wdf summit reportv1 - world diabetes foundation · at the university of sydney and the children’s...

A Report From

The World Diabetes Foundation(WDF) Diabetes Summit

Hanoi,Vietnam February 21st - 23rd, 2006

MINISTRY OF HEALTHViet Nam

WESTERN PACIFIC DECLARATION ON DIABETES

A supplement to

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Professor Pierre LefèbvreChairman of the Board of Directors of the WDF; President ofIDF; Emeritus Professor of Medicine at the University ofLiège, Belgium

Dr Anil KapurManaging Director of World Diabetes Foundation, Denmark

Dr Hans TroedssonWorld Health Organization Representative, Hanoi,Vietnam

Professor Paul ZimmetDirector of the International Diabetes Institute, Professor atMonash, Deakin and Pittsburgh Universities, Australia

Professor Martin SilinkPresident Elect of IDF, Professor of Paediatric Endocrinologyat the University of Sydney and The Children’s Hospital atWestmead, Sydney, Australia

Dr Gojka RoglicTechnical Officer of the WHO diabetes programme,Department of Chronic Diseases and Health Promotion,Geneva, Switzerland

Dr Viswanathan MohanChairman of Dr Mohan’s Diabetes Specialities Centre,President of the Madras Diabetes Research Foundation,Chennai, India

Professor Clive CockramProfessor of Medicine, Honorary Consultant Physician inEndocrinology and General Internal Medicine, Head ofDivision of Infectious Diseases, Prince of Wales Hospital,Chinese University of Hong Kong, Hong Kong

Dr Narayanasamy MurugesanProject Director, Diabetes Research Centre-WDF Project,Chennai, India

Dr Gauden GaleaRegional Adviser for Non-communicable Diseases,WHORegional Office for the Western Pacific

Professor Ib BygbjergHead of Department of International Health at the Instituteof Public Health, University of Copenhagen, Denmark

Dr Jerzy LeowskiRegional Adviser for Non-communicable Diseases,WHORegional Office for South East Asia

Mr Gordon BunyanChair, IDF’s Western Pacific Region Council, Board Memberof Diabetes Australia, Australia

Professor Ta Van BinhDirector, Endocrinology Hospital, Hanoi,Vietnam

Dr Pradeep K ShresthaAssociate Professor, Department of Medicine, TribhuvanUniversity Teaching Hospital, Kathmandu, Nepal; ProgramDirector, Astha Nepal

Associate Professor Ruth ColagiuriAssociate Professor in the School of Public Health, Directorof Diabetes Unit, Australian Health Policy Institute, Universityof Sydney, Australia

Dr Abraham JosephDirector, Schieffelin Leprosy Research and Training Centre,Karigiri, India

Professor Wenjuan WangProfessor, National Center for Chronic and Non-communi-cable Disease Control and Prevention, Chinese Center forDisease Control and Prevention, China

Dr Ritulal SharmaMedical Superintendent, Mongar Regional ReferralHospital, Ministry of Health, Bhutan

Dr Perumalsamy NamperumalsamyFounding Member and Vice Chairman, Aravind Eye CareSystem, Professor of Ophthalmology, Madurai, India

Dr Sharad PendseyChairman of ‘Step-by-Step’ Project, India

Dr Sanjeev KelkarNovo Nordisk Education Foundation, India

Professor Veerasamy SeshiahChairman of the Dr V. Seshiah Diabetes Care and ResearchInstitute, Medical Director of the Diabetes Unit, ApolloHospitals, Chennai, India

Dr Khasag AltaisaikhanDean of the School of Medicine, Health Sciences Universityof Mongolia, Mongolia

Dr Francis PasaporteDiabetologist, President of the Philippine Association ofDiabetes Educators

Ms Ida NicolaisenSenior Research Fellow, Nordic Institute of Asian Studies,Copenhagen University, Denmark

2 Pract Diab Int Supplement 2006 Copyright © 2006 John Wiley & Sons, Ltd.

SPEAKERS

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Asia is home to four of the world’sfive largest diabetic populations andtherefore a fitting focus for the WorldDiabetes Foundation (WDF) Summit:highlighting the rising prevalence of the condition and developingstrategies for reducing the healthand socio-economic burden it presents for individuals, communities

and governments. The Summit provided a forum for interaction between the key diabetes stakeholders andWDF partners, aimed at creating a network of committedglobal influencers who can drive the agenda of diabetesprevention and care in the developing world. The ultimateaim is to encourage governments, policy makers andfunding bodies worldwide to prioritise diabetes care:facilitating the implementation of much needed sustain-able and far-reaching solutions.

The Summit was hosted by the WDF, the Ministry of Healthin Vietnam and the Western Pacific Declaration onDiabetes; which includes the Secretariat of the PacificCommunity (SPC), the World Health Organization (WHO)and the International Diabetes Federation (IDF). OurVietnamese colleagues welcomed us to Hanoi with sincere courtesy, friendliness and enthusiasm and over100 participants from Vietnam, Asia and further afieldattended the Summit, including representatives from theMinistry of Health Vietnam, the World HealthOrganization, IDF, SPC and WDF project partners.

The day before the start of the World Diabetes FoundationSummit in Hanoi, a party of WDF, IDF,WHO and Vietnamesehealth officials, together with representatives of the media,visited one of the WDF-funded community-based pilot

project sites in the provinces. On the way, passing throughthe rural areas, we saw many hundreds of schoolchildrenriding bicycles. This contrasted with Hanoi, where all theyoung people now travel everywhere on small motorbikes.This seemed to me to exemplify one of the reasons why allthe countries of the developing world are facing such disastrous increases in the prevalence of diabetes. Theprevalence of diabetes in urban areas in Vietnam has doubled since 1993 and, in response to this, the Ministry of Health in Vietnam has been working on an integratedcommunity-based approach to the prevention of diabetesin collaboration with the WDF and WHO, which will berolled out nationally, based on the learning from the pilotprojects in two provinces over time.

But it is not only in Vietnam that health workers, govern-ments and international organisations, such as the WDF, areworking fervently together to stem the tide and treat diabetes.This Summit heard from experts, project partnersand key stakeholders from across Asia about a number ofencouraging projects which hope to make a significantimpact upon the rising prevalence of diabetes by raisingawareness, improving care and implementing screeningand prevention programmes. I hope that this publication ofthe proceedings will give you an insight not only into theextent of the problem, but will also hearten you when youread about the extraordinary dedication and ingenuity ofthese people who are working in some of the poorestregions of the world.

Pierre Lefèbvre. Chairman,WDF; President IDF.

Pract Diab Int Supplement 2006 Copyright © 2006 John Wiley & Sons, Ltd. 3

INTRODUCTION

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The Summit was opened by Dr Anil Kapur of the WDF, whowelcomed all the participants and prominent guests, whichincluded the Minister of Health, Professor Tran Thi TruangChien and the Vice Minister of Health, Madame Nguyen Thi Xuyen of Socialist Republic of Vietnam; Dr HansTroedsson, the World Health Organization Representativein Vietnam; Mr Peter Lysholt Hansen the Royal DanishAmbassador to Vietnam; and representatives from theAsian Development Bank, regional WHO NCD advisors andWDF project partners. He reminded delegates that theWDF – founded in 2002 – is dedicated to supporting peo-ple with diabetes in the developing world by funding sus-tainable projects in the fields of awareness and education.The aim of the Summit was to highlight the public health,social and economic burden posed by the rising incidenceof diabetes and its complications in the Western Pacific andSouth East Asia region and to discuss steps to reduce thisburden. During the Summit, evidence was provided onongoing projects and steps that have already been taken.

Professor Tran Thi Truang Chien (Minister of SocialistRepublic Vietnam Ministry of Health) added her welcomeand thanked the WDF for choosing Vietnam for itsSummit. In recent years Government initiatives haveaimed to improve the diagnosis and treatment of peoplewith diabetes in Vietnam. There has been a particularfocus on young people and care is free for those undersix years of age. There are projects underway for the

prevention; detection and management of the disease,and delegates heard more about some of these duringthe Summit. They demonstrate the huge potential that can be achieved by taking a community-based approach and pooling the resources of both national and international partners.

Dr Hans Troedsson (WHO Representative in Vietnam)welcomed delegates on behalf of the WHO. The Summitis of major significance, marking a milestone in efforts todevelop effective strategies to meet the challengesposed by diabetes, which is predicted to be one of themajor health crises of the 21st century, and the brunt ofthe predicted rise will be in the developing countries.Already in Vietnam three out of every 100 adults are estimated to have diabetes. This alarming figure represents a doubling of the number in the last ten years– a pattern seen in many Asian countries. This will notonly have implications for individuals, but also for theoverall socio-economic development of the countriesconcerned. The Prime Minister of Vietnam’s targets, set in2002, are rightly ambitious. Action needs to be takennow. If we fail to do so, the costs of illness and lost pro-ductivity will pose an intolerable burden on emergingeconomies. Many of the complications are potentiallypreventable and community-based projects – such asthose in Vietnam – are demonstrating the huge potentialof sustainable solutions.

WELCOME


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Globalisation and health: intervention and diabetesDelivering the opening address, the Chairman of theWDF, Professor Pierre Lefèbvre said that in 2003 therewere an estimated 194 million people in the world withdiabetes – half of them known and half yet undiagnosed.This figure is projected to rise to 333 million by 2025 – an increase of 62% (see Figure 1). This will affect everyregion of the world, but particularly South East Asia,which is predicted to increase from 43 million to 75.8 mil-lion (+76%). However, said Professor Lefèbvre, in additionto this there is a hidden epidemic of impaired glucose tol-erance (IGT) and it is estimated that there could now beover 310 million people with this condition worldwide, ofwhom 60% could go on to develop diabetes.

Professor Lefèbvre posed four questions:• What should we do for those people who are recognisedto have diabetes? • What should we do about those who have diabetes butin whom the condition is not recognised? • Is there anything we can do about those who are at riskof developing diabetes? • What can we do about making the general population ofthe world aware of the problem?

The aims of modern diabetes management for thoserecognised to have diabetes is the prevention of acutecomplications (such as hyperglycaemia and ketoacid-osis) and chronic complications (such as blindness,kidney failure, amputations, strokes and heart disease), toachieve an overall reduction in morbidity and mortalityand to ensure the quality of personal and professionallife. A “sadly now forgotten” landmark study by JeanPirart in 1975 and the DCCT study – some twenty yearslater – have both demonstrated the advantages of inten-sive control in type 1 diabetes. Therefore, it is essentialfor people with this form of the condition to have avail-able and affordable insulin and monitoring devices. Thisis still not the case in many parts of the world.

In the case of type 2 diabetes, prior to 1955, this waslargely neglected and between 1955 and 1995, treatment

was essentially glucose control-orientated. Since 1996, andpost the UKPDS, it has been recognised that managementand treatment should be much more broad based. Peopleshould be treated for lipids, blood pressure and hypergly-caemia and encouraged to exercise and give up smoking.

The problem of unrecognised diabetes is particularlyserious in developing countries – in Vietnam for example,for every patient diagnosed there are three, maybe four,undiagnosed. Randomised controlled data are not avail-able, but undiagnosed diabetes causes similar if not moreproblems to diagnosed diabetes, and opportunisticscreening (for example, whenever taking a blood samplefor any reason) should be encouraged.

For those who are at risk of developing diabetes(impaired glucose tolerance) there are excellent studiesshowing that the progression to type 2 diabetes can bedelayed by diet, exercise and, sometimes, metformin. Asthe DPP study has confirmed, the most effective treatmentfor those at risk is to change their lifestyle (see Figure 2).However, observed Professor Lefèbvre, it is very easy totell someone to, ‘change your lifestyle’. Factors influenc-ing lifestyle include education, income, profession, family,age, sex, health and religion and mental stress. These differ greatly between countries:“They are not the samein Vietnam as in the USA”. Components of lifestyleinclude diet, exercise, rest, smoking, alcohol, leisure time,work pattern and habits and attitude. These all have animpact on health, quality of life and life satisfaction andthere is a lot still to be done to understand how lifestylecan be changed.

Professor Lefèbvre concluded by reminding the audiencethat obesity and diabetes are becoming major publichealth problems (the global diabetes tsunami) that needimmediate urgent attention and action.

THE PRESIDENTIAL ADDRESS

23.036.257%

World2003 = 194 million2025 = 333 millionIncrease 62%

48.458.620%

14.226.285%

7.115.0111%

39.381.6108%

43.075.876%

19.239.4105%

Figure 1. Global projections for the diabetes epidemic:2003–2025 (millions)

Figure 2. Cumulative incidence of diabetes DPP study (Adaptedfrom N Engl Med J 2002; 334466:: 393–403)

Placebo

Cumulative Incidence of Diabetes (%)

40

30

20

10

0

0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Metformin

Lifestyle

To prevent diabetes in one individual:6.9 persons to be treated for 3 years with lifestyle interventions13.9 persons to be treated for 3 years with metformin


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The global diabetes tsunami: tracking, treating andtackling the epidemicContinuing on the theme of the global diabetes tsunami, Professor Paul Zimmet addressed many of hisobservations towards the Asian ‘diabesity’ epidemic – acombination of obesity and diabetes – but much of whathe said has worldwide implications. The world media isnow waking up to the size of the problem and ProfessorZimmet remarked that “What AIDS was in the last 20years of the 20th century, diabetes and its consequenceswill be in the first 20 years of this century”. In Asia,acute problems such as bird flu and SARS – althoughundoubtedly serious – are nothing compared to the morbidity and mortality caused by diabetes. Whereasdiabetes is set to be one of the biggest catastrophes the world has seen, in 2002 only 3.5% of the total WHO budget of US$ 43.6 million was spent on non-communicable diseases (NCDs) including diabetes.

The first reports of high rates of diabetes were from thePacific area in the mid 60s.Worldwide the prevalence isincreasing rapidly and Professor Zimmet showed a seriesof dramatic maps of the age-standardised prevalence ofdiagnosed diabetes in the USA, where in 1994 only twoStates had a prevalence of over 6%, compared to 11 in1998 and 24 in 2002. Indeed, in New York’s Harlem, one inevery four adults has diagnosed diabetes and, on aver-age, only half are diagnosed;“Probably, in reality, nearlyhalf of the adult population has the condition”. Australiahas joined the global epidemic with surveys showingapproximately 250 000 people with diabetes in 1981 compared to about one million now. Even more disturbingis that the average age of onset has fallen in that timefrom 55 to 35 in Australia (this trend of younger peopledeveloping type 2 diabetes is being mirrored in Asia and throughout the world). Professor Zimmet noted that in Australia the growth in prevalence amongst the indigenous peoples is accompanied by the increasing‘coca-colonisation’ of their diets.

Professor Zimmet suggested that Mauritius is a harbingerof the global situation. The population consists of 1.2 million Asian Indians, Blacks and Chinese – three groupswho together coincidentally constitute 66% of the world’spopulation. The prevalence of diabetes in Mauritius hasrisen from 14.3% in 1987 to 19.5% in 1998. In Singaporethere has been an approximately fourfold increasebetween 1975 and 1998. In China in 1980 less than 1% ofthe population had diabetes; by 1996 this had risen to3.2%, with over 11% of those over 60 years of age havingthe condition. India has the world’s largest populationwith diabetes. A study on the prevalence of diabetes andimpaired glucose tolerance in South India showedincreases from 5% and 2%, in 1984; to 12% and 14%, in2000. Data from Pakistan presented a similar picture –even in rural populations. Reported rates of diabetes inCambodia were 7.3% in urban populations and 3.2% inrural areas; the respective figures for Vietnam were 4.1%

and 2.2%. It is predicted that the numbers of people withdiabetes in both these countries will double between2007 and 2025.

Professor Zimmet then discussed the increase in compli-cations. Australian figures show that the prevalence ofend-stage renal failure has remained constant in type 1patients but has shown a fourfold increase in type 2 dis-ease. Economies will be devastated by the costs of renaldialysis. Turning to cardiovascular disease, he noted thatalmost all stages of glucose intolerance are associatedwith a doubling in cardiovascular disease.

Other conditions accelerating the condition include:• The metabolic syndrome (‘the deadly quartet’ of IGT/IFG/diabetes, abdominal obesity, hypertension and dyslipidaemia) • Sleep disturbances, particularly sleep apnoea • Non-alcoholic steato-hepatitis (NASH) • HIV/AIDS drugs (the metabolic complications of HAARTincluded insulin resistance, hypertriglyceridaemia andlow HDL-cholesterol) • Antipsychotic drugs.

Touching briefly on the treatment of diabetes, ProfessorZimmet observed that this is still unsatisfactory:“We areall hoping that there will be developments in genomics,leading to new therapeutic approaches for obesity anddiabetes and that we will come up with a magic bulletaddressing all the associated risk factors”.

Discussing lifestyle changes, he pointed to an Australianstudy in aborigines where the impact of seven weekstemporary reversion to a ‘hunter gatherer’ lifestyle resul-ted in weight loss, improvements in glucose tolerance andinsulin response, normalisation of dyslipidaemia andblood pressure reductions. The Finnish DPS study has alsoshown the benefits of lifestyle change. He suggested that,


THE KEYNOTE ADDRESSES

Figure 3. HbA1c distribution in people with type 1 diabetes

(unpublished data – Children’s Hospital Westmead)

2001200220032004

Percentage

HbA1c (%)

35

30

25

20

15

10

5

03.9-6.9 7.0-7.9 8.0-8.9 9.0-9.9 10.0-16.9

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if opinion leaders can be persuaded to exercise publicly,this could have an enormous impact.

Professor Zimmet summarised by saying that diabetes isthe greatest healthcare challenge that we face; no devel-oping nation will be able to cope with its costs. None ofthe global health agencies are addressing the issue prop-erly; for example, the UN Millennium Healthcare goals didnot even mention chronic non-communicable diseases.He implored everyone attending the summit to return totheir own countries and campaign for diabetes action. Hepaid tribute to the work that the WDF and other organisa-tions are doing in this direction.

Diabetes and the youngThe second keynote lecture was on the theme of thechanging face of diabetes in young people and was givenby the IDF President-Elect, Professor Martin Silink(Australia) who is, appropriately, a paediatrician.Professor Silink started by discussing type 1 diabetes.Worldwide there are about 430 000 children with type 1diabetes compared with 194 million adults with diabetes.Of these children, 250 000 live in developing countries –63 000 in the 58 least developed countries with unreliableaccess to insulin and virtually no monitoring. Metaboliccontrol is a matter of a balance between insulin and exer-cise on one hand and education, diet and mental healthon the other. Overall, diabetes control has improved, withsignificant progress in the area of microvascular compli-cations, but less so in managing HbA1c (see Figure 3) andpsychological outcomes.

Turning specifically to developing countries, ProfessorSilink pointed out that, in many of these, the most com-mon complication of childhood diabetes is death. InCambodia, before 1997, there was no child alive withdiabetes; life expectancy in Mali was about one year, inMozambique it was three years and in Uzbekistan, 19years. Survivors usually had poor control with life-threatening episodes of hyperglycaemia; they were

usually chronically ill with early complications and limited educational and work prospects. There is a lackof paediatric diabetes educators and paediatric expert-ise around the world, but the IDF has initiatives in place(IDF and ISPAD Science schools; IDF and ESPE proposalfor African centres), to help overcome this. A globalapproach is needed to provide insulin and blood glucose monitoring for all children with type 1 diabetesand Professor Silink reminded delegates about the jointIDF Child Sponsorship and Insulin for Life programmes.

Discussing type 2 diabetes in young people, he said thatthere are some key messages that the IDF is developingas position statements. The prevalence is, as yet, unknownbut is known to be increasing. It is a serious disease andtreatment is difficult. Healthcare costs are high and com-plications are likely to occur earlier. The condition isassociated with obesity and prevention is needed.

He said that type 2 diabetes is emerging in younger andyounger individuals as the worldwide pandemic of dia-betes progresses. The true prevalence remains unknown:“I find it incredible that the world is able to count thenumber of dead geese in Germany but is unable to

Figure 4. Glucose tolerance in Japanese obese children (10–13 yrs)(Adapted from Okhi Y, Study Group, Ministry of Health WelfareJapan, 2000 and Kida K, et al, 1992)

Type 2 diabetes (3.9%)

IFP/IGT(19.2%)

n=280

Normal(77.9%)

(Obesity ≥ 30% overweight)

IGT

Type 2 DM

30%

Figure 5. Complications in Japanese young people with type 1and type 2 diabetes (A adapted from Yamamoto T, et al, J Journ SocOpthalmol. B adapted from Yokoyama H, et al, 2000)

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uenc

y of

abn

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etin

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)Cu

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calculate the number of children with type 2 diabetes,”he remarked. However, junior and high school data froma Japanese urine screening programme for chronic renaldisease and glycosuria have shown that the incidence oftype 2 diabetes is eight times that of type 1. It is knownthat genetic and cultural factors strongly influence theprevalence. For example, data from NHANES III has esti-mated a prevalence of 0.4% for the adolescent US population as a whole, but much higher figures havebeen found in some ethnic subgroups; the prevalenceamong young Pima and Navajo Native Americans wasapproximately three-times and ten-times higher respec-tively. A recent study using oral glucose tolerance testinghas found that 6% of six to 14-year-old Torres Strait chil-dren had type 2 diabetes.

Turning to the links with obesity, he reported that a USstudy by Sinha et al found IGT in 25% of 55 obese children and 21% of 112 obese adolescents. Type 2 diabetes has been identified in 4% of these obese adolescents; all Afro-Americans. Data from the StudyGroup, Ministry of Health Welfare, Japan, have revealed

type 2 diabetes in 4% of 280 obese children. IGT wasfound in 19.2% and, five years later, 30% of these hadconverted to type 2 diabetes (see Figure 4). The USCenter for Disease Control has predicted that one inthree children born in the USA in 2000 will develop type 2 diabetes in their lifetime but, observed ProfessorSilink, for minorities and indigenous peoples, the situa-tion is even worse; for them the figure is one in every two children.

Children with type 2 diabetes are likely to developserious complications earlier. Japanese data suggestthat retinopathy developed at the same rate for bothtype 1 and type 2 children but that in type 2 children,nephropathy develops earlier (see Figure 5). Type 1and type 2 diabetes in children and adolescents are seri-ous disorders, summarised Professor Silink.

Prompted by a suggestion from a young lady with diabetes– Clare Rosenfeld – Professor Silink and his IDF colleaguesare now campaigning for a United Nations Resolution onDiabetes with the theme ‘Unity in Diabetes’.


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The need for global awareness raising, advocacy andaction in diabetes: the responsibility of WHO and IDFDr Gojka Roglic (WHO, Switzerland) presented the latestestimates of figures for the prevalence of diabetes.According to the IDF Atlas of 2003, there were an estimated 195 million people with diabetes in the world.However, warned Dr Roglic, the latest figures will bereleased at the IDF summit in South Africa in December.These consistently showed an increased prevalence incountries with large populations such as India and China.The latest estimates for 2007 show that the global dia-betes burden is likely to be over 230 million. The WHOestimates that the numbers of people with diabetes willgrow to more than 330 million in 2025 with developingcountries expected to bear the brunt of the epidemic.

What is driving the diabetes epidemic in developingcountries?Dr Viswanathan Mohan (Madras Diabetes ResearchFoundation, Chennai, India) explained that differentparts of the world are undergoing different stages ofepidemiological transition. For example, in the westernworld, deaths from infectious diseases are falling as therates for non-communicable disease such as diabetes,obesity, hypertension, cardiovascular disease and cancer are increasing. This is not the case in the leastdeveloped parts of the world. The developing world isundergoing transition wherein it faces a double burdenof diseases (see Figure 6). Furthermore, eight out of thetop 10 countries in terms of numbers of cases of dia-betes are in the developing stage of transition – six ofthese are in Asia.

Dr Mohan discussed the possible reasons for theseincreases. A growth in population size has been sugges-ted as the cause of this epidemic but this is not necess-arily the case; China is a bigger country than India, yetIndia has more cases. Genetic predisposition and rapid

lifestyle changes are also implicated. For example, thePPARγ gene has been shown to regulate fatty acid genesinvolved in fatty acid uptake and lipogenesis, leading toinsulin resistance and type 2 diabetes. Recent evidencefrom Dr Mohan’s group suggests that the PRO 12 Alapolymorphism of the PPARγ gene is protective againstdiabetes and insulin resistance in Europeans, but doesnot protect Indians. Urbanisation is also implicated; in thedeveloping countries, this is around 40% in 2000 and isestimated to rise to 57% by 2025. Lifestyle changes arehaving a major impact; “Today the developing world issuffering from a disease called affluenza,” declared DrMohan. These lifestyle changes embrace diet and physi-cal activity. For example, visible fat consumption is linkedto the increase in diabetes and IGT (see Figure 7) andthe amount of physical activity (light, moderate or heavy)is also linked to prevalence. Turning to the links betweenphysical activity and inheritance, he noted that theChennai Urban Population Study has shown a synergisticeffect; a positive family history of IGT and a sedentarylifestyle increase the risk of IGT in an individual three-fold. Dr Mohan concluded by saying that prevention has to start early: 20% of the world’s total population are adolescents – and over 80% of these are in the developing world.

Mapping the status of care in Asia – The DiabcareAsia studies Professor Clive Cockram (Hong Kong) presented findingsfrom the Diabcare Asia studies which were conducted in three phases: 1998, 2001 and 2003. The objectives of thesestudies were to describe diabetes control, managementand complications in the diabetes population in Asia, toinvestigate the relationship between these factors and to provide a means of measuring the quality of diabetes

MAPPING THE HEALTH, SOCIETAL AND ECONOMIC CHALLENGES OF DIABETES

Figure 6. Epidemiologic transition and diseases in developingcountries

Least developed countries

Developingcountries

Non-communicablediseases: diabetes,obesity, hypertension,cardiovascular disease, cancer

Infections

Epidemiologic transition

Mor

talit

y ra

te

Developed countries

Figure 7. Visible fat consumption and prevalence of newly diagnosed diabetes and IGT (Adapted from Saroja Ragharan, et al,Chennai Urban Population Study 2006)

Prevalence (%)

Diabetes* IGT* *p<0.05 for the trend

Visible fat consumption

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01st qtr 2nd qtr 3rd qtr 4th qtr


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management. There were collaborative studies betweenNovo Nordisk, the Bio-Rad company, IDF-WPR and partici-pating Asian national diabetes associations from, at vari-ous times, Bangladesh, China, India, Indonesia, Korea,Malaysia, the Philippines, Singapore, Sri Lanka, Taiwan,Thailand and Vietnam. More than 650 diabetes centresparticipated in the three phases. The 2001 study (over8500 patients) looked at the primary healthcare sector(Chuang LM, et al. Diabet Med 2002; 19: 978-985), the1998 study (over 22 000) (Chuang LM, et al. Diabetes ResClin Pract 2006; 71: 146-155) and the 2003 study (over 15 000) took place in specialist clinics. HbA1c blood sam-ples and data from patients’ medical records, interviewsand laboratory assessments were entered directly into thecomputer system. The vast majority of patients (95% in allthree cohorts) had type 2 diabetes and in each study a little more than half were female. The average age was 60 years and the duration of diabetes averaged 9 years.Between 36% and 45% had abnormal albuminuria, 30%to 34% had neuropathy, 12% to 21% had retinopathy and25% to 29% of the study population had cataracts.“Someof the most basic methods of looking at complicationswere not all that well done”, observed ProfessorCockram. For example, in 2003, only 53% of patients hadhad their feet examined in the previous 12 months. About5% of patients had well-established renal failure. Onlyabout 20% of patients had achieved the optimal bloodpressure control target of <130/80 mmHg; in 2001, 43%were treated for hypertension but this figure rose to 56% in 2003. A total of 80% failed to reach the targets forfasting plasma glucose (FPG) (6.1 mmol/L) or HbA1c(6.5%). In 2001, local HbA1c measurements carried out byGPs within one year averaged 32%, but improved in thespecialist clinics from 44% in 1998 to 58% in 2003. In2001, local HbA1c measurements carried out by GPs with-in one year averaged 32%, but improved in the specialistclinics from 44% in 1998 to 58% in 2003. A total of 80%failed to reach the targets for FPG (6.1 mmol/L) or HbA1c(6.5%). However, the status of glucose control did differbetween countries.

Reporting on the diabetes management findings,Professor Cockram said that in all three studies oralantidiabetics constituted the mainstay of therapy –between 70% and 80%; insulin alone or in combinationaccounted for between 15.6% and 25.1%; and diet or traditional herbal medicine was used only sparingly (see Figure 8). He also presented figures on the level ofglucose self-monitoring (see Figure 9). The proportion ofpatients who said that they were dieting regularly wasapproximately 50% and the proportion of those exercis-ing regularly was between 40 and 45%. The proportion ofpatients given insulin in the primary care study was only16%, compared with 24% and 27% in the other two stud-ies (an improvement between 1998 and 2003). A quality oflife survey (adapted from the DAWN survey) indicatedthat about 63% of patients were worried about having tostart insulin therapy, or believed that starting insulinmeant that they had not followed treatment recommenda-tion properly;“In other words, they attributed this to fail-ure on their own part – not a good reflection on our abilityto educate them properly,” Professor Cockram observed.

He reminded delegates that throughout the region, onlybetween 20% and 50% of those with diabetes have beendiagnosed. Of those who have been diagnosed, less thanhalf received a recognised process of care and, of these,only 20% achieved treatment targets.

Overall, the Diabcare Asia studies showed that 95% ofpatients with diabetes had type 2, their mean BMI was~24 kg/m2, HbA1c and FPG were above recommendedtargets in about 80%, hypertension was observed in 80%(49% on treatment), complications were common: oralantidiabetics were commonly used to normalise glucoselevels and insulin treatment (alone or in combination)appeared under utilised – particularly in the primary caresector. He finished by saying that our attention clearlyneeds to be refocused on non-communicable diseases.

Knowledge, perceptions and beliefs about diabetesDr Narayanasamy Murugesan (Diabetes Research Centre,India) told the meeting that people in urban areas of Indiaare becoming conscious of diabetes, but that opportunitiesFigure 8. Diabetes management

1998

Diet 5%

Insulin 14%

Insulin andOAD 9%OAD 72%

2001

Trad/herb medicine 0.8% None 2.9%Insulin 8.1%

Insulin and OAD 7.5%

OAD 80%

2003Trad/herbmedicine 1.2% None 2%

Insulin 11.5%

Insulin andOAD 13.6%

OAD 71.3%

Figure 9. Glucose self-monitoring

No. times/mth 2003 (rr=99%)2001 (rr=18%)1998 (rr=46%)

13

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11 1113

17

Urine glucose

Blood glucose

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n= 3571 849 5689 665 870 4090% of

respondents 23 54 56 4 55 40

OAD – oral antidiabetics Trad/herb – Traditional/herbal medicines

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to obtain information are limited. He presented results froma WDF systematic study carried out in Chennai city jointlywith the WHO in order to assess knowledge, perceptionsand beliefs regarding diabetes. From a cluster sample of3681, a general population of 3357 representative of allsocio-economic strata (of whom 324 had diabetes; most in 40–60 age group) and policy makers were covered. Inaddition to knowledge, perceptions and beliefs, the policy makers were asked to respond on policy issuesrelated to diabetes (Dr Murugesan added that theresponse was poor among policy makers). He started byquoting some random responses indicating that somepeople thought, for example, that obesity is associatedwith wealth and beauty, that ‘mild’ diabetes is not a prob-lem, that lifestyle changes are difficult to practice, thatjuice of bitter gourds and fenugreek seeds can bringdown sugar levels and that irregular and untimely mealsaffect health.

The results of the survey showed that only a small proportion of the responders knew that diabetes is relatedto excess sugar in the blood and insulin deficiency (seeFigure 10). Surprisingly, even diabetic subjects did notknow that diabetes is related to high blood glucose levels.However, people with diabetes had a better awareness ofthe symptoms of the condition.Whilst about half the respon-ders thought family history was a cause, about a thirdblamed an excessive intake of sugar and only 22% sawbeing overweight as a cause. People with diabetes had bet-ter knowledge about complications, but all responders hadlittle knowledge regarding foot complications.

Turning specifically to knowledge, perception andbeliefs among people with diabetes, Dr Murugesanreported that only 54% realised that their diabetes wasalways there rather than ‘coming and going’. Of the 46%who said that it comes and goes, 23% said that theyrecognised it when they got ‘tiredness and weakness’.When asked about consultations and care, 93% said thatthey approached doctors when they wanted to know more about diabetes and almost an equal

percentage (92%) approached doctors when they needed treatment.

The survey found that 37% of people with diabetesreported complications: 15% had ‘foot problems/nerves’,13% had ‘problems related to eyes’ and 8% had ‘heartproblems’. A total of 95% thought that everyone with dia-betes would get complications and, of these, 86% thoughtthat they could have prevented diabetes.When askedhow they could prevent the condition, 72% said by regu-lar exercise, 62% by avoiding fat and rich fried food and26% by reducing weight.

An analysis of the findings revealed that gender, education,occupation, family income and family history of diabeteshad an impact on the awareness of diabetes among the gen-eral population. Among people with diabetes, education andoccupation had an influence on their awareness.

Dr Murugesan concluded that 90% of subjects had heardabout diabetes but that their knowledge on symptoms andcauses of diabetes was poor. Many of them had heardabout the benefits of a healthy diet, physical activity andthe possibility of developing diabetic complications.However, the general public were less aware than peoplewith diabetes.

Socio-economic consequences of diabetes in lowresource economiesDr Anil Kapur discussed the socio-economic consequencesof diabetes in low resource economies, taking India as anexample. He started by explaining how eating habitsevolve with economic development. As people move upthe economic ladder their eating patterns change fromsubsistence to more luxury items (see Figure 11). Food pro-cessing is growing rapidly; for example, rural India is noweating in a similar way to urban India 20 years ago. Theconsumption of fast food, fried food, sweets and carbonat-ed drinks has increased, and now 5% of people eat outdaily, 11% do so five to six times a week and 17% do sothree to four times a week. Dr Kapur added that it is no usetotally blaming the multinational fast food industry for this;“We have in our own cultures enough junk food”. Thegrowth in the consumption of such food has been paral-leled by a decrease in exercise. The result of this, asresearch in New Delhi has shown, is that, in that area, everysecond person fulfiled the criteria of obesity or had excessabdominal fat. A study from an Indian village has shownthat, over 14 years, diabetes has increased from 2.2% to6.4% and that this has been accompanied by increases insuch factors as regular use of motorised transport, nearbywater supply and watching television regularly. But, admit-tedly, there were both gains and losses with economicdevelopment and lifestyle changes.

Dr Kapur explained how socio-economic issues arelinked closely with poor health consciousness because ofpoverty, illiteracy, ignorance, apathy or vested interestmarketing. Being overweight is often seen as a sign ofprosperity and good health; high-energy foods are oftenseen and promoted as good for health and there is a lackof acceptance of the concept of chronic illness. Poverty

Figure 10. Diabetes knowledge in people with diabetes and thegeneral public

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and under-nutrition, as well as affluence and obesity,exist side-by-side in our societies. There are mixed pub-lic health messages; for example, a mother would be toldto ‘feed-up her baby in early childhood’ only to be latertold that the child is overweight. There is a lack of socialsecurity and health insurance; in rural India only about3% of people have such insurance. There is a poor infrastructure and heavy load on doctors.

As the global diabetes epidemic had already been discussed during the conference, Dr Kapur did notrepeat the known facts, except to remind the audience ofthe great disparity between expenditure on communi-cable diseases and non-communicable diseases, such as diabetes. The official overseas development aid to thehealth sector constitutes $2.9 billion of which only 0.1%is allocated to chronic diseases. Indeed, diseases suchas HIV/AIDS have traditionally taken up most of thefocus and resources. But the WHO predicts that non-communicable diseases such as diabetes will become

the world’s main cause of disability and death during thenext 25 years and, in 2005, 35 million people will diefrom these – more than the number of deaths from allinfectious diseases (including HIV/AIDS, tuberculosisand malaria). The developing countries carry 90% of theworld’s total disease burden, yet they benefit from only10% of global health resources. Indeed, WHO estimatesthat one third of the world’s population lack regularaccess to essential drugs, and this figure is expected to rise to over 50% in the least developed parts of Africa and Asia.

Dr Kapur explained that people with diabetes use higherhealthcare resources and these costs can be divided intodirect, indirect and intangible costs. He discussed some ofthe factors influencing costs based on his studies in India.For example, education and awareness are importantdeterminants of costs; college-educated people on aver-age are diagnosed seven years earlier than people withno literacy. Despite a longer average duration of diabetes,those with a college education have a considerably lowerrate of diabetes complications (45% complication-free)compared with people with low or no literacy (20% complication-free). The place of residence, employmentand income, also have an important bearing on cost.People in lower-income groups are diagnosed on averagefour years later – as are people living in remote ruralareas. Employed and working people with diabetes havefewer complications compared with those not working orthose in rural areas engaged in agricultural labour, due toa better ability to afford care. People from semi-urban orrural areas have higher rates of complications – despiteshorter duration of diabetes – compared with urbanareas. And with similar diabetes duration, more peoplefrom higher socio-economic groups are free of complica-tions compared with people in the lower group.

Dr Kapur explained how complications impact on thecosts of diabetes. In the CODE-2 study (Cost of Diabetestype 2 in Europe) the cost in people with microvascularcomplications was 1.7 times higher compared with peo-ple with no complications; with macrovascular complica-tions, 2.0 times higher and both together, 3.5 times high-er. Similar findings were noted from the Indian study,where an increasing number of complications increasedthe annual cost of care. Overall, hospitalisation is a majorcost and is higher for people with type 2 diabetes thanfor type 1 (see Figure 12). The mean direct cost per per-son with type 2 diabetes (including hospitalisation) aver-ages 7158 rupees ($149) but, if indirect costs are added,the total annual cost averages 19914 rupees ($415).

How do people pay for their treatment? Although medicalinsurance coverage has improved from under 2% in 1998 to14.2% urban and 3.2% rural, it still remains very low.Delayed diagnosis and poor treatment has socio-economic significance – those who need advanced care canoften ill-afford it. Personal and family income can help, butover 56% borrow or use all of their savings. Non-earningfamily members often have to start work prematurely at lowwages – significantly reducing their education and nega-tively impacting their long-term earning capability.The

Figure 11. Changes in eating habits with economic development

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Per capita income US$, purchase price parity

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Per capita income (thousand) US$, purchase price parity

GDP per capita @ purchase price parity

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average per capita income is $460 per annum (44% of thepopulation live below $1 a day) and the cost of their diabetes treatment can consume up to 45% of their income.“If there are two or three people with diabetes in a family,the consequences are quite disastrous,” Dr Kapur observed.

Between 1998 and 2005 the cost of medicines increasedby 40% and the cost of laboratory tests increased by336%; medical consultations have gone up by 199%;hospitalisations have increased by 109% and surgeryhas soared by 632%. Overall, treatment costs have doubled.

Dr Kapur summarised that diabetes has attained epidemic proportions; care is generally inadequate andcomplications are common at diagnosis and increasewith duration. These factors combine to increase the economic burden on society, families and individuals.

Delayed diagnosis and improper treatment have socio-economic significance – those who need advancedcare are often the ones who can ill-afford it, trappingthem and their families into a cycle of debt and furtherimpoverishment. “For those of you who think that treatingdiabetes is expensive, I would like to say that NOT treat-ing diabetes is very expensive,” he concluded.

DiscussionProfessor Lefèbvre observed that studies have shown thatthe main obstacle to prescribing insulin has been mainlyin the mind of the doctors rather than the patient.Professor Cockram thought it is a combination of both,since the feeling of failure on the part of the patient is areflection on the failure of the doctor to educate.

When asked to comment further on the differences inthe prevalence of diabetes in rural and urban areas, DrMohan said that the exact reasons are not yet clearlyunderstood. Certainly, the level of physical activity anddiet are involved but other factors, such as inflamma-tion and pollution, might also be involved. The reasonsare further complicated by, for example, the fact thateven within urban areas there are large differences inprevalence between income groups.

Speaking from the floor, Professor Silink alerted delegates to the fact that the IDF is starting a campaignseeking a UN resolution on diabetes. It is hoped thatthis will be proclaimed on World Diabetes Day 2007.All departments of governments – health, sport, trans-port, education etc – need to work together to producea societal solution. Furthermore, large corporationsneed to be involved. He asked that all delegates will,on returning home, lobby for their countries’ supportfor the resolution. Professor Lefèbvre added that theWDF and the WHO support the IDF initiative.


Mean expenditure per hospitalisation (INR)

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7668

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Figure 12. Differences in the cost of hospitalisation between people with type 1 and type 2 diabetes

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Diabetes prevention and care – entry point for anational non-communicable disease programme Dr Gauden Galea (WHO West Pacific Region) describedhow, in the WHO’s Western Pacific Region, they are tryingto integrate, prevent and control non-communicable disease (NCD) and how diabetes fits into this programme. He started with the paradoxical statementthat “The best way to work for diabetes…is not to workfor diabetes”, saying that he would explain this at a laterstage in the presentation.

It is essential to find a framework within which to work.This should consist of intervention on behavioural deter-minants (tobacco, diet, physical activity and alcohol),environmental (socio-cultural, policy, economic and physical). These can lead to intermediate risk factors(raised blood sugar, raised blood lipids, central obesityand raised blood pressure) and the end-points areischaemic heart disease, stroke, cancer and chronic lungdisease. These consist of a set of intimately integratedconditions with common causation where integratedintervention is possible.

The WHO tries to work with individual countries by delivering a unifying package of interventions with fourapproaches. These are the development of a national planand programme; working within a common surveillancesystem; promoting healthy lifestyles and fostering clinical preventative approaches. Each has its own sub-components. The national plan has to have stakeholderinvolvement and government participation; surveillanceneeds international research; effective communicationand supportive environments are essential in implement-ing healthy lifestyle approaches and good quality clinicalpreventative services are needed for those at high risk.

Together, these components produce a planning modelsuch as a stepwise intervention, which approaches a NCDframework addressing the whole population and individu-als at high risk. This will then be classified into either acore approach (what can be done in the short term withavailable resources); an expanded approach (what can bedone in the medium term with realistically augmentedresources) or a comprehensive approach (what must bedone for complete response to chronic disease in thelong term).

Thus, these approaches can be classified in order to take into account the resources of individual countries.Dr Galea explained how the list of countries will be whittled down to identify those in most need of WHOsupport. He gave some examples of integrated actionusing the stepwise approach in China, Mongolia, thePhilippines and Vietnam. In China, a task force is workingon final drafts and consultations on a national NCD planfor integrated prevention and control of chronic diseases:a ‘first’ for this country. In Mongolia, after three years indevelopment, the government has recently approved the

national NCD plan. The Philippines does not have anational NCD plan but has an active coalition of govern-mental and non-governmental partners. They have devel-oped a set of key performance areas, which include jointaction to reduce adult male tobacco smoking and adoles-cent uptake. Vietnam has had a high-level PrimeMinisterial decision (since 2002) mandating action onNCD and has recently (November 2005) held a mid-termreview of its programme of joint action. An NCD TaskForce has close links with VINACOSH (the VietnamCommittee on Smoking and Health). All of these coun-tries have completed their stepwise surveys and aredeveloping initiatives (including the Vietnamese one –see later in this report) and all have developed hyperten-sion guidelines.

Dr Galea concluded by completing his opening remark;“The best way to work for diabetes…is not to work fordiabetes…it is to work for countries”, implying that thegreatest public health benefit will arise from strengthen-ing health systems and from integrated prevention.Vertical programmes can supplement, but should not bethe aim of public health approaches.

He said: “I put it to you that working from a country perspective requires us to step back for a moment fromdiabetes and to make quality healthcare accessible topeople with diabetes, and to decide how we can use a stepwise framework to create synergies with cancer andcardiovascular disease where a lot of similar argumentsare being made”.

Need for integrating control of chronic diseases – thelink between diabetes, HIV/AIDS and tuberculosisProfessor Ib Bygbjerg (Copenhagen) explained the linkbetween diabetes, HIV/AIDS and tuberculosis. NCDs andcommunicable diseases often hit the same populations.Various communicable diseases interacted (for example,HIV and tuberculosis) in the same way that various NCDs(such as cardiovascular disease, hypertension, and dia-betes) interact in the metabolic syndrome. NCDs andcommunicable diseases might also interact (for examplediabetes and tuberculosis). Furthermore, said ProfessorBygbjerg, the long-term treatment of HIV may induceNCDs. The prevention of some CDs and of malnutrition(for example, malaria and malnutrition in pregnancy and infancy) might prevent NCDs. The prevention of themetabolic syndrome implied the prevention of under-nutrition as well as of over-nutrition. He concluded thatthe control of NCDs and communicable diseases couldbenefit from integration.

WHO diabetes initiatives in South-East Asia Dr Jerzy Leowski (WHO, South East Asia) reminded delegates that the South East Asia Region (SEAR) comprisesonly 5% of the global landmass but 26% of the world’s pop-ulation. However, within this area there are estimated to be41% of the world’s cases of tuberculosis, 41% of the world’s

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deaths from infectious diseases and 33% of the world’scases of diabetes.WHO SEAR has a regional focus on integrated prevention and control of major NCDs. Their programmes focus on:• Reducing tobacco use • Promoting healthy diet and physical activity • Identifying and addressing determinants of health • Strengthening national capacities for the developmentand implementation of integrated NCD prevention andcontrol programmes• Promoting partnerships.

Comprehensive multidisciplinary, multi-sectoral and integrated action is the means to prevent and controlchronic diseases, he emphasised.

Diabetes is on the increase throughout the region and DrLeowski illustrated examples of its increased prevalencein major urban areas (see Figure 13). He explained thatdiabetes programmes and WHO supported initiativesare in existence or under development in the majoritycountries in SEAR. They are working with the DiabetesAssociation of Bangladesh; establishing diabetes ser-vices in Bhutan and strengthening diabetes programmesin DPR Korea. There is a CVD and diabetes programmeand diabetes guidelines in India and a diabetes educa-tion programme in Indonesia. WHO supported activitiesare implemented in the Maldives, Mayanmar, Nepal,Sri Lanka and Thailand and an initial assessment of thesituation in Timor Leste has been undertaken.

DiscussionProfessor Cockram started an interesting debate whenhe suggested that the terms NCD and communicable

diseases should be abandoned as the dividing linesbetween them are becoming increasingly blurred.He also suggested that hepatitis C and B should beincluded in the mix discussed by Dr Galea as studieshave shown links with diabetes. Dr Galea agreed thatboth these points are valid; indeed, there are many other diseases associated with diabetes. However, ProfessorLefèbvre criticised the ‘stew’ approach. He argued thatdiabetes is unique and that its specificity should berecognised. Professor Silink felt that the terms NCD and communicable diseases should be abolished as both terms were holding progress back.

Bangkok 1982

Bangkok 1986

Dhaka 1985

Dhaka 1993

Jakarta 1982

Jakarta 1992

Madras 1989

Madras 1995

Madras 2000

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Figure 13. Increase in prevalence of diabetes in urban areas

Prevalence (%)

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The need for global awarenessDr Gojka Roglic started by explaining that the WHO andIDF are complementary; WHO works with governmentswhilst IDF works through its members. During her pres-entation, she described a joint project between the WHOand IDF supported by the WDF on awareness raisingcalled Diabetes Action Now.

The programme focuses on low- and middle-income communities, particularly in developing countries and itsoverall purpose is to achieve a major increase in aware-ness of diabetes, its complications, and its prevention,particularly among health policy makers in low- and middle-income countries and communities. DiabetesAction Now will initiate and support projects to generateand widely disseminate new knowledge about diabetesand its economic impact in low- and middle-income com-munities. It will produce and widely disseminate reviewson the prevention of diabetes and the complications ofdiabetes. It will produce up-to-date, practical guidancefor policy makers in low- and middle-income countries,on the content, structure and implementation of national diabetes programmes, and will provide and maintain aweb-based resource to help policy makers implementnational diabetes programmes.

Dr Roglic added that all the arguments used in DiabetesAction Now will be based on solid research data, muchof this produced in the developing countries.

Improving care – a consumer perspective Mr Gordon Bunyan (Australia) is not only an active BoardMember of the IDF Western Pacific Region Council andDiabetes Australia but also has type 1 diabetes and so hisreflections on improving care added a different perspec-tive to the summit. He felt that the involvement of ‘lay’people with diabetes in scientific conferences has a positive impact – certainly, from his experience, in theIDF’s Western Pacific region. Involvement of ‘lay’ peoplein diabetes organisations is essential.

He emphasised the importance of building awarenessand the community recognising the enormity of the

epidemic. What will be the impact on business workforces? He suggested that the much-criticisedglobalisation could be turned to advantage; interna-tional business needs to recognise that it is part of thepartnership to fight the problem. “If they don’t, theywon’t have an economic base to work on,” he said.

Education is essential, not only for people with diabetesbut also for care providers, their loved ones and thecommunity. It is not simply a singular medical-basedactivity and it falls to people with diabetes to focus on abroader-based education and support. He is concernedthat many doctors listen to, but do not necessarily hear,the experiences of patients and their partners.Understanding how people actually manage their diabetes can only improve the quality of the advice doctors provide.

The community as a whole needs to understand the facts, because only in that way would discrimination disappear. People with diabetes should not be silentabout their condition. He observed that openness aboutone’s diabetes could have a beneficial effect on control –other people with knowledge of one’s condition can actually help.

In his personal experience, diabetes is no impediment tosuccess. But it is important to take personal responsibilityfor one’s condition. Perhaps healthcare workers take ontoo much responsibility rather than leaving it to theirpatients who are often willing to take on the responsibility.Educators and healthcare workers should emphasise the importance of people with diabetes taking on respon-sibility. And he emphasised the importance of involvingone’s family, and the respect they should be given by thehealthcare team – “very often my partner knows moreabout my condition than I do!”

He felt that events such as the present WDF summit reflect the way the diabetes movement has grown. It is areflection of the growing connections with governments,and of the importance that governments are now attaching to diabetes.

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Community-based approach to improving the qualityof management of diabetes in VietnamProfessor Ta Van Binh (Vietnam) is the Director of theEndocrinology Hospital in Hanoi and he commenced byoutlining the problems of diabetes in Vietnam. Vietnam isa developing country with a population in excess of 80 million. As it grows economically, the incidence ofNCDs is rapidly increasing. The prevalence of diabetes inurban areas (see Figure 14) has doubled since 1993 and the prevalence of IGT is more than double that of diabetes. The management of diabetes in the communityis inadequate and complications are common. Diabetes is emerging as a major public health problem – approx-imately 1.3 million citizens aged 30 and over have the condition but there is little awareness of risk factors andthe need for prevention. The problem is compounded bylow numbers of medical staff and facilities; for example,there is only one hospital that specialises in endocrin-ology, five provincial centres of endocrinology and fivedepartments of endocrinology. As diabetes will becomean economic burden in the near future, prevention andcontrol are necessary. This requires comprehensive andmulti-sector integration and more support from interna-tional collaboration.

Professor Binh outlined the progress that has been madeto date. Since 2000 the Ministry of Health, the WHO and the IDF have collaborated to develop an evolving,integrated and collaborative approach to primary,secondary and tertiary prevention. An integrated NationalPlan for NCD Prevention has been developed, which hasbeen approved at the highest levels of government. Anational diabetes survey and guidelines, backed by education, have been implemented. A National VietnamDiabetes Association has been established and nation-wide media campaigns have begun.

The Minister of Health has officially supported thedevelopment of endocrinology centres in the provincesand Professor Binh described a pilot prevention project,funded by the WDF and the WHO. The project aims toimprove the quality of life of people in two provinces –Thanh Hoa Province and Thai Binh Province – throughthe prevention and control of diabetes, and to establish asustainable model that can be extended nationally aspart of the National Plan for the prevention and controlof NCDs. The project hopes to raise the awareness ofdiabetes in the community and to reduce the proportionof people with undiagnosed diabetes to under 60%.

A summary of the activities, so far are covered in thereport on the field visit to the project (see next page) butProfessor Binh outlined the preliminary achievements,and challenges, that have been made.

The achievements have included an improved quality of management and education, baseline data from thesurveys and the development of early detection of

diabetes. In Thanh Hoa Province, the number of visits tothe Endocrinology Centre has grown from 6120 (700patients) in 2004 to 11 648 (2009 patients) in 2005.But there are challenges – the management of diabetes atdistrict level is limited and while the quality of manage-ment has improved, the number of people with diabeteswho have been tested for all components such as lipidsand HbA1c is not very high.

The action plan for 2006–2007 involves the continuationof the activities implemented in 2005, focusing on build-ing capacity, developing and improving the quality ofdiabetes management, widening the project and evaluating its efficiency. Professor Binh summarised thatkey factors in the success of the project so far have been the support, understanding and seed funding fromthe government; the co-operation and support of international agencies and consultants; funding supportfrom WHO and WDF; grass roots support from the population and the commitment of the medical staff.

Community diabetes in NepalDr Pradeep Shrestha (Nepal) described an education,management, prevention and awareness programme inNepal. In 2006, mortality from NCDs was 60% and pro-jected to rise to 73% by 2020. Nepal is sandwichedbetween two giants with a high prevalence of diabetes(India and China) and Kathmandu (which has an urbanprevalence of known and undetected diabetes of morethan 19% in those aged 40 and over, can been called the‘capital of diabetes’ [see Table 1]). To date, blood glu-cose, blood pressure and BMI have been poorly con-trolled in people being treated for diabetes. There is alsoa low awareness of disease prevention among familymembers of people with diabetes.

Hospital-based programmes were not satisfactory (andattendance declined) for a variety of reasons, includingaversion to hospitals, difficulties of travel, perceived

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Figure 14. Prevalence of diabetes in urban areas in Vietnam

Adjusted rate

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authoritarian attitudes by the diabetes education teams(resulting in very little interaction) and the unwillingnessof family members to participate away from home.

In order to run the diabetes programmes more effectively,Astha Nepal was established in 2002. Its major aim is to conduct community-based education and awareness programmes on NCDs throughout the country, startingwith diabetes. In 2003, Astha Nepal collaborated with theWDF to create ‘Community Development Programme onEducation Management and Prevention of DiabetesMellitus’. Its aims include:• Creating awareness about diabetes among the generalpublic • Emphasising that diabetes is preventable by lifestylemodifications • Empowering patients with knowledge on diabetes andprevention • Motivation for better management of diabetes as awhole • Clarifying dietary and other misconceptions • Helping to form diabetes clubs and associations.

One of their initiatives has been the establishment of diabetes camps. The Local Community Team (trained aspart of another initiative by Astha Nepal) approachbetween 25 and 30 known diabetics in their community.An appropriate date is assigned to the group and familymembers for a day long camp. They are asked to come tothe camp at 07.00 having fasted and with their medicinesand medical records. Following registration and comple-tion of a questionnaire on diabetes and its prevention,examinations are carried out (fasting blood glucose and

lipid profile, urine microalbumin, blood pressure andBMI). After a breakfast provided in the camp suitable forpeople with diabetes, there are education classes on diabetes and its prevention in the family and community,specific topics such as footcare, insulin and yoga/exercise for people with diabetes. Following these edu-cation classes lunch is provided. This is followed by edu-cation on a healthy diet and what people with diabetesand their families should be eating at home. Eye tests,postprandial glucose tests, personal consultations and aninteractive group session take place in the afternoon.

Although the camps have been well appreciated someparticipants have felt that the all-day camp, from 07.00until 18.00, is too long. Other challenges have been therecruitment and motivation of people with diabetes forthe camp due to age-old misconceptions (myths) aboutdiabetes mellitus in the community and availability ofinterested medical manpower due to the lack of funding.

Astha Nepal study:Ombahal, Kathmandu• Incidence of undetected diabetes: 13% in 40 years and above

healthy persons• IGT: 6.08% males and 9.56% females• IFG: 0.86 females only

Patan• Incidence of undetected diabetes: 15.325 in 30 years and above

healthy persons• IGT: 5.1% males and 10.25% females• IFG: 5.1 males 7.60 female

Table 1. Incidence of diabetes in Nepal

Seeing the project in action

Just before the Summit, members of the international media, accompanied by Members of the Board of WDF, Professor Ta Van Binhand Vietnamese Ministry of Health and agency officials visited theVietnamese/WDF/WHO pilot prevention scheme in Thanh HoaProvince, 153 km from Hanoi in the north-central region. The projectcurrently involves managing over 2000 people with diabetes in ThanhHoa and approximately 550 in Thai Binh. Activities undertaken in 2005included building capacity for medical staff, educating and consulting,carrying out surveys, detecting new cases, supplying new medical anddiagnostic equipment and setting up diabetes associations and clubs ata provincial level.

The clubs have been a particularly successful part of the project; theymeet monthly in Thai Binh and every three months in Thanh Hoa and,on average, over 200 people with diabetes attend them. The visit coincided with one such club meeting and, in a crowded hall, ProfessorTa Van Binh answered questions from an obviously highly motivatedgroup of patients and their relatives on nearly every aspect of diabetes, including risk factors, diet, physical activity and the prevention of complications.

The group had the opportunity to talk with attendees both at the cluband at the clinic, which handles well over 100 people a day, some ofwhom were there to be tested to determine if they have diabetes. Le ThuQuy, aged 48, developed type 2 diabetes two years ago. She is only 44kg in weight (one of the group colleagues expressed surprise at howpetite many of the type 2 patients were: not at all the Western obesearchetypes). She is very well informed (she already knew quite a lotbecause she is a nurse) but attends the club regularly and says that this

has increased her knowledge. So far, her condition is controlled by dietand exercise. Is she worried about the future? She says that she is some-times a bit anxious but her family thinks that everything will be fine.

Van Dinh Giao, aged 62 is a retired soldier and a very fit-looking andcheerful man. He was diagnosed some seven years ago and attends theclinic but this is his first visit to the club. He thinks it will be useful and iscurrently managed ‘very well’ by his doctors who have put him on‘some pills’ (he wasn’t sure what they were) but not, so far, on insulin.

So, all in all, the people seemed very happy with the project. This proj-ect will undoubtedly make a difference to the prevention, identificationand management of diabetes amongst the Vietnamese people.

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The present unstable political situation in Nepal has nothelped. Dr Shrestha finished by saying that Astha Nepal’smission statement is “Community diabetes education andawareness now will prevent diabetes or its complicationsand thus control the diabetes epidemic predicted by2025.”

A Pacific Islands model for diabetes careAssociate Professor Ruth Colagiuri (Australia)described a partnership between the Ministries ofHealth in two Pacific Island countries – Samoa andVanuatu – and the WDF to build capacity for diabetesprevention and care and reduce diabetes complica-tions. Despite their ‘tropical island paradise’ image,these countries are small, resource-poor, developingnations experiencing rapid urbanisation, a shortage ofdoctors and a huge and growing burden of obesity andrelated chronic diseases. Accurate current data forVanuatu are not available but, in Samoa, the prevalenceof diabetes has increased from 5.8% in 1978 to 22.5%in 2002 and the rate of amputations and other seriousdiabetes complications in both countries far exceedsthose found in developed countries.

The project aims to develop a workable model for secondary and tertiary diabetes prevention using asimple ‘recipe’ of:• Baseline assessment of the status of care, services, work-force, costs and needs • Engaging providers, consumers and the community inbuilding a locally relevant model • Implementing, monitoring and adapting the model• Measuring the difference.

The baseline measurement draws on locally availableprevalence and health service utilisation data, and hos-pital visiting teams conducted clinical screening of asample of people with diabetes in each country whichconfirmed high complications rates. Other baselinemeasurements include the status of services and equip-ment, an analysis of amputations (including interviewswith patients), the status of policy (national strategiesfor nutrition and chronic diseases) and the cost of diabetes. This information will be collated and provi-ded to local health professionals, ministry of health officials, consumers, community representatives andother stakeholders, and will inform the development ofa model that is optimally effective in the Pacific Islandsetting.

The overarching project goal is to reduce diabetes-related amputations, eye and kidney disease. Trainingfor capacity building is integrated into every aspect ofthe project including the development of an in-countryorganisational structure and job descriptions for theproject staff. From a clinical service perspective,treatment standards and targets have been agreed anda computerised patient register and database for complications screening has been introduced tostreamline the diabetes service. Although the countriesare too small to support highly-specialised clinicalservices (which are brought in from outside) local staff

are being up-skilled to a semi-specialised state andequipment to measure HbA1c and cholesterol (whichwere previously not possible to measure locally) havebeen provided. Diabetes kits containing simple riskassessment tools and referral criteria are being preparedfor distribution to the village health workers and will beused as a mechanism for strengthening referral pathwaysand relationships with the main hospitals.

The long-term sustainability of gains made under theproject will depend on the ability of the project partnersand staff to engage the full range of in-country stake-holders and must be supported by strong advocacy.Although the project is still in its early stages, localhealth authorities have been engaged and the Samoan Minister for Health has already signalled hiscommitment by acting as a role model and attending the baseline complications screening. Communityengagement resulted in a street march on WorldDiabetes Day (WDD) (see Figure 15) with significantmedia coverage on diabetes, and Vanuatu is now in theprocess of establishing a national diabetes association.

This model is about local empowerment for self-determination for health. It engages the local comm-unity in determining how best to use their human andmaterial resources to build and maintain a model thatcan deliver internationally recommended standards ofdiabetes organisation and care, or as close to this aspossible within local resource limitations.

Prevention and control of diabetes mellitus in ruraland semi-urban India through an established networkof hospitalsDr Abraham Joseph (India) described a WDF project toset up model diabetes clinics in rural hospitals of India.Most programmes targeted the urban communities (diabetes prevalence 11%) and health service is poor inthe rural areas (prevalence 3%), he observed. He alsomentioned that even though only 3% of rural people havediabetes, the actual numbers of people with diabetes, inrural and urban areas are similar, as 75% of the popula-tion in India live in rural areas. The initial objective is to

Figure 15. Street march on World Diabetes Day

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train doctors, nurse educators, footcare technicians andorthopaedic shoemakers for these clinics. The clinicshave to be self-sustainable and function as suitable secondary care facilities. They should be integrated diabetes clinics offering medical, footcare, education,dietary, exercise and ophthalmic support.

The Christian Medical College, Vellore, provided doctorsand nurse educators with training over two weeks andthe Schieffelin Leprosy Research & Training Centre,Karigiri (of which Dr Joseph is Director) trained footcare

technicians and orthopaedic shoemakers over two andfour weeks respectively. So far, staff from 35 hospitals havebeen trained and there are 28 functioning clinics. Of theones so far that have been inspected and rated by theChristian Medical College and the Schieffelin LeprosyResearch & Training Centre, two rated B; four,C; three Dand one, E (see Table 2).

Among the benefits of the project for rural hospitals arebetter therapeutic and preventive diabetes managementand the establishment of educational cells for diabetescontrol in regions with poor health services. The projectoffers improved networking between the group of hospi-tals to help in medical management and education. Thereis also future potential for diabetes clinical research inselected centres collaborating with the Christian MedicalCollege. As well as strengthening diabetes managementat hospital level, the programme also has a goal to develop community-based prevention initiatives.

Common obstacles encountered to date include:• Lack of, or poor, laboratory facilities• Long-term continuation of trainees• Administrative support• Functionality of the teams• Lack of commitment for community-based work.


A Green: Good infrastructure/smooth functioning moving towardsWorld Diabetes Foundation goals

B Blue: Strong efforts made in attempting to achieve the WDF goal,some limitations in local infrastructure

C Red: Some efforts made in setting up clinical and supportive work -can do significantly better

D Grey: Some effort made – but well short of WDF goals

E Black: No progress. Need to initiate programme

Table 2. Rating system for hospitals involved in the WDF modeldiabetes clinic project in India

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China National Diabetes Management ProjectDelivering this presentation on behalf of Professor KongLingzhi, Professor Wenjuan Wang (China) began byexplaining the background to the China NationalDiabetes Management Project.With the improvements inliving standards and lifestyle changes, diabetes hasbecome one of the most prevalent chronic diseases inChina. There are about 40 million people with diabetes.Ninety-five percent have type 2 diabetes (nearly 54% ofthese have at least one complication) and the total med-ical cost in the major cities of China amounted to nearly4% of the national medical expenditure. The InternationalHealth Exchange and Co-operation Centre (IHECC), theMinistry of Health, the WDF and Novo Nordisk jointlylaunched the National Diabetes Management Project. Thisaimed to create a systematic model for the preventionand treatment of diabetes in different areas of China andto promote a national guideline for diabetes prevention.The project started in 2003 and is due to finish in 2008.The Chinese Centre for Disease Control and Prevention(China CDC) and the China Diabetes Society (CDS) implemented the project, which is divided into two sub-projects: 1, model exploration and 2, guideline promotion.These were planned integrally but administered separately. Professor Wang discussed each of the sub-projects in turn.

In summary, sub-project 1 explored a community-hospital integrated diabetes management model. Itstasks were to select appropriate areas to explore the co-operation mechanism between the centre for primaryhealthcare and the hospital. Six project sites were chosen: Shaghai, Chengdu, Xiamen, Changsha, Dalianand Shenzhen. Questionnaires and interviews with healthmanagers, medical staff, patients and their family mem-bers revealed that the demands of healthcare areincreasing in patients with diabetes. Nearly half of thepatients could not be detected early and diagnosed.Nearly 51% complained of at least one complication.They could not get regular treatment and over half couldnot get their blood glucose and blood pressure undercontrol. The project also discovered that there was notenough provision for diabetes healthcare. However, mostpatients preferred hospitals to community health centres.Knowledge of diabetes and skills in medical staff couldnot meet patient needs and adherence to guidelines isweak. A patient registry form and self-management man-uals (for patients and doctors) are to be implemented. Adiabetes patient management system is to be developedand documents changed into electronic form.

Sub-project 2 will concentrate on the promotion of theguideline, explained Professor Wang. After developingthe text, the faculty developed multimedia teaching materials for uniform training. The guideline promotioncovers over 900 hospitals of key cities of each provinces,5 cities specifically designated in the state plan and 4municipalities directly under the central government with

3600 trainees; and 1000 hospitals from 300 key countieswith 3000 trainees. The first national training initiativetrained 71 participants from 29 provinces to be trainers.These will be the backbone trainers for nationwide train-ing and promotion of the guideline. A training templatehas been developed in order to facilitate standardisation.

Future responsibilities will include:• Enhancing the exchange and co-operation with theWHO,WDF and other international organisations • Strengthening government support • Developing interdisciplinary collaboration in variousdistricts • Conducting epidemiology, pathogenesis and risk factorintervention research• Creating an appropriate model for diabetes managementwhich is adaptable for the Chinese characters.

Developing the capacity for treatment as well as primaryand secondary prevention of diabetes in IndiaDr Narayanasamy Murugesan (India) reported on a project to ensure that people living in rural, semi-urbanand remote areas have access to economically afford-able, effective diabetes care, utilising the existing publicand private healthcare delivery system. The project,funded by the WDF, runs in seven states in India. Theintention was to establish a network of diabetes manage-ment and prevention centres in district hospitals andcommunity and primary health centres and to integratediabetes into the existing systems. The project also aimsto increase knowledge amongst stakeholders, other organisations and the general public and patients.Dr Murugesan reported that, as of January this year, 2062doctors have been trained in all aspects of diabetes andits complications (see Figure 16). The interactive trainingtook place in 41 batches over five days and was conduct-ed by eminent experts. Slogans and rhymes were devel-oped to encourage patient compliance:

BUILDING CAPACITY FOR NATIONAL PROGRAMMES

Figure 16. Numbers of doctors trained in diabetes and its complications

2500

2000

1500

1000

500

0

Total Male/Female Govt/Pvt Rural/Urban

2062

1493

569

1173

889999 1063


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“Two miles a day, keeps diabetes away”

“Laugh like you have never cried, play likeyou have never lost, live today like there isno diabetes tomorrow”

“Humpty Dumpty always sat in the house,Humpty Dumpty always played with themouse, They ate lot of chips and pizzas, Andthey ended up with diabetic comas”

“Eat less, weigh less, you will become sugarless“

Course evaluation feedback established that 98% thoughtthat objectives had been achieved, 80% had their expec-tations met and 97% would recommend the training toothers.

In addition to the doctors, 812 paramedics have beentrained over three days in 20 groups using, in house faculty members experienced in training. Prioritised topics are covered to play supportive roles in the overallservice delivery and the focus is on simple technical

details, lifestyle modification and communications skills.So far, 116 health educators and dietitians have beentrained over three weeks in four batches.

Establishment of diabetes healthcare services inBhutanDr Ritulal Sharma (Eastern Bhutan) explained that dia-betes is an emerging NCD in Bhutan with 446 cases in2001 and 701 in 2002 (out of a population of 600 000). Theobjectives of the Diabetes Health Care Services project(funded by the WDF) are:• To prevent or delay of onset of diabetes in those at risk • To ensure optimal case management• To delay the onset of complications.

This will be achieved by improving access to standarddiabetes care by establishing diabetes clinics at tworeferral hospitals and by improving knowledge andmanagement among healthcare providers, by providingthe general population with information about diabetesthrough advocacy and by carrying out relevant researchon risk factors. While there has been some delay inimplementation, a prevalence study for diabetes alongwith other NCD risk factors is underway in one area andhypertension is planned to be incorporated along withdiabetes in the proposed clinic approach.

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Aravind Diabetic Retinopathy Management Project There are an eestimated 32 million persons with diabetesin India – mostly type 2 and only less than 15% have beentreated, said Dr Perumalsamy Namperumalsamy (AravindEye Care System, India). Among these, the prevalence ofdiabetic retinopathy is between 20% and 30%. Althoughtimely treatment could prevent up to 60–70% of visionloss (a late symptom of diabetic retinopathy) this isexpensive. The numbers of health professionals trained totreat diabetic retinopathy is low (currently there are only 11 000 ophthalmologists, 11 000 surgeons trained incataract surgery and about 1000 doctors trained in themanagement of diabetic retinopathy). Laboratory facili-ties are rare and currently most disease is detected toolate for effective laser surgery. Patients need regular eyeexaminations but overall, a comprehensive model forscreening and treatment is not available.

Dr Namperumalsamy described a number of initiativesundertaken by Aravind. The Lions Aravind diabeticretinopathy project, covering the Madurai, Theni andCoimbatore districts of Tamil Nadu (a population of 7.5 million), ran for five years. The strategies of the project have included development of a service deliverymodel, awareness creation, seminars and workshops,training, screening and laser surgery.

There are now two Aravind-WDF diabetic retinopathyprojects – with a third due to get underway (see Table 3)– covering a population of nearly 30 million betweenthem. Awareness has been created by the production ofposters and pamphlets and educational booklets for bothpatients and healthcare professionals.

Dr Namperumalsamy outlined some of the achievementsof this project to date. At the 22 Aravind/WDF exhibitionsand diabetes fairs there have been nearly 14 000 atten-dees. Seminars and workshops have been organised withover 600 medical practitioners and over 1700 paramed-ical workers participating. The 118 patient interaction ses-sions held to date have attracted nearly 7000 participants.

A screening protocol has been developed to coverpatients who need urgent referral, those who need

routine referral and for those who need regular screening and annual follow up. So far, in the areas ofTirunelveli and Pondicherry, over 2000 patients havehad laser surgery. At a remote rural screening centre inTheni, nearly 4500 new cases of diabetes have beendetected – including over 1000 with diabetic retinopathyof whom 600 have been treated with laser surgery.The rural screening centre has also made use oftelemedicine to treat retinal and other cases. A mobilescreening unit fitted with a fundus camera and linked viasatellite to the major hospital in Madurai has been usedin 53 camps.

‘Step-by-Step’ – improving diabetes footcare in thedeveloping world Dr Sharad Pendsey (India) described the ‘Step-by-Step’approach to improving diabetes footcare in the developing world. In India there are no foot screening programmes, podiatry is non-existent, orthoses is unheardof and patients – as well as doctors – are ignorant aboutfootcare in diabetes. However, 40 000 legs are amputatedevery year, the most common indication being the infected neuropathic foot. The Step-by-Step pilot footcareproject (funded by the WDF) is being conducted in India,Nepal, Bangladesh, Sri Lanka and Tanzania with 115 physi-cians and paramedics being trained. The goals are to create awareness of diabetic foot problems, to providetraining for healthcare professionals, facilitate dissemin-ation of information, to reduce the risk of lower limb com-plications and to empower people with diabetes to carefor their feet and detect problems earlier.

Of 700 applications received, 95 teams (doctor and paramedic) have been selected, with a preference givento small towns and younger delegates with no previousfootcare training. A basic course has been held in 2004and followed by an advanced course in 2005.

Dr Pendsey reported that approximately 45 000 patientswere screened in the first year of the basic course andhad received footcare education. Approximately 15 000of these had high-risk feet; 4500 had trivial foot lesions and received appropriate treatment and 350were referred to tertiary centres. Future plans include


ADDRESSING SPECIAL NEEDS

Project Population served Activities

WDF project 1 (2003–2006) Tirunelveli, Kanyakumari and Tutocorin (6 million) Awareness, screening and treatmentTheni (1.2 million) rural remote centre

Diabetologists, AEH hospital, other eye hospital, Reading and grading centreWDF 02-039 rural centre and screening camps mobile screening unit

WDF project II (2004–2007) Pondicherry, Villupuram and Cuddalore (6 million) Awareness, screening and treatmentWDF 04-079 Theni (1.2 million) epidemiology survey

WDF project III (2006–2009) Coimbatore, Salem and Erode (9 million) Awareness, screening and treatmentForthcoming WDF 05-148 Tirunelveli, Kanyakumari and Tutocorin (6 million) extension of Project I

Table 3. Aravind-WDF diabetic retinopathy management projects

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follow-up visits to monitor the progress being made bythe teams and a proposed roll-out of the project in otherdeveloping countries.

Also on the subject of diabetic foot clinics, Dr Sanjeev Kelkar(Novo Nordisk Education Foundation India) said that there isa need for such facilities in India. In addition to the 40 000annual amputations, the lifetime risk of ulceration is 15%. Asan example of a foot clinic, he reported that at the DrAmbedkar Institute of Diabetes (Kilpauk), 6800 people withdiabetes have been examined and 5700 had foot problems(peripheral neuropathy, 59.3%; peripheral vascular disease,3.5% and foot ulcers, 4.5%).There were 36 major and minoramputations (nearly half the 1 to 1.5% expected rate).

Diabetes in Pregnancy – Awareness and PreventionProject (DIPAP)On behalf of the WDF and the V Seshiah Diabetes Careand Research Institute, Dr Veerasamy Seshiah reported

some preliminary findings from the Diabetes inPregnancy Awareness and Prevention Project – an ongoing community-based observational study in bothrural and urban areas in India. The baseline awarenessstudy used an open-ended questionnaire and found a lowlevel of awareness of diabetes (DM) and gestational dia-betes (GDM) in both rural (DM 15.9% and GDM 15.4%)and urban settings (DM 18.3% GDM 13.2%). A number ofinitiatives were put in place to try to increase the aware-ness of diabetes, from street play, drum beats, scriptpainting and wall banners to health education by trainedparamedics and health workers at antenatal clinics, self-help groups, books and handouts. The objective of theprevalence study is to focus on GDM and the interimone-year analysis shows that the prevalence of GDM isgradually increasing. However, approximately 95% ofwomen with GDM are managed with medical nutrition therapy and the birth weight of newborn babies isappropriate for their gestational age.

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Setting up diabetes clinics in MongoliaAs delegates heard throughout this summit, many countries in Asia are currently undergoing dramatictransformations and Mongolia is no exception. A mainlynomadic population is now moving to the cities with significant changes in their lifestyles and a rapidlyincreasing rate of diabetes. Dr Khasag Altaisaikhan(Mongolia) is the President of the Mongolian DiabetesAssociation and he described a national project run bythe Association, which helps to fight diabetes inMongolia in collaboration with the WHO, the WDF andthe Japan Association for Diabetes Care and Education(JADCE). A fully equipped new three-room diabetescentre has been established at an outpatient clinic inErdenet City Central Hospital. Nearly 2500 patientshave visited the new centre in the six months since it opened.

Dr Altaisaikhan outlined some other achievements of theproject. Twenty-three endocrinologists participated inworkshops where the IDF guidelines were adapted toMongolian needs and 31 nurses attended a training

course for diabetes educators. A curriculum on diabeteseducation, prevention training materials and a handbookon diabetes care have also been published.

Setting up diabetes clinics in the PhilippinesDr Francis Pasaporte (Republic of the Philippines) saidthat the delivery of diabetes care should be continuous,proactive and planned. He explained that it should be patient-centred rather than provider-centred and population-based as well as individual-based. It alsoinvolved coalitions between governmental and non-governmental and international healthcare organisations.One of the coalitions formed to help in diabetes preven-tion is the ALEAD (Advocacy, Leadership in Education,Access to Diabetes care) Foundation. An ALEAD Projectfunded by WDF has a short-term goal of addressing thesecondary and tertiary prevention of diabetes through the development and capacity building of local diabetesclinics. The long-term goal is to advance prevention programmes and develop awareness campaigns and integrate diabetes clinics within the local healthcare system and between several clinics on a national level.

PARTNERSHIPS TO BUILDING INFRASTRUCTURES

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Public health measures to deal with the burden of diabetesParticipants discussed four measures in groups and theirfindings and recommendations were briefly presented tothe plenum.

Strengthening and building capacityThis was summed up by one group as ‘making what youhave work better’. There is always a danger of duplica-tion (particularly, for example, in training) and it is necessary to bring together all capacity building effortsto maximise use of limited funds and resources. Key players will be national healthcare agencies and non-governmental organisations. Many of the latter are partic-ularly effective in educational roles.

Integrating prevention and careThere are positive and negative consequences to suchintegration. Negative consequences include not takinginto account such specificities as eye and footcare and nottaking into account national and local cultures. There willbe timing problems; not all stakeholders will move at thesame speed. Indeed, there can be strengths in decentrali-sation. A positive effect is that there are many risk factors

common to NCDs and CDs. Also, with limited resources,there will be opportunities for clear simple messages tobe communicated.

Awareness and advocacy At present this probably depends too heavily on nationaldiabetes associations and an international communica-tions strategy is needed.Ways have to be found toengage the general public and opinion leaders and thiswill involve the media. Simple and striking messageshave to be put across. Diabetes should not be seen just asa part of everyday life: comparisons should be made withother diseases, the seriousness of which has captured thepublic imagination. The proposed UN resolution shouldbe a good starting point.

Resourcing and funding prevention and careMuch of this will depend on the extent to which diabetesachieves a high profile. Thus there is a direct link withadvocacy and awareness profiling. There is currently agap between reality and funding. It is necessary to under-stand how both public and private resource providersthink and operate. There are specific areas where fundsare perhaps easier to obtain; for example, for children.

For the concluding ceremony of the WDF Summit,Professor Lefèbvre was joined by Ms Ida Nicolaisen(Denmark) and Professor Ib Bygbjerg who are membersof the WDF Board. Professor Lefèbvre thanked the staff ofthe WDF for their organisation of the summit and paidtribute to all the work that the WDF is carrying out inAsia. He said that he has learnt a lot which will help himin his capacity as the Chairman of the WDF.

Professor Bygbjerg said that the Summit has been a mag-nificent experience. The key message is that while a lothas been done, there is still more to do to control theproblem of diabetes. But all the delegates have learnt alot from each other. Einstein’s famous equation, E=MC2

can be adapted to sum up the WDF: Excellence = Money

and Commitment (squared). The WDF does not have a lotof money but has much commitment and lots of excel-lence. He added that the same could be said of theirVietnamese hosts.

Ms Nicolaisen said that she had been impressed with theexpertise of the projects presented. She added, that as allscientists discover, the more they know, the more theyrealise there is to learn. She learnt of the commitment ofeveryone to work for people with diabetes. This is at thecore of policies for both big and small populationsthroughout Asia. She hoped that the WDF Summit wouldfacilitate co-operation between all the participants andtheir countries. She added her thanks to the exceptionaland warmly hospitable hosts in Vietnam.

GROUP WORK

CLOSING REMARKS

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This WDF Diabetes Summit has been avery successful event with the partici-pation of 100 experts, projects partnersand key stakeholders in the field ofdiabetes from all over the world.Withits series of global initiatives the WDF hopes to make a significant change increating awareness, prevention at alllevels and improvement of care forpeople with diabetes.

The WDF is dedicated to the prevention and treatment ofdiabetes with a particular focus on:• Raising awareness• The prevention of diabetes and its complications• Education and training for patients and professionals• Improving access to the detection, treatment and monitoring of diabetes.

Role as a catalystThe role of the WDF is to create partnerships and act as acatalyst; link people and resources; to advocate globallyand provide care locally. Our focus is the poorest of thepoor in developing countries and we strive to achievesustainable solutions

To date the WDF has carried out 72 projects in more than65 countries and in 2005 carried out eight fundraisingactivities (see Figure 17). These projects were highly cost effective and attracted outside support, creating amultiplier effect; for example, the project portfolio costwas $76.4 million, of which $19.9 million was donated bythe WDF. The projects funded by the WDF will, in the coming three to four years, potentially directly influencethe diabetes treatment of 25 million people.

Creating awareness and prevention at all levelsThe WDF works in partnership on a global, regional and locallevel with many organisations including DANIDA/MOFA, theIDF,WHO, the Insulin Foundation, Fundacion para la Diabetes,Church Aid, national health ministries, foot societies, localdiabetes associations and industry.The WDF has worked incollaboration with the IDF on two key projects: the DiabetesAtlas, and the Diabetes Action Now initiative.

Raising awareness at a global level is a key aim. The WDFGlobal Diabetes Walk attracted 68 582 participantsaround the world in 2004 and 87 548 participants in 2005.The website is visited by 19 000 people per month for anaverage of 6.2 minutes per visit.

Twenty-five media participants representing China, France,Germany, India, Indonesia, Malaysia the Philippines,Singapore,Vietnam and the UK attended the Summit andreported online and in the press in a number of languagesaround the world on the key messages from the Summit.Headlines included:

Anil Kapur. Managing Director,World Diabetes Foundation

A

B

H

CD

F

EG


THE ONGOING COMMITMENT OF THE WDF

Asia warned of diabetes threat

Diabetes set to be a health ‘Tsunami’

Silent killer stalking us

Diabetics watch what you eat!

Figure 17. WDF projects underway in 2005

Fundraising activitiesA El Salvador - diabetes hospitalB Tanzania - diabetes clinicsC India - foot care clinicsD Bangladesh - insulin for children

with type 1 diabetes E Vietnam - diabetes careF Mongolia - diabetes clinicG Philippines - diabetes clinicH Afghanistan - diabetes centres

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This supplement is supported by a grant from the World Diabetes Foundation.Printed and published by Wiley Interface Ltd – a division of John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ © John Wiley & Sons Ltd 2006 The views expressed in this publication are not necessarily those of the publisher or the World Diabetes Foundation

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