Which disease causes one death globally every six seconds, or, put another way, five million deaths a year? In India, 78.3 million have the disease, in Mauritius 22 per cent of the population is affected. Yet it is far from only being a disease of the developing world – more than 24,000 people (65 people a day) die before their time from it each year in England and Wales and one in 16 people in the UK has it.
The answer is diabetes and it has emerged as one of the world’s most ubiquitous and chronic illnesses. A lifelong condition that causes a person’s blood sugar level to become too high or too low, diabetes means the body is unable to break down glucose into energy. This is because there is either not enough insulin to move the glucose, or the insulin produced doesn’t work properly (insulin is a hormone that helps to move glucose out of the blood and into cells for energy).
The scale of the problem is daunting: the International Diabetes Federation (IDF) estimated that in 2015 seven countries had more than ten million people with diabetes: China, India, the United States of America; Brazil, the Russian Federation, Mexico and Indonesia. Globally, 422 million people between the ages of 20 and 79 have it, while 47 per cent of diabetes-related deaths occur in those under 60 years of age. By 2040 one person in ten – 642 million people – will, according to IDF projections, have the condition.
For decades, diabetes – specifically, type 2 diabetes – has been lazily dismissed as a disease of the West, and true enough, it does have strong links to lifestyle and obesity. Accordingly, it has been held up as a consequence of much that is wrong with wealthy societies, where people gorge on fast food and sugary drinks. You reap what you sow goes this argument, and diabetes, seen through this prism, can end up crystallising the problems of over-consumption and cheap, sugar-rich food.
The only trouble is that such an over-simplification is grossly misleading: 30 years ago the highest rates of diabetes were indeed to be found in high income countries but in the intervening decades, low and middle income countries have caught up and the incidence there is rising much more quickly. According to the IDF, three quarters of people with type 2 diabetes now live in low or middle income countries.
‘It took the higher income countries 50 years to get to this point, it’s taken low and middle income countries just 15 years,’ says Dr Gojka Roglic of the Department for Management of Non-Communicable Diseases at the World Health Organization. The IDF now says the highest diabetes prevalence can be found in places such as Tokelau, a non-self-governing group of atolls belonging to New Zealand, Nauru, Mauritius, Cook Islands, the Marshall Islands and Palau.
Over those decades, major progress has been made in increasing access to clean water and sanitation, reducing malaria, tuberculosis, polio and the spread of HIV/AIDS. Diabetes has bucked that trend. ‘Diabetes is right up there in the order of magnitude, it kills more people than TB but it doesn’t inspire the fear that epidemic diseases do,’ says Roglic. ‘The problem is that it is not scary enough, it doesn’t threaten the security of the state in a direct way.’
Diabetes is primarily encountered in two forms, type 1 and, much more widely, type 2. There are also rarer forms, including gestational diabetes which is usually temporary, occurs during pregnancy and can affect up to one in seven births. ‘It’s incredible,’ says Roglic. ‘If you have type 1 and you can’t afford insulin then you have to die. But when you talk of diabetes the image is of an obese middle-aged person and that doesn’t generate as much sympathy. That's not as touching as a young person cut off in their prime.’
Yet such widespread misconceptions mean that societal attitudes towards the disease can be less sympathetic and governments less involved than would otherwise be the case. This is all the more puzzling, since the impacts of diabetes can be shocking: the WHO’s list of serious complications linked to diabetes includes irreversible blindness, heart disease, stroke, kidney disease, amputations and premature mortality. People with type 2 diabetes have a two-fold increased risk of stroke compared with the general population and diabetics are twice as likely to suffer an episode of depression.
The problems are grievous enough in the West: according to the UK National Paediatric Diabetes Audit, a little over a third of young people with type 1 diabetes receive all their recommended key care processes; matters are even more burdensome in poorer countries where diagnosis is often later and management of the disease is poor.
One big issue is money. In less-resourced countries, many children quickly die from misdiagnosis, or a lack of either insulin or experienced medical care. Only $5.9billion was spent on diabetes healthcare in Africa in 2015, the lowest of any region. Australia had the highest spending per person with diabetes ($14,498) and Myanmar the lowest ($40).
‘People living on or below the poverty line tend to be diagnosed later,’ says Dr Mohga Kamal-Yanni, a senior health policy advisor at Oxfam UK. ‘They have less access to treatment and suffer more acute and late complications than the rich. The majority of poor and even middle-class people in developing countries do not have health insurance and are forced to pay for medicines. Diabetes is a lifelong condition, the cost of medicines can drive people into a downward spiral of debt and poverty. Being middle class in developing countries is relative. They are just coping – if they develop diabetes they go under the line. You might get diagnosed with diabetes but you are then subject to market forces of drug companies. Insulin is horrendously expensive. You can’t just use insulin today but not tomorrow. It’s a huge burden.’
The point is relevant to Mexico, which has a huge problem with diabetes. ‘There is a very high cost related to the disease as well as its complications,’ says Dr Roxana Valdés-Ramos, Leader of the Nutrition and Health Research Group at the Universidad Autónoma del Estado de México in Toluca. In 2014, the cost of type 2 diabetes represented 0.74 of Mexico’s total national income, equivalent to one sixth of the national health budget. ‘The most dramatic effect is in the economically productive age span,’ she adds. ‘The real impact is seen in the reduction of the ability to work.’
In Africa, more than two thirds of diabetes cases are undiagnosed and the IDF says that investment, research and health systems there, focused primarily on infectious diseases, are slow to respond to this burden. The western Pacific – including China – has the highest number of people with diabetes (110 million) and the highest number of deaths due to diabetes (1.9 million). With 1.2 million deaths in 2015, Southeast Asia (including India) had the second highest number of deaths attributable to diabetes.
The challenge for those advocating some kind of global unified action against diabetes is that it is true that lifestyles and obesity are largely to blame for type 2 diabetes and account for as much as 85 per cent of the overall risk of developing type 2. Two billion people globally are overweight or obese (meanwhile, almost one billion people go undernourished and another billion hungry) and the consumption of high-sugar, high-fat snacks by both rich and poor children is increasing. ‘Lifestyle issues such as food/energy intake – high-calorie low-nutrient beverages or foods, which include high-sugar and high fat items and extreme sedentary behaviour – have become a lethal combination,’ says Valdés-Ramos.
Nuance, though, is important and Valdés-Ramos and others are careful to distinguish between people choosing to live a certain lifestyle and those having it thrust upon them. ‘As a nutritionist I believe that there is a huge individual responsibility in the types of foods we choose,’ she says. ‘However, poverty and lack of education – which are very prevalent in Mexico – may lead to inadequate choices.’
‘The perception is that it’s “your fault, you brought it on yourself by sitting around eating and watching TV all day – you have to go and sort it out yourself”,’ says Kamal-Yanni. ‘It’s easy to put it that way even though it is incorrect and unfair.’
‘Lifestyle implies you have a choice. Many people, if they are poor, do not have that choice,’ adds the WHO’s Roglic. ‘Rapid and accelerating urbanisation in big cities is increasing the risk of diabetes, and it brings unhealthy diets and reduced physical activity. People have moved from villages and have lost the protective effect of the physical labour they did there. You don’t get that in the slums.’
Poverty, argues Kamal-Yanni, is driving people of all ages, including children, to work longer hours, especially in cities where low-paid work is often all that can be found. Such workers depend on take-away food from street stalls where the traditional nutritious diet is being replaced by poor quality Western-style cooking that uses more fat, salt, sugar, and meat. ‘If you walk around a big city in a developing country you will see a lady on a street corner selling cheap food that has been fried in oil,’ she says. ‘Can you say she is lazy because she is sitting there all day or that’s it the fault of the people who buy from her because it’s the only food they can afford? She is working from early morning to night so she can feed her own children. This style of life is not lazy, it’s the nature of their work and their income. Cola is cheaper than milk, crisps are cheaper than apples. That’s not about personal responsibility, it’s about government responsibility. Good nutrition is often not economically viable for a poor family.’
Nevertheless, because the disease puts a physical, emotional and financial strain on lives, governments can find it convenient to pass blame onto those with diabetes. ‘Unlike TB and malaria which can be cured, you have diabetes for life,’ says Kamal-Yanni. ‘That costs the state money. Nobody politically wants to take responsibility for it.
Others believe governments are increasingly less keen to blame their citizens. ‘They are beginning to acknowledge that it is not easy or affordable to eat well or in many places even safe to walk and take exercise,’ says Roglic. Instead, she argues, more attention needs to be paid to the food production sector. ‘There is a whole industry of food that is not particularly responsive, that wants maximum profits and wants to sell what sells best. It’s really getting quite serious. Relying on industry to self-regulate has not worked, relying on education has not worked, there is a space for something creative to emerge. The sugar tax [in Mexico] is a brave attempt.’
Kamal-Yanni is even more scathing. ‘They are giving people food that damages their health. They have huge responsibility for the salt, sugar, the chemicals and the advertising. They need to clean up their act and they need real regulation. If you can afford both a packet of crisps and an apple you have a choice but many people do not have that choice.’
The lobbying arms of the food and drinks sector, however, are strong: the Corporate Europe Observatory says the sector has a disproportionate influence on food and drink policy in the EU, the US and elsewhere and spends millions of dollars annually on influencing regulatory bodies and using free trade agreements to undermine anti-sugar or pro-healthy eating legislation. Fearing compulsory legislation, the sector has even lobbied against UN proposals to cite the cutting of sugar from diets and linking sugar to diabetes. ‘There are many more conflicting interests, profits and margins in diabetes than there are for TB or malaria,’ says Roglic. ‘There are more obstacles to overcome because of the nature of diabetes.’
The problem, Roglic points out, is that other cultural issues are at work which means that blaming food producers alone is too simplistic. ‘People eat and cook unhealthy food at home that isn’t manufactured,’ she says. Mexico, for example, faces huge cultural challenges. ‘Mexico is predominantly Catholic and there is a huge fatalism that God gives you diabetes as he gives you other illnesses, that it is somehow beyond your control,’ says Valdés-Ramos. ‘Another cultural problem is that a lot of Mexican moms tend to want their children to be chubby. The more they eat, the healthier they feel their kids are. Shifting a cultural idea is no easy task. We need to remember that not very long ago in Mexico – and maybe it’s still the case in some places – that healthy drinking water was not available everywhere, and bottled water was non-existent. The only way to obtain liquids that would not cause disease was through commercially available beverages or boiling water to make it drinkable.’ The industry introduced beverages everywhere, thereby filling a particularly important niche. This tilted the balance towards the consumption of sweetened beverages.
Other issues involved in the spread of diabetes include genetic susceptibility, particularly in type 2 – this is an important genetic risk factor which is present in populations such as Mexico’s. Elsewhere, given the same level of obesity, people from South Asian and black communities are two to four times more likely to develop type 2 diabetes than those from Caucasian backgrounds, though the exact causes for this disparity are unclear. Type 2 also tends to cluster in families: people with diabetes in the family are two to six times more at risk than those without diabetic relatives.
All is not necessarily lost: the increasing prevalence of diabetes can be reversed; and since type 2 diabetes can to a large degree be reversed by lifestyle changes, so can the effects of diabetes on individuals. ‘We need to reduce overweight levels and obesity, increase physical activity and promote adequate nutrition in order to reverse the diabetes epidemic,’ says Valdés-Ramos.
In this respect, diabetes is closely linked to the UN’s sustainable development goals (SDGs) that were launched in 2015. The goals overlap with many pertinent issues: good health and well-being, reduced inequalities and sustainable consumption and production. The lifestyle-related causes of type 2 diabetes raises wider issues about the global food system: if type 2 is caused by eating the wrong kinds of food, the corollary is if we address sugary, high-fat food and lack of affordable nutrition then we would resolve some of the inequalities that exist within the global food system.
‘One SDG aims to reduce mortality from non-communicable diseases – diabetes is certainly relevant to that,’ says Roglic. An NGO-led push is growing for universal health coverage and simultaneously seeking for non-communicable diseases to be placed higher on the political agenda. ‘The SDGs talk about “leaving no-one behind”. If political leaders understood what that meant they would probably never have signed it,’ says Oxfam’s Kamal-Yanni. ‘If you’re not leaving anyone behind, then you are not leaving anyone behind with diabetes.’
Diabetes prevention could benefit from an HIV/AIDS-style programme, she suggests, which developed enthusiasm from civil society. ‘What stimulated treatment for HIV was a global UN target of treating three million people by 2005. That slipped by a couple of years but it was effective. We need that with diabetes; for it to be recognised that as governments, it is your responsibility to undertake mass diagnosis and treatment for diabetes. It doesn’t appear anywhere on the political agendas of developing countries. That’s frustrating. The international donor community is concerned about anti-microbial resistance and emerging diseases. Ebola has been causing problems in Africa for years but because we had a case in Europe we have now decided we care about it. There is little left for anything else. Diabetes has to fight with HIV, mental health and other issues for what’s left of the pie.’
Meanwhile, other less favourable parallels with HIV/AIDS tell their own story. In sub-Saharan Africa, many HIV/AIDS clinics are clean, well-funded and provide free medication. ‘You hear some people in sub-Saharan Africa almost genuinely saying they wish they had HIV rather than diabetes because if they have HIV then they go to a clean clinic and get free medication,’ says Roglic. ‘With diabetes they go to a run-down building and pay five days’ wages for a months’ treatment. Society reacted for HIV in a way it hasn’t done for diabetes.’ An effective public health strategy for poor countries, Kamal-Yanni suggests, would require access to low-cost, high-quality generic medicines.
Free health care is also crucial. Mexico has an extensive programme of free health care, Valdés-Ramos says. A government programme declared obesity and diabetes national public health emergencies in 2014, while the Ministry of Health dedicated a large budget to prevention and control of obesity and its related diseases. ‘There are many decisions governments can take – food prices are not only controlled by manufacturers; governments can decide whether a park is built over by a parking lot; or if computer lessons replace physical education,’ adds Roglic.
The Mexican sugar tax, introduced in 2014, is perhaps the most high-profile example of a government initiative that has at least indirectly addressed the issue of diabetes. The tax was a response to a concerted national campaign by the health service and nutritionists. According to Mexico’s National Institute for Statistics, Geography and Informatics, type 2 diabetes is the second leading cause of mortality in Mexico and the primary cause in the 45 to 64 age range. This is attributed to an adult population of which 70 per cent is either overweight or obese (69.4 per cent of men and 73.0 per cent of women). An analysis of sugary-drink purchases, carried out by academics in Mexico and the United States, found that the 5.5 per cent drop in the first year after the tax was introduced was followed by a 9.7 per cent decline in the second year.
‘According to the economists there has been a real reduction in the purchase of sugar-sweetened beverages and probably other solid products,’ says Valdés-Ramos. ‘However, this reduction is not equivalent in obesity and diabetes rates. So it is not clear if the effect is positive in terms of health indicators. There is a possibility that the effect will be seen more in the mid- or long-term.’
Valdés-Ramos believes Mexicans will find the sugar habit hard to kick. ‘The problem is that diabetes is highly linked to obesity and in Mexican culture people tend to eat a lot, they eat out and they eat a lot of fried food. People walk less partly because of security concerns. The education level in the majority of the population is quite low – Mexico has an abundance of fruit and vegetables but people don’t tend to eat them. I don’t think it will be so easy to find an equilibrium. Home-made sugar-sweetened beverages are also very common in Mexican culture and their consumption will most probably not decrease with the tax. I believe that we need to educate individuals and guarantee that they have the economic power, so that they can make better choices with respect to lifestyles.’
Children and Diabetes
Type 2 diabetes is on the increase in children in all countries irrespective of socio-economic status. According to Dr Kamal-Yanni of Oxfam, watching television has become a popular social activity in developing countries and may often be the only recreational activity for both children and adults. Across all social strata, children’s time in front of television has come at the expense of normal play. In urban areas of developing nations, children’s physical activity is also constrained by the need to work, the lack of play space, and the lack of facilities and physical exercise in schools.
Type 1 diabetes in children is a much more pressing issue – and more problematic to deal with. It is usually diagnosed – at least in developed nations – in children under the age of ten. There are about 31,500 children with diabetes under the age of 19 in the UK. The vast majority – 95 per cent – have type 1 diabetes. Globally it is estimated that there are 497,000 children under 15 years with type 1 diabetes. A very small number of children have other rare forms.
A particular concern for children is the risk that blood glucose levels drop too low and hypoglycaemia results, or blood glucose rises too high and hyperglycaemia occurs. Accordingly, children and their families are required to monitor their blood glucose levels carefully.
The relentlessness of having to live with the disease day in, day out means a significant psychological burden is placed on the young person and their family. Parents of children with type 1 will typically monitor their child’s glucose levels several times during the night.
Blood glucose levels are affected by several factors, including stress, illness and hormones which can impact significantly on school life. Adolescence can be a particularly challenging time for young people with diabetes as children often struggle to take part in the same activities as their friend and encounter loss of peer groups and social isolation.
Either way, diabetes is now beginning to demand attention. ‘Even if they don’t care about it on a human rights level, governments should care because of the economic implications,’ says Kamal-Yanni. ‘It’s a chronic, debilitating condition. A diabetic person cannot work as hard as a diabetic on treatment would do.’
Inaction is no longer an option. ‘There will certainly be repercussions in the long-term,’ says Roglic. ‘Diabetes has the capacity to cripple almost every health system, not just those of low and middle income countries. We are already at the cliff edge, it just depends on whether the drop is a long or a smaller one. It’s already serious enough to warrant intervention. I don’t see change happening suddenly, only in small increments, one step after another. Each step will be a difficult one.’
Combining a range of approaches and tactics is tricky but the only option, according to Valdés-Ramos. ‘I have to be optimistic, I believe things can be done but it requires a lot of work. How do we decrease the intake of high-fat non-nutritious food among those who need to be educated about this? At the same time, how do you lower the price of healthy food for those people who cannot afford it? It’s difficult – you can have a family where the adults are obese and the child is undernourished. How do you find a way to get both generations into the middle ground?’
Kamal-Yanni wonders just what is required to stir international action. ‘It’s a big rising concern, you have people living with diabetes, dying of diabetes, yet it’s a totally ignored issue. We are really just waiting for governments to notice. How many people need to die and suffer before the world wakes up and realises that diabetes is a big problem?
This was published in the May 2017 edition of Geographical magazine.