Diabetes - Interview with Dr Gojka Roglic, WHO Specialist
Q: Not long ago, I read that, for the first time in history, there are more people who are overweight than starving in the world. Does this have an influence on the risk of diabetes?
Yes. Being overweight or obese are the most widespread risk factors for diabetes; not only for diabetes but also for several other chronic diseases, including some cancers. So the implications go well beyond diabetes itself. It is true that now even poor countries have an increasing prevalence of obesity. In fact, they have the double burden of an under-nourished population and an overweight and over-nourished population at the same time in the same country. It’s a very paradoxical situation.
I do not know of any country that has reported a decrease in the number of overweight or obese people. Wherever it has been measured and examined, there is a constant increase. If you look at studies going back twenty or thirty years, body weight has been constantly increasing. The proportions of people that are overweight are constantly increasing everywhere. So that’s a risk factor for diabetes - a well-recognized, well-documented risk factor and it therefore translates into a higher frequency rate for diabetes. More and more people are becoming diabetic.
Q: I understand that it is alarmingly high and nobody really talks about it.
People have started to take notice. Many countries have recognized that the problem of diabetes is increasing. What is particularly alarming is the increasing number of reports of type 2 diabetes in children, adolescents and young people. In the past, it used to be a condition of middle-aged and elderly people. Nowadays, as more and more children are becoming obese, the risk of diabetes is increasing in young people. I’m referring to type 2 diabetes because there are several types of diabetes. Type 1 diabetes is the result of an autoimmune process where the pancreas cells that produce insulin are destroyed. So in type 1 diabetes people need insulin from outside the body in the form of injections in order to survive. Before the discovery of insulin, these people died within a very short period of time, but today they can live normally as long as they regularly receive a proper dosage of insulin. Type 1 is much less frequent than type 2 diabetes, which is linked to obesity. Roughly 90% of all diabetic persons in the world have type 2 diabetes.
Type 2 is related to obesity. There is no cure yet, and it is managed by lifestyle intervention in terms of a healthy diet, loosing excess weight and maintaining optimal body weight. Some people can be treated only with diet and physical activity. If they lose weight then their blood sugar level can drop to acceptable levels. But for some people diet and exercise is not enough to control their diabetes and they need additional treatment in the form of pills or insulin injections.
Q: You are talking about a change of life style. Will some people then be "cured"?
There is no cure for diabetes. But with proper treatment, it is possible to avoid complications and achieve normal or near- normal blood glucose levels.
Q: What are the first symptoms of diabetes?
Type 1 diabetes usually has quite pronounced symptoms and signs - thirst, frequent and copious urination, marked weight loss, fatigue. Without treatment this progresses to loss of consciousness, coma and death.
Unfortunately, the symptoms of type 2 diabetes are rarely very pronounced and diabetes is often diagnosed only when people suffer one of its many serious complications. The most common complications affect blood vessels; people suffer a heart attack, end up in hospital and then actually find out that they have
diabetes. Or unhealing foot ulcers and gangrene requir -ing a limb amputation - this is also a frequent complication of diabetes. Many persons with diabetes lose their eyesight. If people’s eyesight deteriorates, they will consult a doctor and find out that they have diabetic changes in their eyes. They have probably had diabetes for several years, but because their blood sugar has never been measured they were unaware of it. So that is one aspect of diabetes — it does not really hurt until it triggers complications. That is why it is often called the "silent killer". People can sometimes feel tired, but they tend to attribute it to stress, overwork or a recent flu.
In developed countries many people have regular health check-ups, during which their blood sugar will be measured. In many other countries, people will not go to the doctor if they do not feel any symptoms and there are fewer opportunities to discover that you have diabetes.
Q: What can ordinary people like myself do in order to prevent diabetes?
For example, you drove here in your car. Your office is within walking distance and if you had walked, that would have been a preventive measure. Ideally, if one could prevent being overweight and obese and physically inactive, one might prevent up to 60 or even 70% of all diabetes cases. There are not many studies available, but the data available go in that direction. It is very likely that more than 50% can be prevented. Nevertheless, some people would still get diabetes type 1 diabetes, the autoimmune process that destroys the pancreas cells. There is no known prevention for type 1 diabetes.
Q: Is type 1 diabetes hereditary?
Both types of diabetes do have a genetic component, but that it is not enough for triggering the illness. There has to be something else. The number of people with diabetes has been increasing so fast in recent decades that this cannot be explained by changes in the population genetic profile because these would take much longer. For type 1 diabetes, we do not know what that "something else" is. There have been studies that have looked at the role of viruses, toxins in food and water, lack of breast feeding in infancy, early use of cows’ milk in infant nutrition. All of these potential risk factors have been investigated, but there are no conclusive and definitive answers. At this point we cannot say that there are any measures for preventing type 1 diabetes. So, at this point, there is not much you can do to prevent type 1. For type 2, there are preventive measures: physical activity; maintaining healthy body weight; or trying to lose the weight that you have accumulated, but that it extremely difficult due to our lifestyle. We have an increasing dependence on going quickly from one place to another using transport — not walking, not cycling, no physical activity, etc.
This is a glimpse of what should be done and how to prevent diabetes, but it is not very easy to do.
Q: You talked about a healthy diet. What should parents do in order to prevent obesity among their children?
Encourage physical activity and intake of fresh fruit and vegetables, less of the high-calory sugary drinks or replace them with a lower-calory alternatives. Even though the really sweet ones might be more appealing, unsweetened fruit juice has fewer calories and is very palatable. Water should not be forgotten as a the best thirst-quencher, and should not be frequently replaced by drinks that are packed with calories which will not be used up but will accummulate as body fat. You do not notice that you have
ingested a large amount of calories while drinking sugary soft drinks, and it is sometimes almost the caloric equivalent of a plate of spaghetti…
Q: Why did you start working with diabetes?
Almost by chance I got involved in diabetes-related research as a medical student. I went on to work as a "diabetes doctor", a diabetologist, and I carried out daily clinical work in Croatia. I was also involved in research and later became more interested in the public health aspect of diabetes.
Q: What does WHO do in this field?
We have a project called Diabetes Action Now, with the aim to create awareness about diabetes. We collaborate and conduct several joint projects with the largest umbrella NGO, the International Diabetes Federation. What we do most is to try to increase awareness about diabetes in low- and middle-income countries, especially among the general public and the policy-makers, because these are the ones who count. The health professionals are already aware of the magnitude of the problem, because they see the consequences every day. We also do a lot of norm-ative work, such as setting norms and standards. We answer questions like - What is diabetes? Where is the diagnostic cut-off point? How is diabetes classified? How many types do we have? New research is constantly bringing new information and our knowledge has to be modified and updated. We also participate in training and education. A lot of our work is directed towards people in developing and low-income countries, where there is often a lack of technical expertise and a shortage of resources.
Q: Do you feel that it is difficult to create awareness about diabetes among people?
I think we are becoming increasingly successful in creating awareness. I believe that more and more people are becoming aware of diabetes. The difficult part is to actually bring about a change, because changes are more complex and difficult to carry out. In order to encourage people to walk, for instance, you need the whole society to change in many ways — safe levels of pollution, safe roads so that there is no immediate danger to your life. It is not only the health sector that is involved but other sectors as well, such as transportation, education, agriculture, etc. so it is much more complicated. One starts with awareness — we have a problem, ideally this is how it should be resolved, but it takes small steps for governments to accept this. For instance, governments in many countries will not feel responsible for obesity among their population; obesity is perceived as a personal choice. However, people do not always have a choice of what they eat, especially if they are poor, and there are measures that governments can take to make healthy food accessible to their people.
Q: In my country, never before have people been involved in so many sports, so much physical activity, but, at the same time, the population has never been so fat. How do you explain this?
It’s the balance between intake and how much energy you use up. If you eat less and do the same amount of exercise, you would probably not gain so much weight. In developed countries, diabetes is closely related to social class. You do not often see well-off people who are terribly obese; they eat in a healthy way and take more exercise, either because they can afford it or have more incentives and opportunities to do so. You find obesity among poor people.
Q: For people who would like to get more information about diabetes, do you have a web-site?
We have information on the diabetes programme on the WHO web-site. However, it is not really designed for the general public to find out about diabetes. Our website shows what our projects are and what documents are available, but this information is not particularly interesting to the lay public. They are usually normative documents intended for the use of health professionals and policy makers. There are some good Internet sites that have been set up by NGOs. The American Diabetes Assocation is one of them. You will even find recipes for food as well as a lot of other information for people with diabetes, the general public and health professionals. Another good website is that of the International Diabetes Federation.
Q: Would you encourage people to go and have their blood sugar level checked?
In developed countries, there will already be a kind of screening policy. It is probably a good thing to do, as there are existing treatments, so you can start the treatment earlier, before complications have developed. In low-income countries, the situation might be slightly more complicated, because even those who are already diagnosed with diabetes are not being treated properly due to lack of resources. In many poor countries, there is no insulin for people with type 1 diabetes — they just die.