Review
Diabetes: a 21st century challenge

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Summary

The number of people with diabetes worldwide has more than doubled during the past 20 years. One of the most worrying features of this rapid increase is the emergence of type 2 diabetes in children, adolescents, and young adults. Although the role of traditional risk factors for type 2 diabetes (eg, genetic, lifestyle, and behavioural risk factors) has been given attention, recent research has focused on identifying the contributions of epigenetic mechanisms and the effect of the intrauterine environment. Epidemiological data predict an inexorable and unsustainable increase in global health expenditure attributable to diabetes, so disease prevention should be given high priority. An integrated approach is needed to prevent type 2 diabetes, taking into account its many origins and heterogeneity. Thus, research needs to be directed at improved understanding of the potential role of determinants such as the maternal environment and other early life factors, as well as changing trends in global demography, to help shape disease prevention programmes.

Introduction

Lifestyle changes and globalisation have, during the past five decades, resulted in remarkable changes in societies, political systems, the environment, and human behaviour. The number of people with diabetes and obesity has increased substantially in both developed and developing countries,1, 2 with the greatest burden tending to fall on socially disadvantaged groups and Indigenous peoples. Diabetes ranks highly on the international health agenda as a global pandemic and as a threat to human health and global economies,2 and has been termed “the diabetes apocalypse” by Edwin Gale (Gale E, University of Bristol, personal communication).

In 1971, when Bennett and colleagues3 reported the very high prevalence of diabetes in the American Pima Indians (50% for adults older than 35 years), who could have predicted that this was the harbinger of a worldwide diabetes epidemic? Yet, diabetes (predominantly type 2 diabetes), long thought of as a Cinderella disease, has become a major health challenge of the 21st century, together with other non-communicable diseases such as cardiovascular disease.4

After Bennett and colleagues' report,3 other similar data started to emerge. In 1975, it was reported5 that the central Pacific island of Nauru had a national diabetes prevalence of more than 34% in people aged 15 years or older—the highest national prevalence of any country, both at that time and at present. This Micronesian population had become almost totally westernised,6 or, as Arthur Koestler7 aptly described, had undergone “Coca-colonisation”. In the case of Nauru, the profound and rapid lifestyle changes were caused by wealth from mining of rich phosphate deposits on the island. Findings from further studies in the Pacific islands8, 9, 10, 11, 12 confirmed the high prevalence of diabetes in this region. Furthermore, accumulated evidence from the past 20–30 years shows a rapidly increasing burden of diabetes worldwide.1, 2 Paradoxically, the burden of this so-called western disease, caused by western lifestyles, has the greatest effect on developing countries; more than 80% of the global total of people with diabetes live in these countries.

Section snippets

Recognition of the challenge of diabetes

International health agencies and national governments ignored the rise and rise of diabetes and other non-communicable diseases until quite recently. Funding for the prevention and control of such diseases (including diabetes) was of low priority compared with funding for the control of communicable diseases.13 Against this background, in 2006 the UN General Assembly unanimously passed Resolution 61/225,14 calling for diabetes to be recognised as an international public health challenge. In

Global predictions and patterns

Since 1994, when the first global predictions of a major increase in the number of people with diabetes were published,18 many efforts have been made by both the International Diabetes Federation and WHO19 to regularly update these figures. In 1994, 110 million people worldwide were estimated to have diabetes, and by 2010 the number was predicted to increase to 239 million.18 In 1998, King and colleagues19 reported that 135 million people had diabetes in 1995, and predicted that 300 million

Evidence of increasing prevalence

The study of the occurrence of diabetes over long periods (ie, secular trends) shows the magnitude and speed of the evolution of this epidemic. Although the situation in Nauru was an early warning of the global epidemic, studies in the Indian-Ocean island of Mauritius provide another indicator of the seriousness of the global epidemic.8, 31

Mauritius has a population of 1·3 million, predominantly of Asian-Indian (68%), African (27%), and Chinese (3%) ethnicity. The study in Mauritius covered a

Emergence of type 2 diabetes and prediabetes in youth

The global epidemiology of diabetes is changing. Type 2 diabetes was traditionally thought of as a disorder of middle-aged and elderly people, and almost exclusively as an adult disorder. However, diabetes has become more common, not only in young adults, but also in adolescents and children.2 This change has occurred predominantly in Indigenous populations and other high-prevalence groups.2 Earlier age of onset of type 2 diabetes will affect the future global burden of diabetes and prevention

Epigenetics and the developmental origins of type 2 diabetes

The importance of genetic contributions and their interaction with the environment as key risk determinants of type 2 diabetes has long been accepted.56 In the past 5 years, about 600 genome-wide association studies have examined more than 100 human diseases, uncovering more than 800 genetic variants associated with one or more diseases.57 However, in nearly every case, most of the factors that cause the disease are still unknown, which has led to growing interest in exploration of non-genetic

The cost of diabetes and its complications

The economic effect of diabetes is enormous. In 2010, global health expenditure attributable to diabetes was estimated to be US$376 billion—that is, 12% of all global health expenditure.69 In the USA in 2012, the direct medical cost of diabetes was $176 billion.70 Health-care expenditure attributable to diabetes by cost component for the USA for 2002–12 is shown in figure 3. Expenditure attributable to outpatient medications and supplies increased from about $18 billion to $50 billion,71, 72

Prevention of diabetes: challenges ahead

Strategies for prevention of type 2 diabetes are well developed in some settings, but predominantly in developed nations. Lifestyle intervention has been effective in several countries, but its success depends on uptake of intervention programmes and on compliance.78, 79, 80 These barriers are not trivial, and the strategies used to overcome them might not be practicable in many low-income and middle-income countries. When diabetes prevention programmes developed from successful clinical trials

Conclusions

Type 2 diabetes is one of the great health-care challenges of the 21st century. Over the past two decades, diabetes has become an increasing threat not only in developed but also in developing countries. Diabetes can adversely affect productivity through premature morbidity and mortality, and its effects will probably become even more serious because the disorder is beginning to affect younger generations. The main effect will be in disadvantaged minority ethnic groups and in developing

Search strategy and selection criteria

We searched the scientific literature and other data sources regarding global diabetes incidence for articles that we judged to be important and timely contributions to the topics addressed in this Review. Our reference list was modified on the basis of comments from peer reviewers.

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