes is therefore classified increase insulin secretion and stimulate regrowth of insulin as an auto-immune disease and typically presents over a few producing cells or thiazolidinediones to reduce glucose weeks with weight loss, lethargy, production of large volumes resistance) but these remain expensive and usually if of urine, dehydration and the development of life-threatening metformin and the sulphonamides are insufficient then the derangement of the body’s chemistry (acidosis). Insulin next line of treatment is the introduction of insulin injections.4 therapy lowers the elevated glucose levels and corrects the Type 2 diabetes increases the risk of cardiovascular disease acidosis. It can only be given by injection and is not only life- and therefore control of blood pressure and cholesterol are saving but is needed life-long. Good control of the disease is as important as controlling glucose levels.4 essential to reduce the risk of developing blindness, kidneyfailure and nerve disease2 as well as cardiovascular disease(heart attacks, strokes and amputations).
Gestational diabetes
Gestational diabetes is diabetes diagnosed for the first time Type 2 diabetes
during pregnancy. The hormones of pregnancy cause insulinresistance and often this form of diabetes disappears after Type 2 diabetes is even more complex to understand but delivery of the baby. Women who have had gestational also involves the interplay of many genes (different to those diabetes have an increased risk (as high as 30-70 %) of responsible for the risks of type 1 diabetes) and the subsequently developing type 2 diabetes. In Asia the environment. A strong family history of diabetes is frequent incidence of gestational diabetes has increased dramatically and many ethnic groups are at greater risk of type 2 with 10-15 % of all pregnancies affected. Many countries now diabetes (virtually all indigenous populations, Asians, South- recommend routine screening of all pregnancies at 28-30 East Asians, Pacific Islanders, African and Hispanic peoples) weeks with a 75 gram oral glucose test and if abnormal, (refs in 1). In this form of diabetes the environmental risk institute dietary and lifestyle changes and when necessary factors are linked to changes in the foods eaten (more insulin therapy. The problems related to gestational diabetes energy-dense), an increasingly sedentary lifestyle, increases are significant and can affect the health of the foetus and the in body weight and probably social factors such as stress, mother. There is a higher risk of abortions, stillbirths, foetal lack of job satisfaction and poverty. These together with abnormalities and the need for Caesarean Sections. The multiple genetic risk factors lead to the body becoming baby has a greater risk of being born either small for resistant to the effectiveness of insulin in lowering blood gestational age with a low birth weight or macrosomic (high glucose levels (ie insulin resistance). Normal aging birth weight, typically > 4 kg) and be at risk of developing contributes to insulin resistance and until relatively recently severely low blood glucose levels in the newborn period.
type 2 diabetes was regarded as a disease of the elderly.
Subsequently these individuals are at increased risk of However, over the past 50 years type 2 diabetes is occurring developing insulin resistance, obesity and type 2 diabetes.
in younger and younger age groups and is increasingly Breast feeding should be encouraged and obesity avoided by being seen in adolescents and even children.3 With time the discouraging over-feeding with nutrient-rich formulae, pancreas is unable to produce enough insulin to overcome especially of the low-birth weight babies.
the prolonged and increasing resistance to insulin andeventually, due to the combination of insulin resistance anddeveloping insulin deficiency, glucose levels rise and The diabetes epidemic globally
changes in lipid levels occur. For many years the glucose and in Mexico
abnormalities may only be detectable by elevated fastingblood glucose or after an oral glucose tolerance test and the The data are robust now and indicate that diabetes has truly clinical features remain very subtle. Often type 2 diabetes assumed epidemic proportions. The IDF Diabetes Atlas (3rd may only declare itself as lethargy and an increased risk of edition) estimated that in 2007 the global prevalence of bacterial or yeast infections (monilia). Subsequently other diabetes among adults was 246 million, representing 6% of symptoms such as thirst, passage of large quantities of the adult population with annual projected rises of 7 million so that by 2025 the numbers would have risen to 380 million Universal screening for type 2 diabetes is not cost- or 7 % of the adult population.1 For Mexico the 2007 estimates effective and not recommended.4 It is preferable to identify and the projections for 2025 are indicated in table 1.
people at risk according to a risk score featuring age, gender, It can be seen that in Mexico the 2007 estimated prevalence family history, increased body weight or waist circumference, of diabetes among adults was 9.4 % (6.1 million) and that by ethnic background and family history. Initially treatment is far the predominant diabetes prevalence was in urban areas aimed at reducing insulin resistance by lifestyle modification indicating that, for the Mexican population, city living is a high Gac Méd Méx Vol. 145 No. 4, 2009
Problemas globales de salud de impacto local risk factor for diabetes. These figures suggest that the major Table 1. 2007 and 2025 prevalence estimates for diabetes in
public health risk reduction strategies in addressing the risk factors and the social determinants of diabetes should befocused on cities. Unless solutions are found, the problem is projected to increase so that by 2025 it is estimated that thenumbers with diabetes will have risen to 10.8 million. It is very likely that these numbers are an under-estimate as all previous global projections since 1985 have been exceeded. It should also be noted that more women than men (ratio 1.54) have diabetes and this has significant social implications for family welfare and gender equity issues. The figures also bear out the fact that type 2 diabetes is no longer a disease of the elderly.
In 2007, the estimates indicate that 3.9 million (62.3 %) are in the 20-59 year age group, which includes the reproductive years and the most economically productive age group.
Children, obesity, the metabolic
syndrome and diabetes
deaths attributable to communicable and non-communicabledisease are similar in number and these countries struggle The health of children should be seen as a national asset. It with a double burden of disease. In the middle income and is distressing the high number of children who fulfill the IDF upper income countries, non-communicable diseases are criteria for having the metabolic syndrome (increased waist responsible for the largest burden of disease and far outweigh circumference, elevated blood pressure, decreased plasma the burden of communicable diseases. Diabetes now is HDL cholesterol, raised plasma triglyceride levels and elevated responsible globally for 3.8 million deaths, which exceeds fasting or 2 hour glucose tolerance levels).5-7 Their risk of those for HIV/AIDS (2.6 million) and malaria (1.2 million) developing frank diabetes and cardiovascular disease in combined. In terms of DALYs (Disability Adjusted Life Years) adulthood is greatly increased. Clinically, the metabolic diabetes is estimated to be responsible for 55.6 million life syndrome in children may also be suspected by the presence years lost compared to 168.4 million for cardiovascular disease, of acanthosis nigricans, a brown discolouration along the 70.8 million for HIV/AIDS and 39.9 million for malaria.1 neck line, in the axillae and in pressure areas on the elbows, The financial crisis which declared itself in 2008, together knees and knuckles, which indicates the presence of insulin with environmental factors such as climate change, will resistance (Figure 1). Girls with the metabolic syndrome or undoubtedly have a major impact on chronic disease. The type 2 diabetes may be further affected by having the consequences of the global economic recession (the “Great polycystic ovarian syndrome which causes menstrual Recession”), rising food prices, the failure of food crops due to irregularities and hirsutism, with male type hair pattern on climate change, the diversion of food crops to bio-fuels will increase unemployment and reduce access to more healthy Accurate data on the prevalence type 2 diabetes in foods and reduce affordability of essential medicines for adolescence are not available however, in Japan, type 2 dia-betes is 4 times more common than type 1 diabetes.8 In theUSA and Australia 20-30 % of newly diagnosed diabetes inadolescence is type 2 diabetes. Type 2 may present with veryhigh blood glucose levels as well as acidosis and is far froma benign condition. Insulin therapy is required in approximately20-25% and long-term intensive medical management isneeded to maintain good control. The risks for the diabetes-specific microvascular complications of blindness and nervedisease are at least as high as for type 1 diabetes, withJapanese data suggesting that the risk for kidney disease iseven higher.9 The economic burden of diabetes
The World Health Organization’s World Health Report in 2005pointed out that 60 % of the burden of diabetes and otherchronic diseases occurs in the low and middle incomecountries.10 It is only in the low income countries where the Figure 1. Acanthosis nigricans.
Gac Méd Méx Vol. 145 No. 4, 2009
diabetes, blood pressure and lipid control. During economic made the decision that everyone is at risk of non-communi- downturns, the health of a country’s population worsens due cable diseases and that nationwide public health measures to lowered household income and reduced access to health are warranted.13 In some developed countries with well care. The poor in low-income countries are most affected developed health care systems, the emphasis has been on because they pay a large portion of their health-care costs out- identifying individuals at risk by using self-applied health-risk of-pocket without the benefit of social safety nets.
score instruments. Randomized control studies have The economic impact of cardiovascular disease, stroke demonstrated that weight loss in those overweight, together and diabetes on developing countries is immense. The WHO with a modest increase in physical activity is able to reduce estimates that the mortality from diabetes, heart disease and by half the conversion of people with impaired glucose stroke cost about 250 billion International dollars (ID) in tolerance to diabetes.14,15 Those at high risk of diabetes and China, ID 225 billion in the Russian Federation, and ID 210 cardiovascular disease would be encouraged to visit their billion in India. Much of the heart disease and stroke in these doctor for assessment, given dietary and lifestyle modification estimates was linked to diabetes. WHO estimates that advice and, if needed, prescribed medication such as diabetes, heart disease and stroke together will cost about ID metformin, aspirin and treatment for hypertension and lipid 555 billion in lost income in China over 2005-2010, ID 303 elevation.4,15 Those with morbid obesity could be considered billion in the Russian Federation, ID 337 billion in China and for bariatric surgery (gastric banding, gastric sleeve resection ID 2.5 billion even in a very poor country like Tanzania. These or in extreme circumstances, pancreatico-biliary by-pass estimates are based on lost productivity, resulting primarily surgery). The scale and urgency of the non-communicable from premature death. Accounting for disability might double disease epidemics in low and middle income countries exceeds their capacity to pay for strategies focusing on The direct health care costs of people with diabetes are individual risk factors and individual treatments.
generally 2-3 fold greater than for those without diabetes and Population-based methods will be more cost-effective 4-8 fold more if diabetes complications are present.1 Indirect but much research will be needed to optimize public health costs of diabetes become increasingly more important in low strategies to promote healthy eating and physical activity, income countries when costs such as the cost of travel to breast feeding, school sport and eating programs, tobacco clinics and loss of earnings have a greater impact on the reduction, government controls over inappropriate advertising, whole family. Newer health economic research has identified urban design and transport. In addition, whole-of-government this ripple effect on low income families who bear a greater population based strategies will need to address the social proportion of healthcare costs as out-of-pocket expenses.
gradients in health within countries “caused by the unequal Often the greatest impact is on the children, especially girls, distribution of power, income, goods, and services, globally, who are denied educational and vocational training and are and nationally, the consequent unfairness in the immediate, at greater risk of turning to crime and prostitution. Clearly visible circumstances of people’s lives – their access to diabetes in the bread-winner in the family has an obvious health care, schools, and education, their conditions of work effect on reducing household income, but because of the and leisure, their homes, communities, towns, or cities – and extended family structure in developing countries, the impact their chances of leading a flourishing life “as outlined in the of chronic disease on the elderly is also significant as they 2008 report of the WHO Commission on Social Determinants fulfil an important role in freeing the breadwinners from childcare duties. There are good data on the impact of For the secondary prevention of diabetic complications, diabetes on Mexico with one report indicating a 26 % the World Bank has identified the following four treatments increase in health care costs between 2003 and 2005, with which were not only cost-effective but actually cost-saving if 140 million dollars spent on direct and 177 million dollars on applied in any country: improved glucose control for those with indirect costs and another report outlining the high proportion a HBA1c > 9.0 %, blood pressure reduction to below 160/95, of out-of-pocket expenses in diabetes care.11,12 foot care for those with a high-risk diabetic foot, and pre-pregnancy care in women known to have diabetes.17 Thesewould be regarded as minimal care and current glucose control Prevention of diabetes
recommendations aim to achieve HbA1c < 6.5 %, BP < 130/80, and its complications
normal blood lipids, regular screening for eye, kidney, nerveand vascular disease with intervention to prevent progression Prevention of diabetes itself (primary prevention) and its complications (secondary prevention) are largely feasibleand clearly desirable. Globally, the benefits of preventing 7million more people having diabetes annually would be International recognition of impact
immense. Most developed economies are already spending of diabetes
10-12 % of their health-care budgets on diabetes.1 ForMexico, the projected number of people developing diabetes Globally, the potential role of diabetes and other non- communicable diseases in subverting economic development Strategies to prevent this rise can be directed at the is beginning to be recognized. Even though the 2000-2015 UN individual or more generally at the population. Finland has Millennium Development Goals do not contain any reference Gac Méd Méx Vol. 145 No. 4, 2009
Problemas globales de salud de impacto local to the impact of non-communicable diseases, the UN General of glucose, blood pressure and lipids needs to be made Assembly in 2006 adopted UN Resolution 61/225 which available to all to prevent the progression of costly complications recognized that “diabetes is a chronic, debilitating and costly in diabetes and other non-communicable diseases.
disease associated with severe complications, which posessevere risks for families, Member States and the entire worldand serious challenges to the achievement of internationally References
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care services and access to low cost medication for the control Gac Méd Méx Vol. 145 No. 4, 2009

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