Introduction of Type 2 Diabetes Type 2

Introduction

Type 2 Diabetes as a Chronic Disease

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Type 2 diabetes is a largely preventable chronic disease
resulting from the body’s inability to utilize insulin produced by the pancreas.
Insulin allows the body to process sugar, taken into the body in the form of
food. Therefore, when the insulin response is not functioning properly,
hyperglycemia results (World Health Organization, 2017). Hyperglycemia, also
known as elevated blood sugar, can lead to a variety of life-threatening
complications including coronary artery disease, heart attack, stroke,
hypertension, neuropathy, kidney damage, diabetic retinopathy, and even
circulatory issues that can result in amputation, among others (Mayo Clinic, 2018; World Health Organization, 2017; International
Diabetes Federation, 2017). Type 2 diabetes
results primarily from excess body weight, poor diet, and lack of physical
activity, and should be distinguished from Type 1 diabetes, which is marked by
insufficient insulin production by the pancreas and requires an individual to
manually administer insulin to themselves (via injection or insulin pump) (World Health Organization, 2017). Type 2 diabetes
accounts for approximately 9 in 10 diabetes cases worldwide (International Diabetes Federation, 2017).

Global Prevalence of Type 2 Diabetes

Type 2 diabetes has
been widely recognized as a growing threat in both developed and developing
countries, with both health and economic consequences (World Health
Organization, 2016). While global prevalence rates for type
2 diabetes specifically is difficult to pinpoint due to the sophisticated
laboratory testing required for diagnosis (World Health Organization, 2016), it is estimated
that diabetes now affects approximately 425 million people, 90% of which suffer
specifically from type 2 diabetes (International Diabetes Federation, 2017). This is expected to
rise to 629 million by 2045, with an additional 352 million at risk of
developing diabetes (International Diabetes Federation, 2017). Furthermore, type 2
diabetes is often undiagnosed (International Diabetes Federation, 2017). Figure 1
demonstrates the upward trend of this disease since 1980.

Figure 1. Trends in prevalence
of diabetes, 1980-2014, by WHO region (International Diabetes Federation, 2017)

 

The economic burden of type 2 diabetes poses a significant
problem for nearly all countries around the world. The International Diabetes Federation
(IDF) estimated that for 2017, USD 850 billion dollars will be spent on
diabetes of all types, though primarily for type 2. This is an 8% increase in
just two years. By 2045, this is expected to reach USD 958 billion. As
indicated in Figure 2, the North American and Caribbean region has the highest
expenditures for diabetes (International Diabetes Federation, 2017). While type 2
diabetes generally onsets during adulthood, there is evidence that more
children are beginning to suffer from it due to increasing levels of obesity
and physical inactivity in youth. As these children grow into adulthood, this
poses a significant public health and economic issue if not tackled urgently (International Diabetes Federation, 2017).

Figure 2. Total healthcare expenditure
on diabetes and mean expenditure per person with diabetes (ID) 20-79 years in
2017 by IDF region (International Diabetes Federation, 2017)

 

The Impact of Diet on Type 2 Diabetes

Type 2 diabetes is a preventable disease that is thought to
be driven in part by unhealthy diet habits characterized by a high intake of
carbohydrates (sugars) and fat as well as little fiber (International Diabetes Federation, 2017). Both the World
Health Organization (WHO) and IDF recommend limiting free sugars to less than
10% of one’s total energy intake (International Diabetes Federation, 2017; World
Health Organization, 2015). However, given the
abundance of fast food in both developed and developing countries, as well as
the rising cost of produce and “healthier” foods, this is easier said than
done.

Because one of the primary risk factors for type 2 diabetes
is poor diet, one of the most effective strategies to both prevent and manage
type 2 diabetes is to adhere to healthful diet low in sugar (American Diabetes Association, 2015). A study comparing
the Mediterranean diet, a low-carbohydrate/high-protein diet, a vegetarian
diet, and a vegan diet found that all four diets improved metabolic conditions,
though with varied success (Khazrai, Defeudis, &
Pozzilli, 2014).
However, since there are several different diets that can prevent type 2
diabetes or improve disease management in individuals who already have it, this
makes it easier for healthcare providers to recommend dietary regimens that are
tailored to their patients, which may increase patient adherence (Davis, Forbes, & Wylie-Rosett, 2009).

Mediterranean Diet

A Mediterranean diet (Estruch,
et al., 2014; Widmer, Flammer, Lerman, & Lerman, 2015; de Lorgeril, et
al., 1999)
is traditionally characterized by:

·      
a high intake of healthy fats from sources such
as olive oil and nuts;

·      
an abundance of fruits, vegetables, and whole
grains;

·      
moderate consumption of poultry and fish;

·      
low intake of red and/or processed meats, dairy
products, and sweets; and

·      
wine in moderation.

A Mediterranean diet has been widely recognized as one of
the most healthful diets and has been shown to prevent coronary heart disease,
breast cancer, depression, colorectal cancer, obesity, asthma, erectile
dysfunction, and cognitive decline (Widmer, Flammer, Lerman, & Lerman, 2015). Given that some of
these diseases, particularly obesity and cardiovascular disease, often
co-occurr with and may contribute to the development of type 2 diabetes (International
Diabetes Federation, 2017; World Health Organization, 2016), it is logical that
this nutritional approach would be beneficial for those suffering from or at
risk for type 2 diabetes.

A 2015 systematic review that examined glycemic control,
cardiovascular risk factors, and the existence of metabolic syndrome found that
the Mediterranean diet is effective in improving these factors and should be
recommended as an approach for preventing or managing type 2 diabetes.
Furthermore, authors indicated that adherence to a Mediterranean diet may
reduce the incidence of future diabetes by 19-23% (Esposito, et al., 2015).

Low-Carbohydrate/High-Protein Diet

Low-carbohydrate/high-protein diets, also known as ketogenic
diets, typically restrict carbohydrate intake to 20-30 grams daily and replace
those foods (that would previously have been carbohydrate-heavy) with proteins
from meat and other sources (Cunningham, 2006). While effects of this diet have been
varied, the reduction of carbohydrate and therefore sugar consumption complies
with guidelines from the WHO and American Diabetes Association (ADA) for
prevention and management of type 2 diabetes. Low-carbohydrate/high-protein
diets have been shown to improve glucose control (Tay, et al., 2015; Hussain, et al., 2012; Nuttall
& Gannon, 2006) and reduce weight (Tay, et al., 2015; Hussain, et al., 2012; Bueno, de
Melo, de Oliviera, & da Rocha Ataide, 2013). Therefore, a
low-carbohydrate/high-protein diet is likely to be beneficial for individuals
that are pre-diabetic or working to manage their existent type 2 diabetes.

Vegetarian Diet

Generally speaking, a vegetarian diet is one that does not
include meat, poultry, or seafood. While there are variations on the vegetarian
diet in terms of consumption of eggs and/or dairy products, the commonality is
the avoidance of meat (Pilis, Stec, Zych, & Pilis, 2014). In a large
observational study of approximately 60,000 people, a vegetarian diet was shown
to correlate with a lower prevalence of type 2 diabetes compared to meat-eaters
after adjusting for differences in age, sex, ethnicity, education, income,
physical activity, television watching, sleep habits, alcohol use, and BMI (Tonstad, Butler, Yan, & Fraser, 2009). Other evidence
suggests that plant-based diets, characteristic of vegetarianism, may improve
blood glucose levels as long as low-glycemic-index foods are selected. In
essence, a vegetarian diet that is heavy in simple carbohydrates and unhealthy
foods such as French fries, non-whole grains, and an abundance of sugar will
likely not have the same health-promoting outcomes as a more nutrient-dense
vegetarian regimen (Jenkins, et al., 2003; Kahleova & Pelikanova,
2015).

Vegan Diet

A vegan diet is similar to a vegetarian diet in that it emphasizes
plant-based foods and excludes all meat, poultry and seafood. However, a vegan
diet takes this one step further by excluding all animal products, such as
eggs, dairy products, honey, etc. In a randomized, controlled, 74-week clinical
trial, study participants with type 2 diabetes adhering to a vegan diet saw a
decrease in weight and Hb A1c levels (a metabolic marker that is
used to assess the management of type 2 diabetes) (Barnard, et al., 2009). However, these
outcomes were not significantly different than those of participants adhering
to 2003 ADA guidelines, which focus on consumption of whole grains and fiber,
and reduced intake of total fat, particularly saturated fat (American Diabetes Association, 2015). However, a
systematic review found that vegan diets were more effective at improving
glycemic control than ADA guidelines (Trepanowski & Varady, 2015). Therefore, while it
is possible that the benefits of a vegan diet on type 2 diabetes result not
from the avoidance of animal products specifically, but the increase in
nutrient-dense foods that result within a plant-based diet, it seems as though
veganism as an option to prevent and/or treat type 2 diabetes may be suitable
for some individuals.

The Impact of Physical Activity on Type 2 Diabetes

WHO emphasizes the importance of regular physical activity
for adults and children alike. WHO defines physical activity as “any bodily
movement produced by skeletal muscles that requires energy expenditure –
including activities undertaken while working, playing, carrying out household
chores, travelling, and engaging in recreational pursuits” (World Health Organization, 2016; World Health
Organization, 2017). Official WHO guidelines for physical
activity by age are outlined in Table 1.

Table 1. Official WHO
Guidelines for Physical Activity (World Health Organization, 2017)

Age Group

Amount of Physical Activity
Recommended

Frequency of Muscle-Strengthening
Activities

Children and adolescents aged 5-17 years

60+ minutes of moderate- to vigorous-intensity physical activity
daily

3 times per week

Adults aged 18-64 years

150+ minutes of moderate-intensity physical activity per week, or 75+ minutes of vigorous-intensity
physical activity per week; or some
combination of the two

2 or more days per week, involving major muscle groups

Adults aged 65 years and above

150+ minutes of moderate-intensity physical activity per week, or 75+ minutes of vigorous-intensity
physical activity per week; or some
combination of the two
Those with poor mobility should perform physical activity to enhance
balance and prevent falls 3 days per week

2 or more days per week, involving major muscle groups

 

Physical Activity and Type 2 Diabetes

Given that physical activity is known to reduce obesity (World Health Organization, 2017), is it to be
expected that it would be beneficial in efforts to prevent or manage type 2
diabetes, either directly by improving blood glucose control or indirectly by reducing
weight and therefore reducing the risk of diabetes. A systematic review and
meta-analysis conclusively identified an inverse association between physical
activity and type 2 diabetes (Aune, Norat, Leitzmann, Tonstad,
& Vatten, 2015). Studies examining the effects of
exercise on blood glucose control have found that individuals engaging in
regular physical activity had improved metabolic markers (Herbst, et al., 2015; Hu, et al., 1999). The American
College of Sports Medicine and the ADA’s joint position statement on exercise
and type 2 diabetes strongly supports physical activity as a type 2 diabetes
prevention and/or management strategy (Colberg, et al., 2010).

Combining Diet and Physical Activity Interventions
to Prevent and Manage Type 2 Diabetes

While diet and physical activity alone have both been proven
to prevent the onset of and/or improve existing type 2 diabetes, combining
these two strategies is the most effective strategy to improve health overall
and reduce the burden of type 2 diabetes in individuals and among entire
populations, from a public health standpoint (Franz, et
al., 2002; World Health Organization, 2017; Mayo Clinic, 2018). One example of such
an intervention is the Diabetes Prevention Program (DPP), which emphasizes a
low-fat diet and increased physical activity. DPP has been shown to reduce
diabetes risk by 58% relative to standard care and participants lost an average
of 7% of body weight within the first year, which was mostly maintained at the
3-year follow-up mark (Wing, Venditti, Jackicic, Polley, & Lang, 1998;
Tuomilehto, et al., 2001). For individuals already diagnosed with
type 2 diabetes, interventions combining diet and exercise have proven
effective in reducing complications related to the disease. The Look AHEAD
trial demonstrated reduced incidence of very-high-risk chronic kidney disease
in participants randomly assigned to such an intensive lifestyle intervention
compared to those assigned to diabetes support and education (Look AHEAD Research Group, 2014). A 2015 systematic
review for the Community Preventive Services Task Force found that programs
combining diet and physical activity resulted in a lower incidence of type 2
diabetes, decreased body weight, and decreased fasting blood glucose level (Balk, et al., 2015).

Ongoing Initiatives

Preventing Type 2 Diabetes

Type 2 diabetes is a preventable disease resulting from
lifestyle factors that imposes a massive burden on the health and economic
status of individuals, communities, healthcare systems, and governments alike. While
initiatives targeting pre-diabetic individuals such as DPP have demonstrated
success (Molitch, Fujimoto, Hamman, Knowler, & Diabetes
Prevention Program Research Group, 2008; Wing, Venditti, Jackicic, Polley,
& Lang, 1998),
WHO stresses the importance of combining “fiscal policies, legislation, changes
to the environment and raising awareness of health risks” to improve diets and
increase physical activity levels in an effort to reduce this burden across
whole populations (World Health Organization, 2016). This sentiment is
echoed by IDF (International Diabetes Federation, 2017). Innovative
strategies may target urban planning, such as creating more walkable communities
to increase levels of moderate physical activity among residents or investing
in transportation to encourage residents to choose a commute that integrates
some walking or biking. To simultaneously target diet, zoning laws can be
enacted to limit the number of convenience stores and/or fast food restaurants,
replacing them with farmers’ markets or full-service grocery stores in order to
improve the accessibility of high-quality, nutritious food. For youth, school
policies should require a minimum amount of physical activity per week and
ensure that food provided by the school meets high nutrition standards (World
Health Organization, 2016; Herman & Zimmet, 2012).

An example of targeting chronic disease, and particularly
diabetes, is currently taking place in Mexico, which has one of the highest
rates of diabetes in the world. In January 2014, Mexico enacted a nationwide
tax on sugary beverages that resulted in a 10% price increase for such drinks.
While it will take several years to determine the impact of such a tax on the
rates of diabetes, obesity, and chronic disease, an early win was that
purchases of sugary beverages decreased by 6% (World Health Organization, 2016). This tax is
expected to impact the prevalence and incidence of type 2 diabetes in the
coming years.

Managing Type 2 Diabetes

For individuals already diagnosed with type 2 diabetes,
strategies to improve blood glucose control may reduce the need for medication,
the risk of cardiovascular events and other diabetic complications, and cost of
the disease. Interventions vary widely and should be tailored across
communities and countries, depending on cultural norms, the structure of the
healthcare system, availability of and access to resources (financial, medical,
and human), and policies in each location (World Health Organization, 2016). One challenge is
educating primary care providers on how to treat type 2 diabetes, because
providing care in a primary care setting is often lower-cost than specialist
and/or emergency room care that may result from poor management of the disease (van der Heijden, et al., 2014). IDF has created
courses within the IDF School of Diabetes to ensure that health professionals
are equipped with the tools they need to identify and manage type 2 diabetes in
patients around the world. They have also implemented the Diabetes Education
Network for Health Professionals, developed IDF Clinical Practice
Recommendations for Managing Type 2 Diabetes in Primary Care 2017, and
published a multitude of educational resources on type 2 diabetes (International Diabetes Federation, 2017).

Conclusion

The prevalence of type 2 diabetes is increasing at a pace
that not only is negatively impacting the health of individuals and
populations, but is proving to be an urgent economic issue for nearly every
country around the world. Furthermore, while type 2 diabetes was previously
seen solely in adults, evidence suggests that it is becoming an increasingly
large problem in youth (International Diabetes
Federation, 2017).
While prevention and disease management efforts are both cost- and
resource-intensive, the world cannot afford to be ignorant. Immediate action is
needed both to reduce the incidence of new type 2 diabetes cases in coming
years and improve the management (and reduce the costs related to) existing
type 2 diabetes cases. Initiatives should target both diet and physical
activity, and be driven by population-level strategies such as fiscal policies,
environmental changes, laws, and education. Not only are such strategies likely
to impact type 2 diabetes, but given its correlation with other chronic
diseases such as obesity and cardiovascular disease, investing in such
initiatives will pay off in the long run in a multiplicative manner. Healthcare
systems and governments around the world have an opportunity not only to better
care for their citizens, but to also reduce the long-term economic burden of
this chronic disease.

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