The incidence and prevalence of type 2 diabetes is increasing worldwide. In Ireland the latest figures were recently released by the Institute of Public Health report¹ which showed that in 2010 more than 10% of adults aged 55 or over have diabetes. More than 41,000 (2.7%) adults aged 45 years or over have undiagnosed diabetes. Diabetes is also more common among older people.¹

This increase in the prevalence of diabetes is happening worldwide (see Table 1).²

The cause of this is very clear. We are becoming increasingly obese as a population. The relationship between obesity and diabetes is clearly illustrated in the studies from Chan and Colditz (see Table 2).³

Diabesity

The term ‘diabesity’ has been coined to link the relationship between the increasing prevalence of obesity and associated type 2 diabetes worldwide. In fact, 90% of the world’s 285 million people with diabetes have type 2 diabetes which is directly related to obesity. This is illustrated clearly by the fact that people with a body mass index (BMI which is a measure of obesity) of over 30 (ie. those who are technically obese) for 16 years or more have a 20-fold increased risk of developing type 2 diabetes for females and 10-fold increased risk for males.⁴

Schulz et al commented that: “The increasing prevalence of obesity – fuelled by excessive calorie intake, suboptimum dietary quality, and sedentary lifestyles – is driving this epidemic”.⁵

Thus, we are sleepwalking our way as a society into an epidemic of diabetes. This epidemic is threatening to bankrupt our healthcare systems within a generation, as increasing numbers of patients are managed with increasing numbers of increasingly expensive drugs.⁶ The diabetes drugs bill in the British National Health Service (NHS) for example, is estimated to rise from the current £9.8bn to a predicted £16.9bn by 2035.⁶

A public health approach

It seems to me that the current obesity/diabetes crisis is similar to the typhoid epidemic which pervaded the US and Europe in the late 19th century.⁷ Public health measures won the day here. As a result of the introduction of clean water, the rate of death from typhoid fever fell from 80/100,000 of population in 1890 to 7/100,000 in 1918. This coincided with the introduction of clean water in the early 20th century (see Table 3).

In my opinion, we need a similar bold approach to the prevention of obesity to stop the onward march of diabetes. This public health approach must take precedence over the so-called ‘medical model’ which concentrates on individual patients but does not adopt a community approach. 

In other words, instead of just sitting and watching the inevitable increase in obesity which is leading to the current epidemic of type 2 diabetes, we need to adopt a similar approach to the ‘clean water’ act of the late 19th century, only in this case it is an anti-obesity act. So what can be done?

Firstly, for our patients already diagnosed with type 2 diabetes there needs to be a much greater concentration on lifestyle measures to treat the condition. There is an abundance of evidence that this approach is effective.^8-20

No drugs are involved. Lifestyle measures may arrest or even reverse the progress of type 2 diabetes. Lifestyle measures have the added advantage of not costing any money and not having any unpleasant drug side-effects such as nausea or low blood sugar. 

A programme of exercise and diet can also have other benefits such as reducing blood pressure and weight loss. People will also avoid the ignominy of becoming ‘patients with a disease’ and will instead prevent its occurrence and improve their quality of life, which would suffer as a result of being labelled with a chronic illness.²¹

Preventing obesity

So how can we prevent obesity from occurring? What public health measures can we introduce that will reduce obesity and the associated increase in the prevalence of diabetes in the community?

We need to look at measures such as: 

• ‘Walkability’ of neighbourhoods: Ensure that residential development takes place near to shops, schools, churches and places of entertainment such as cinemas and theatres. Adequate policing needs to ensure safety of those walking. This reduces reliance on cars and encourages people to walk and exercise daily as an integral part of their daily life. Other measures such as a ‘walking bus’ scheme,²² encouraging ‘park and ride’ facilities as well as pedestrianisation of cities also encourages exercise as part of the daily routine and not something one does in a gymnasium if one has spare time. Such an approach has successfully been carried out in the town of Colac in the Australian state of Victoria²³

• Is it time to consider a ‘fat tax’? This would make high-energy high fat foods more expensive and would subsidise healthier foods such as fresh fruit and vegetables. The ‘plastic bag’ tax is evident of the effect that such a judiciously placed tax can have on the habits of a community²⁴

• We need to educate our children on the benefits of a good balanced diet. This education is especially important in the lower socio-economic groups where the prevalence of obesity and diabetes is higher²⁵

• The alarming increase in the prevalence of obesity in children²⁶ also needs to be addressed through education and action in the schools.

At present, we seem to be giving far more attention to the treatment of the obesity and diabetes epidemic rather than the prevention of it through public health measures. Over 100 years ago, Joseph Malines lamented this in his poem The Fence or the Ambulance:²⁷

Then an old man remarked, “it’s a marvel to me
that people give far more attention,
to repairing results than to stopping the cause,
when they’d much better aim at prevention”.

Perhaps it is time to start building a good fence?

Ray O’Connor is a GP in Limerick

References

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22. http://www.waterfordsportspartnership.ie/pdfs/walkingbusstartuppack.pdf
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24. http://www.irishexaminer.com/ireland/plastic-bag-levy-nets-166m-in-10-years-185605.html
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26. http://www.dohc.ie/publications/report_taskforce_on_obesity_es.html
27. http://www.nypartnersinoralhealth.com/aboutus/poem.html