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A broad public-health effort is needed to slow the staggering rise in diabetes, local expert says

The number of people with diabetes in this world just keeps climbing. And climbing.

The number of people with diabetes in this world just keeps climbing. And climbing. And climbing.

An estimated 347 million adults now have diabetes — more than double what it was in 1980, according to a new study published last weekend in the British journal Lancet.

That’s much higher than the previous global estimate of 285 million adults, which comes from a 2009 study that used smaller data pools.

Diabetes is now “a rising global hazard,” writes the team of British and American researchers who led the new study.

What an understatement. The World Health Organization has already predicted that annual diabetes-related deaths, which were an estimated 3.4 million in 2004, will double by the year 2025. Sadly, that number will now have to be recalculated as well.

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Although the highest increase in the diabetes rate was in Oceania (one in three women and one in four men in the Marshall Islands now have the disease), the United States also continues to score poorly. Some 11 percent of Americans have diabetes, according to the Lancet report, which means we lead all other high-income countries.

A dubious distinction.

Seventy percent of the rise in diabetes over the past three decades can be attributed to population growth and aging, say the Lancet researchers. The older we get, the greater our risk of developing diabetes. The other 30 percent comes from genetic risk factors like ethnicity, but also from factors we have some control over, especially diet, physical activity (or lack of it), and, of course, weight. Obesity is a major risk factor for diabetes.

Dr. Bergenstal
Dr. Bergenstal

This study’s findings suggest we’re losing the battle against diabetes. Are we? I posed that question and others to Dr. Richard Bergenstal, executive director of Park Nicollet’s St. Louis Park-based International Diabetes Center on Wednesday. He had just returned from the American Diabetes Society’s annual scientific meeting, held this year in San Diego.

MinnPost: The numbers in the Lancet study include both type 1 and type 2 diabetes, but it’s really type 2 that’s reaching epidemic proportions, right?

Richard Bergenstal: Right. There’s a worldwide global epidemic of diabetes, and it’s 95 percent type 2. It’s just taking off and becoming really the major health concern, even in developing countries. It turns out that type 1 is also increasing, but since it’s such smaller numbers, it’s overshadowed by type 2.

MP: Did the numbers in the Lancet study surprise you?

RB: No, but I wouldn’t be surprised if the numbers aren’t even higher than that. Every estimate we’ve ever made — and I’ve been following this for 30 years — we always underestimate it, which is remarkable. We can’t keep up with the estimates. The numbers are always worse than what we project. There’s some data just out of China last week [that was presented] at the American Diabetes Association meeting, and that [data suggest] those numbers may be even 50 percent higher. So this number is certainly not an overestimate.

MP: The Lancet researchers attributed 70 percent of the increase to the world’s aging population. But isn’t some of that 70 percent also associated with lifestyle factors?

RB: Oh, for sure. I was a little surprised by the 70 percent. I would have estimated that it’s 40 percent due to age, 40 percent due to weight, and probably 20 percent due to inactivity. And then there’s increasing ethnic diversity, which you’d put into genetics. We don’t know exactly why, but when non-Caucasian persons gain weight, they tend to have an even higher rate [of diabetes].

MP: But in the past, older people weren’t developing diabetes at these rates, were they? So wouldn’t that point more to lifestyle factors?

RB: I agree. Age and race are risks that only show up if you gain weight or get inactive. We have a more aging population now than we did, but even the same number of 65-year-olds in the past didn’t have that same rate. … Also, why in India are we seeing this explosion [in the diabetes rate], and why in China? It’s just been remarkable in the last few years. It’s because their economies have gone up and they’ve gained [an average of] about four or five pounds — it doesn’t take a lot — and they’re now driving instead of walking.

MP: Obesity is the main factor here that’s driving these numbers up?

RB: I think so. That’s what it appears to be. The two curves just follow each other Non-obese people get diabetes, but that’s only about 15 percent. Obesity is not the only factor, but I’d say it’s the main factor.

MP: If it is obesity, how are we going to stop this rise in the diabetes rate? We just keep getting fatter and fatter worldwide. The trend seems unstoppable right now. Or am I just too pessimistic?

RB: Like a lot of things, it is going to take a public-health approach. And that’s what’s so hard for everybody to do. [The solutions] come in such little doses: Are we going to get the pop machines out of the schools? Are we going to put calories on the menus? Are we going to build walking paths? Are we going to put exercise/fitness facilities at work, and are we going to reward people for joining those? That’s our only hope in slowing the epidemic. I’m all for better treatments and breakthroughs in the management [of the disease] because we’re never going to get rid of it, and we have hundreds of millions of people who need treatment. But to bend the curve we need to do some of these public health initiatives. And they’re hard. The incentive is there for a healthier nation, but who’s driving it?

MP: And who’s going to pay for it?

RB: Yes. There are prevention strategies. I heard a lot of them at this latest meeting. Prevention does work. But we also need to be screening for diabetes and finding it earlier. Maybe that’s a motivating influence [to encourage individuals to improve their lifestyle habits]. I don’t know. No one has quite proven that.

MP: How are we doing in Minnesota?

RB: Better than most places. Now, you could say that’s because we’re not such a diverse population [and therefore don’t have as high a rate of diabetes], but we are more diverse than 20 years ago. I think in Minnesota the health plans, which we sometimes give a hard time, are actually doing some of those [preventive] things. They’re paying for membership to health clubs and for the YMCA’s [Diabetes Prevention Program], which has been shown to be effective. … It’s funny, [health plans] will pay for [diabetes-related] amputations or kidney failure, but they won’t pay for ways to prevent it. … In Minnesota, I think we have a little more enlightened insurers. They pay for some of these preventive measures. And, you know, we’re constantly ranked one of the best biking places in the country. All those little things have to add up. I wish we would do the New York thing and label all the calories on menus. I went to a restaurant in St. Louis Park last week, and they have [calories listed] on the menu. It was remarkable to hear the buzz at all the tables. People were kind of shocked and were saying, “I think I’ll order this instead.”

MP: Are you optimistic? Are we going to get a handle on this epidemic, or are the numbers going to keep going up?

RB: I’m discouraged by the numbers and that we haven’t yet been able to break the curve, but we have to keep working on it or this is going to take over not only the health of our nation, but also our checkbooks. We’re spending about 25 percent of all Medicare dollars — and that’s probably a conservative estimate — on caring for people with diabetes. We’re not going to stop or prevent diabetes, but we can slow this down. But it’s going to take a huge community effort, and I don’t know if that’s going to happen. There are ways of slowing this progression to diabetes, but we have to implement it on a much broader scale.

MP: What is the key message that the public needs to know about diabetes and diabetes care right now?

RB: First, we do need more emphasis on prevention. Families need to know that because it runs so strongly in families, type 2 in particular. And second, individuals with diabetes need to get much more involved in their care. Every advance in therapy shows that if we have more dialogue between patient and doctor and all the options are really laid out, we can find some really good treatments. But it doesn’t work if the doctor is just selecting things and giving it to the patient

MP: That sounds like individualized care.

RB: Yes, it’s a little cliché-ish these days, but it’s true more than ever now. … It’s all about matching the therapy to the patient’s needs.  We have to figure out a way to work more as a team with our patients. Everything is now based around the visit — because that’s our current payment system — but the most effective care happens between visits. We have amazing strategies, from technologies to even simple things such as phone calls. Those things really work, and they can happen at the time when you need them. Those are the things — certainly for Minnesota — that we should continue to explore. Let’s be innovative.  I think that will bring more value to this equation than trying to stay with our current [treatment] models, which are having a hard time keeping up with this epidemic.

This interview has been condensed.