DIABETES: From Cinderella to Australia'a Public Health Enemy Number 1!

PROF PAUL ZIMMET*, AO
DIRECTOR OF THE INTERNATIONAL DIABETES INSTITUTE CAULFIELD, AUSTRALIA

In the last 20 years, the number of people with diabetes mellitus globally has more than doubled. My team at the International Diabetes Institute in Melbourne, Australia, has reported that the number of people with diabetes will escalate from nearly 250 million in 2007 to 380 million by 2025. Diabetes is now a global epidemic with devastating humanitarian, social, and economic consequences. Very few nations will be able to afford the burgeoning costs of diabetes, its complications and comorbidities.

Against this background, December 21st 2006 was very important day as the United Nations General Assembly unanimously passed a resolution declaring diabetes an international public health issue. It is now only the second disease after HIV/AIDS, a communicable disease, to attain that very important status.

Diabetes has now become a hugely important public health problem in Australia with over 1 million people with diabetes and a further 2 million with prediabetes. Therefore, Friday April 13th 2007 was a very important date with relevance to the United Nations resolution. Our Prime Minister John Howard and all of our State Premiers, at the Council of Australian Governments (COAG) meeting, agreed to establish a $200 million fund to fight diabetes as part of the push to lift national productivity.
This decision by Australian politicians was clear acknowledgment that diabetes and its complications such as heart, kidney, and eye diseases can impact seriously on the quality of life of individuals and their families through premature morbidity and mortality. Because diabetes is now appearing in much younger age groups than before, even in childhood, it is affecting many in the workforce. This results in a major effect on both individual and national productivity.

It is only twenty years ago that diabetes had "Cinderella" disease status in this country. Few governments, public health departments and indeed doctors understood how it might one day become a major consumer of health dollars. In a Lead Article in the Medical Journal of Australia in November 1985, I wrote: "How many Australians suffer from diabetes? How many new cases are diagnosed annually? How many people have complications of diabetes that are threatening to their vision or even life? What is the cost of diabetes to the nation? These are not questions from Trivial Pursuit nor is the answer to these questions readily available."

This statement was not surprising given our absence of a national capacity to actually monitor disease trends in Australia. At that time, Australia's situation was best summarised by a statement from a 1985 National Health Statistics workshop in Canberra: "If action was taken now with luck we may hope to reach, in five years time, the kind of level that Papua New Guinea reached 10-15 years ago and which New Zealand reached in 1911". This statement effectively exposed what really was a disgraceful deficit in public health data regarding Australia's health status.

However, by 2000, the situation had changed dramatically. Australia was back in the game and leading the world with the largest ever national study of diabetes. The then Minister for Health, Dr Michael Wooldridge recognised that such a study was an urgent priority and the Australian National Diabetes, Obesity and Lifestyle Study (AusDiab) was conceived by Professor Tim Welborn and myself, organised and executed by the International Diabetes Institute.

In 2000, AusDiab studied 11,247 adults around Australia in every State and territory bar the ACT. The study provided the first national data on diabetes and obesity (1).
We found that:

• the number of adults with diabetes had increased 300% since 1981 reaching almost 1 million people;
• 7.4% of Australian adults had diabetes;
• a further 16.3 percent had prediabetes. This group with prediabetes was already at a greater than two-fold risk of heart attacks and strokes;
• that the prevalence of overweight and obesity were amongst the highest in the world with 60% of the adult population affected.

These data were the impetus for a new look at diabetes as a public health threat to the Australian nation. In 2005, the International Diabetes Institute undertook the 5-year follow-up of the AusDiab 2000 subjects (2).
This revealed:

• each year approximately 100,000 adults develop diabetes equating to 275 people daily;
  
• over 200,000 people progress to overweight and obesity, or nearly 600 people daily.

Diabetes and obesity are but two of the components of the cardiovascular risk factor constellation known as the metabolic syndrome. Over 30% of adult Australians have the syndrome with its accompanying risk of heart disease. AusDiab has also developed an extensive database on other health problems such as kidney disease, hypertension, and lipid disorders. Through AusDiab, we now have a much clearer picture of health trends in Australia.

So from being well behind the game 20 years ago, Australia is now leading the charge in diabetes care and prevention, and is well placed through AusDiab to monitor the epidemic. This makes it even more important that the government fund a 10-year follow-up of AusDiab in 2010. This will provide information on the progression of the epidemic and the means to monitor the success of the proposed COAG initiatives aimed at reducing the burden of diabetes.

Type 2 diabetes accounts for almost 90% of cases in Australia and a strong emphasis on prevention through lifestyle measures including proper nutrition and exercise, both at leisure and the workplace is essential. We urgently need the community framework and infrastructure to allow individuals to exercise lifestyle and behavioral changes. This involves strong leadership by our politicians and intersectoral cooperation between government departments of health, sport, education, agriculture, urban planning, and transport, as well as cooperation between the Federal and State constituencies.

In addition, we need to turn the focus immediately to what is happening in our indigenous population. Type 2 diabetes and its heart, eye, and kidney complications are decimating our indigenous communities. Aborigines have the highest rate of diabetes-related kidney failure in the world and kidney dialysis is known at community level as "Death on Instalment Plan". In addition, we must continue the thrust towards improving the care of persons with type 1 diabetes while pursuing research towards better understand its causes as in order to develop prevention strategies.

The May 2007 Australian Federal Budget was an important and much-needed win for diabetes - just what the doctor ordered!! The Federal Government presented a budget platform from which to launch a concerted attack on both obesity and diabetes. Together, they constitute diabesity, which is the major cause of heart disease and the fastest growing and biggest epidemic in human history.

The Victorian Government played an important role in elevating diabetes to the top of the public health agenda. Victoria's COAG National Reform Agenda plan to address the growing impact of obesity and type 2 diabetes sets out what is needed. Firstly, prevention of diabetes, then earlier detection of new cases and subjects at risk of diabetes, and improved care for persons with both type 1 and type 2 diabetes. All of these appear to have been funded in the 2007 Federal budget.

A high priority has been given to improved care of people who already have diabetes. The budget aims to reduce the financial burden on people with diabetes and improves access to better medical care and the essential ancillary health services such as diabetes education, dieticians, and exercise physiologists. Doctors will be encouraged to spend more time with their patients who already have diabetes.

On the prevention side, funding has been provided for the development of a risk assessment "tick test" which will enable the detection of people at high risk of type 2 diabetes. These people can then be referred appropriately to lifestyle modification programs or to a specialist for examination.

Careful definition and management of the "tick test" is needed to ensure it meets evidence-based criteria. It should have a national focus and the questions that are developed for people at risk must be validated before the program is rolled out. This can be done against the database from the pioneering AusDiab population studies carried out by the International Diabetes Institute which tracked the development of new cases of diabetes in individuals between 2000 and 2005. 

Tackling diabetes and obesity is likely to be the single most important challenge for Australia's public health in the 21st century. It is a battle that we can and must win!

*Professor Paul Zimmet, AO, is Director of the International Diabetes Institute and Co-Principal Investigator of the Australian National Diabetes, Obesity, and Lifestyle Study (AusDiab).

References

1. Dunstan DW, Zimmet PZ, Welborn TA, et al. The rising prevalence of diabetes and impaired glucose tolerance: the Australian Diabetes, Obesity, and Lifestyle Study. Diabetes Care 2002;25:829-34.

2. Barr ELM, Magliano DJ, Zimmet PZ, et al. AusDiab 2005, the Australian Diabetes, Obesity and Lifestyle Study. Tracking the accelerating epidemic: its causes and outcomes. Melbourne, Australia: International Diabetes Institute, 2006.