Diabetes

Introduction

Diabetes mellitus is a chronic disease, characterised by hyperglycaemia, resulting from defects in insulin secretion, insulin action or both. Diabetes mellitus is diagnosed, according to the WHO, by the classic symptoms of polyuria, polydipsia and unexplained weight loss, and/or a hyperglycaemia H 11.1 mmol/l (200 mg/dl) in a random sample or fasting (no caloric intake for 8 hrs), plasma glucose 7.0 mmol/l (126 mg/dl) and/or postprandial value 11.1 mmol/l (200 mg/dl) (2 hrs plasma glucose level during an oral glucose tolerance test). This test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 h anhydrous glucose dissolved in water). In the absence of unequivocal hyperglycaemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day (EUDIP Definition).

In 1997, the WHO issued a new recommendation for the diagnosis and classification of Diabetes Mellitus (DM), according to which the following types of DM are distinguished:
  • Type 1 encompasses diabetes cases with absolute insulin deficiency, triggered by a destruction of beta cells (pancreas islet cells which normally produce insulin). Type 1 is classified as type 1a (immune-mediated diabetes), in which DM is stimulated by a resistance reaction of the immune system, e.g. to viral infections, and type 1b (idiopathic diabetes), which occurs by itself and is not a consequence of other diseases.
  • Type 2 diabetes (T2D) denotes all forms of diabetes with relative insulin deficiency, which can be caused by insulin resistance or secretory defects. The former classification of type 2a (normal weight) and 2b (overweight) is no longer valid. Type 2 diabetes occurs far more often than type 1 diabetes: according to the European Health Report 2002 of the WHO, between 85 and 95% of diabetics suffer from T2D.
  • Type 3 diabetes comprises all other specific forms, which occur comparatively rarely: 3A: genetic defects of the beta cells; 3 B: genetic defects in insulin action; 3 C: diseases of the pancreas; 3 D: diseases caused by hormone disorders; 3 E: DM induced by chemicals or drugs; 3 F: DM caused by infections; and 3 H: other genetic syndromes sometimes associated with diabetes
  • Type 4 is gestational diabetes (GDM).
See the WHO and the International Diabetes Federation (IDF) report 'Definition and diagnosis of diabetes mellitus and intermediate hyperglycemiapdf', 2006

Complications associated with diabetes include diabetic retinopathy (a leading cause of blindness and visual disability), kidney failure, heart disease, neuropathy and diabetic foot disease. Diabetes mellitus and its complications have become a major public health problem in all countries. It causes significant physical and psychological morbidity, disability and premature mortality among those affected and imposes a heavy financial burden on health services. The prevalence of diabetes is rising globally, and the number affected is expected to double by 2030. The prevalence and complications can be reduced through early and appropriate intervention. Within Europe, important differences between potential risk factors (lifestyle, environmental factors, genetic predisposition, etc.) exist.

Responding to the need for EU comparable indicators for diabetes monitoring

The EU has launched the European Diabetes Indicator Project (EUDIP), coordinated by the Centre Hospitalier de Luxembourg, under the EC Health Monitoring Programme, with the joint aims of proposing a set of diabetes indicators to be used in the EU and agreeing on harmonised definitions on diabetes indicators. An inventory of available indicators and data sources in the different EU/EFTA countries has been established. Focusing on different aspects of diabetes mellitus requiring surveillance, further potential indicators and alternative data collection were added to the inventory. A set of indicators was selected from the list, based on relevance, validity, sensitivity, reproducibility and responsiveness. The objective of this project is to provide a set of indicators with underlying data collection to monitor diabetes mellitus and its outcome in the Member States/EFTA countries on a routine, consistent and uniform basis. These indicators are used in the context of the ECHI (European Community Health Indicators) project.

A second stage of the EUDIP Project was the European Core Indicators for Diabetes Mellitus project, coordinated by the CBO, the Dutch Institute for Quality in Health Care, which organized the collection and analysis of data on health status and care delivery for diabetes mellitus in EU countries and the future member states in an effort to promote good diabetes health status and care in the different countries. The first objective was to show the feasibility of data collection. The second objective was to create a stable platform for data collection. The third objective was to establish a reporting platform for the indicators using the existing structure of the EC. These objectives were reported in a paper endorsed by the different participating partners after the start-up meeting, and set out in a final report showing the indicators collected and containing a proposal for collection of data in the future, using a stable paper and electronic platform for reporting. 

Within the framework of the Community Public Health Programme, the BIRO (Best information through regional outcomes) project was launched to provide European health systems with an ad hoc, evidence and population-based information system for diabetes, and to support prevention, coordinated care and outcomes management on a continuous basis. The proposal targeted better integration of regional data collections in Europe, providing a new platform for the routine publication of summary indicators and the rapid updating of epidemiological models. BIRO is a three-year programme that linked the existing knowledge base to regional datasets through specialised software. The rationale of the project was that the best information for health reports can be routinely collected through an alliance between regional initiatives that were already involved in the process. The application proposed was based on robust data and a high quality network of partners managing established and widely referenced diabetes registers across Europe.


Under the second health programme, the BIRO project will be complemented by the EUropean Best Information through Regional Outcomes in Diabetes (EUBIROD) project selected in 2007. EUBIROD targets the sustainability of complex systems of health indicators requiring continuous update and regular maintenance. The project proposes an action to implement, extend, and customize the application of the BIRO technology in at least 20 European Member States. Participants will be connected through a system that will safely collect aggregated data and produce systematic EU reports of diabetes indicators. EUBIROD aims to implement a sustainable European Diabetes Register through the coordination of existing national/regional frameworks and the systematic use of the BIRO technology. The system will fulfil the Conclusions of the EU Council for the systematic data collection and monitoring of diabetes complications and health outcomes across Europe. EUBIROD will actively involve national/regional networks in the collection of diabetes data. The project includes the following activities: - data collection: ensuring wide adoption of BIRO while taking into account privacy/security issues;- epidemiological analysis: adding new functionalities for the delivery of EU standardized indicators;- technological transfer: providing a toolbox to facilitate the connection process and to remove any obstacles in the use of the system; - dissemination: training partners “on field” through the activity of a “BIRO academy”;- evaluation: reviewing major achievements through international experts that will use objective indicators measuring the degree of completeness and the information content of statistical reports.

See EUBIROD (EUropean Best Information through Regional Outcomes in Diabetes) project
See Website of EUBIROD

The EU has also supported the global Health Care Quality Indicators project of the OECD. The overall aim of the Project, in which 23 countries are participating, was to develop a set of indicators that can be used to raise questions for future investigation regarding the quality of care across OECD countries. The second phase of the project will expanded the indicator set with the addition of five to twelve new indicators in priority areas, as developed with experts from participating countries in the first phase of the project. One of these priority areas was diabetes care. The report ‘Selecting Indicators for the quality of diabetes care at the health systems level in OECD countries’pdf presented the recommendations of an international expert group on indicators for diabetes care. Taking a review of existing indicators and an assessment of gaps left open by existing indicators as a basis, the experts set out to select indicators to cover both clinical processes of diabetes care and proximal and distal outcomes of care. The review led to the recommendation of nine indicators (Annual HbA1c testing, Annual LDL cholesterol testing, Annual screening for nephropathy, Processes of diabetes care, Annual eye examination, HbA1c control, Proximal outcomes, LDL cholesterol control, Lower extremity amputation rates, Kidney disease in persons with diabetes, Distal outcomes, and Cardiovascular mortality in patients with diabetes).

See Abbreviated Report of a WHO Consultation 'Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of Diabetes Mellituspdf', 2011

Worldwide estimates

Worldwide estimates of the prevalence of diabetes are scarce and not accurate. A worldwide estimation was provided by a WHO report on estimates of the global prevalence of diabetespdf in the year 2000 (used in the WHO Global Burden of Disease Study) and projections for 2030. The number of cases of diabetes worldwide in 2000 among adults (20 and over) is estimated to be 171 million. This figure is 11% higher than the previous estimate of 154 million. The higher prevalence is more likely to be explained by a combination of the inclusion of surveys reporting a higher prevalence of diabetes than was assumed previously and different data sources for some countries.

The International Diabetes Federation (IDF) Diabetes Atlas, 5th edition provides global figures on the prevalence of diabetes based on estimates for 216 countries and territories for 2010 and 2030. This Atlas aims to inform everyone about the need of evidence in order to best act against this disease. The IDF also gives access to an interactive map with data from the Diabetes Atlas.

European estimates

Prevalence estimates of diabetes mellitus in Europe

According to IDF data, the absolute number of diabetics in the EU-27 will rise from approximately 33 million in 2010 to 38 million in 2030. In 2010, approximately 9% of the adult (20-79 years) EU-27 population was diabetic.

See Prevalence estimates of diabetes mellitus - Diabetes Atlas, International Diabetes Federation, Generated table, Prevalence DM 2003-2025

See the 2011 report 'Diabetes - The Policy Puzzle: Is Europe Making Progress?' (3rd edition)pdf(8 MB) produced by the International Diabetes Federation-European Region (IDF Europe) and the Foundation of European Nurses in Diabetes (FEND), together with Primary Care Diabetes Europe (PCDE) and the European Alliance for Research in Diabetes (EURADIA).
 
See the 2008 report 'Diabetes - The Policy Puzzle: Is Europe Making Progress?' (2nd edition)pdf(4 MB) and the 2005 report 'Diabetes - The Policy Puzzle: Towards Benchmarking in the EU25' (1st edition)pdf(335 KB) produced by the International Diabetes Federation–European Region (IDF Europe) and the Federation of European Nurses in Diabetes (FEND).

A significant proportion of people diagnosed with diabetes in these studies did not know they were diabetic according to the results of the DECODE Study Group, 2003. The prevalence of diabetes known to general practitioners (GPs) in the different European countries shows less variation. For all ages the prevalence known to GPs ranged from 1.6% in Slovenian men and women to 3.1% in Belgian men and 3.4% in Belgian women.

See Age standardized prevalence of known and unknown diabetes mellitus (type 1 and type 2) based on analysis of blood glucose concentrations in some EU countries according to sex (DECODE Study Group, 2003pdf; Rathmann et al., 2003; Glümer et al., 2003; ERGO-onderzoek; adapted by RIVM)

Following a gentlemen's agreement, Eurostat collected data from 17 Member States and 3 other countries who conducted the first wave of the European Health Interview Survey (EHIS) between 2006 and 2009. The EHIS contains questions on self-reported diabetes: 'Do you have or have you ever had diabetes? Was this diabetes diagnosed by a medical doctor? Have you had diabetes in the past 12 months?' The 'self-reported diabetes prevalence' indicator gives the proportion of persons reporting to have diabetes by answering 'Yes' to these EHIS questions. Data is further broken down by gender, age group and educational level. Eurostat foresees a second EHIS round under a legal basis in 2014.

See results of EHIS on diabetes with the Heidi data tool

Diabetes hospitalisations in Europe

According to Eurostat data on hospital discharges, there are around 900 000 diabetes mellitus hospitalisations in the EU in a typical year (2009).

See Eurostat data on number of Hospital discharges due to diabetes mellitus at national level and at regional level

See in Heidi data tool the number of Hospital discharges due to diabetes mellitus per 100,000 inhabitants

Diabetes preventive examinations on Europeans

The Eurobarometer survey carried out in 1996 and 2002 on health preventive examinations on Europeans reveals that, overall, taking own initiative, doctor's initiative and screening programmes together, 21.4% of the EU-15 population said they had a diabetes test in 2002. This is a few percentage points higher than the number of Europeans saying so six years previously (20.2% in 1996). Females (23.0% in 2002) were tested more than males (19.6% in 2002).

The preferred diagnostic screening test for type 2 diabetes is a blood sugar test called the fasting plasma glucose test, in which a blood sample is taken to assess blood sugar levels. In a fasting blood sugar test, a test result of 80 to 110 is considered normal, while results between 110 and 125 suggest a person is at risk of developing diabetes in the future. Levels higher than 125 indicate the presence of diabetes and the test must be repeated at a later date to confirm the diagnosis. Another test that measures blood sugar levels is the haemoglobin A1c (HbA1c) test. This test can indicate blood sugar levels over a period of time, while the typical blood sugar test measures blood sugar levels only at a specific point in time. The HbA1c test measures how much glucose in your blood stream has become bound to haemoglobin. Since blood cells last for about 90 days, the test can indicate how much glucose has been in the blood stream for the past one to three months. People who do not have diabetes should have HbA1c levels of about 3 percent to 6.5 percent. Anyone with diabetes should aim for HbA1c levels of about 8 percent.

See Eurobarometer – Health, food, alcohol and safety 2003pdf(2 MB)

Childhood diabetes in Europe

The Commission has been continuously supporting research on diabetes through the RTD framework programmes In the Seventh Framework Programme (FP7, 2007-2013) the focus is on the causes of the different types of diabetes, and their prevention and treatment, with special attention to juvenile diseases and factors operating in childhood. The 6th Framework Programme (FP6, 2003-2006) allocated over 2 billion Euros to health research, including diabetes. 4 calls during the FP6 included diabetes research for the benefit of patients. Under the 5th Research Framework Programme (1998-2002), 19 projects related to diabetes were supported (total funding ± €40 million).

To study the epidemiology of childhood-onset type 1 insulin-dependent diabetes in Europe, in 1988 the EURODIAB (The Epidemiology and prevention of Diabetes) Project established prospective geographically-defined registers of new cases diagnosed in persons under 15 years of age. This report is based on 16 362 cases registered during the period 1989-94 by 44 centres representing most European countries and Israel and covering a population of about 28 million children. The standardised average annual incidence rate during the period 1989-94 ranged from 6.2 cases per 100 000 per year in Northern Greece to 40.2 cases per 100 000 per year in two regions of Finland. Pooled over centres and sexes, the rates of increase were 6.3% for children aged 0-4 years, 3.1% for 5-9 years, and 2.4% for 10-14 years. The results confirm a very wide range of incidence rates within EU and show that the increase in incidence during the period varied from country to country. The rapid rate of increase in children aged under 5 is of particular concern.

In 1993, a new phase, EURODIAB ACE (Aetiology of childhood diabetes on an epidemiological basis), began. Its aim was to use the, by now, well-established network to research the nature of childhood diabetes in detail using genetic and immunological methods. The ACE study set out to monitor the frequency of diabetes in children and to describe trends in the incidence of the disease throughout Europe. This study also included teams of scientists from Central and Eastern Europe - in total about 40 different groups worked together, representing a study population of almost 30 million children.

The last phase of the project, EURODIAB TIGER (Type I Genetic Epidemiology Resource), was taking the work forward to gain significant clues as to which causal factors are the most important. TIGER scientists collected material from 2 000 patients and their immediate relatives. These samples were screened and analysed for the distribution of specific genetic and immune markers. This provides the centralised facility that does all the laboratory work.

Responding to the need for EU intervention for diabetes prevention

More than half the European population will suffer from hyperglycaemia and type 2 diabetes (T2D) during their lifetime. The main risk factors are well known:

  • Obesity and overweight
    These are important risk factors contributing to the development of micro and macro-vascular complications. The indicator for overweight is the percentage of persons with diabetes seen annually with a Body Mass Index (BMI) > 25 kg/m². The indicator for obesity is the percentage of persons with diabetes seen annually with a BMI > 30 kg/m². Being overweight and obese makes insulin resistance progress. This increases the risk of macro and micro-vascular complications. Height and weight measurements to calculate these indicators should be taken once a year in order to be able to calculate BMI in a reliable way.
  • Sedentary lifestyle
    Being overweight can be prevented by regular physical activity. Regular physical activity improves blood sugar control in persons who already have T2D.
  • Glucose Tolerance
    Impaired Glucose Tolerance (IGT) is a condition closely related to Type 2 diabetes. It occurs when the blood glucose level is higher than normal, but not high enough to be classified as diabetes. People with IGT have a 1 in 3 chance of developing Type 2 diabetes within 10 years, but this can be minimised through healthy eating and physical activity.
  • High Blood Pressure
    Up to 60 percent of people with undiagnosed diabetes have high blood pressure.
  • High Cholesterol or other fats in the blood
    More than 40% of people with diabetes have abnormal levels of cholesterol and similar fatty substances that circulate in the blood. These abnormalities appear to be associated with an increased risk of cardiovascular disease among persons with diabetes.

The prognosis of T2D is characterised by the development of complications and, as such, T2D is a disease which gives rise to excessive rates of heart disease, stroke, peripheral vascular disease, renal disease, eye diseases, and many neurological and mental problems. The most efficient way of managing T2D and its complications is to prevent diabetes from developing.

According to some studies, lifestyle changes can reduce the onset of T2D by as much as 58% in high-risk subjects. While these findings provide compelling evidence for them to be translated into community-based prevention strategies, it is necessary to learn how the prevention of T2D works in reality and to find out the extent to which the prevention of T2D can reduce direct and indirect medical care and non-medical costs engendered by the disease. T2D prevention may help to solve in part the economic crisis of Europe’s health care systems and to improve the productivity and competitiveness of economies in general. The EU co-funded project Diabetes in Europe - Prevention using Lifestyle, Physical Activity and Nutritional Intervention, coordinated by the University of Helsinki, sets out to systematically address the development of national community-based T2D prevention programmes throughout Europe. The objectives of the proposed project are to assess the T2D risk in European populations and to implement and evaluate a lifestyle intervention programme to prevent T2D in high-risk individuals. Fulfilling these objectives will help to improve knowledge of public health in Europe. While the project will promote healthy lifestyle and help to prevent T2D, many important health determinants will be addressed within the activities undertaken.

To meet the objectives of this project a cross-sectional survey to assess diabetes risk will be performed with a questionnaire based on 8 items which persons at risk can easily fill out without help. Addressing the second objective of the project requires the implementation of a core prevention programme in the different European countries. This will need adjustment for the different national conditions (language, behaviour), although this adjustment is expected to be minor because the goals are general and there is a risk that adjustments might not be sufficient (i.e. physical activity in mountain regions, different eating habits in different countries).

The EU Conference on the Prevention of Type 2 Diabetes, under the Austrian Council Presidency, took place in February 2006 in Vienna, and was organised by the Austrian Health Institute (ÖBIG), on behalf of the Austrian Federal Ministry of Health and Women and with the support of the European Commission. The conference was organised and designed together with renowned international organisations specialising in diabetes: the European Association for the Study of Diabetes (EASD), the International Diabetes Federation (IDF) Europe, the Federation of European Nurses in Diabetes (FEND) and Primary Care Diabetes (PCD) Europe. The outcome of the discussions were compiled in an expert paper comprising the main findings and recommendations to be brought to the attention of Health Ministers at the Informal Conference of Ministers in April 2006 and at the formal Council in June 2006. The Austrian Health Institute (ÖBIG) tabled a report entitled ‘Diabetes mellitus – a challenge for health policypdf to present situation and analysis of measures in Austria and Europe’ at this conference. The aim of this study is to give an overview of the corresponding measures in Austria and other European countries. The intention is to identify deficits and describe in detail particularly interesting models which could serve as a basis for future measures in Austria and other European countries. Thus, this survey provides information for implementing the Austrian Diabetes Plan and for shaping the focal theme of the Austrian EU Presidency (in the first half of 2006) in the field of health, as the prevention of type 2 diabetes was selected as one of the main health policy themes.

The EASD European Diabetes Epidemiology Group (EDEG) has as its main goal to lead and facilitate epidemiological research on disorders of glucose tolerance and its complications, and to act as a forum for interchange and dissemination of findings.

See Prevalence estimates of Impaired Glucose Tolerance (IGT) 2010 - 2030, Diabetes Atlas 5th edition, International Diabetes Federation

Diabetes Policy Frameworks in the EU Member States and in other European countries

The significant rise in the number of people with diabetes has led European governments to develop national policy frameworks to tackle the diabetes issue. There are several forms of policy framework. Around 15 Member States have set up National Frameworks or Plans for diabetes. A national plan sets the priority objectives for the prevention and control of diabetes. Most of the EU Member States and in other European countries have developed professional guidelines which are statements with no legal status aimed at assisting and advising practitioners and patients.

See Overview on Diabetes Policy Frameworks in the EU and in other European countriespdf(38 KB)

Responding to the need for diabetes mellitus mortality comparable data

According to the Eurostat data on causes of death based on death certificates, 106,757 persons (46,141 men and 60,616 women) died from diabetes mellitus in the EU27 in 2009. Diabetes was recorded as the underlying cause of death in 2.2% of all deaths registered in 2009 in the EU27. There were more female than male deaths. However, the standard death rate in 2009 was 14.1 per 100,000 in males and 10.8 per 100,000 in females.

In the total pattern of 2009 mortality in the EU, diabetes mellitus is the 9th leading single cause of death. However, the actual number of deaths for which diabetes was a contributing factor is probably several times this figure according to recent studies. People with diabetes usually die from late complications of the condition, such as ischemic heart disease, gangrene or renal disease, and these can be considered uncertified diabetes-related deaths because these complications are, in most cases, recorded as the underlying cause of death. However, the figures do provide an overview of the significance of the diabetes mortality problem.

Although EU mortality data do not make a distinction between Type 1 and Type 2 diabetes, people with Type 1 diabetes are twice as likely to have diabetes listed as the underlying cause of death as those who develop it later in life. In addition, there are other more specific issues in using death certificate data for analysing diabetes mortality: (i) diabetes has been shown to be under-reported on death certificates. Diabetes as a diagnosis is often omitted from death certificates of people known to have diabetes; (ii) the causal role of diabetes in mortality is often unrecognised. It is often difficult for physicians to decide whether diabetes was the cause of death or even if it had a contributory role; (iii) subjectivity may exist when recording diabetes or other diseases (such as diseases of the circulatory system) as the underlying cause of death; and (iv) selection of a single underlying cause of death may be difficult in people with multiple chronic diseases.

In the absence of any national cohort studies on diabetes mortality, death certificate data remain the most comprehensively collected national data pertaining to mortality in the EU.

See Eurostat annual data on number of death due to diabetes mellitus at national level

See Eurostat number of death due to diabetes mellitus by region (3 years average) – Total
See Eurostat number of death due to diabetes mellitus by region (3 years average) – Males
See Eurostat number of death due to diabetes mellitus by region (3 years average) - Females

See Eurostat Standardized Death Rate (SDR) per 100,000 inhabitants due to diabetes mellitus by gender 

The aim of a study by the DECODE Study Group was to assess whether the relation between fasting plasma glucose (FPG) and 2-h plasma glucose (2hPG) and the risk of mortality from all causes and CVD and non-CVD is graded or whether a threshold effect exists. The relevance of the current definition of diabetes with regard to the prediction of mortality was addressed.

See Is the current definition for diabetes relevant to mortality risk from all causes and cardiovascular and non-cardiovascular diseases?

The burden of diabetes: the economic costs

The calculated estimates of the direct cost of diabetes care in 216 countries and territories are available in the IDF Diabetes Atlas, 5th edition (2011). The costs are calculated in international dollars to correct differences in purchasing power but some conversion into US Dollars are available.

There are 3 categories of costs associated with diabetes:

  • Directs costs: Diabetes is costly for the health care systems because of its chronic nature and particularly because of the gravity of its complications.
  • Indirect costs: Diabetes causes a loss of productivity because of disability, sick leave, early retirement and premature death. These costs are borne both by firms and by insurance companies. Indirect costs are often higher than direct costs. A similar survey made in Latin America shows that indirect costs are 5 times higher than direct costs. The same tendency was observed in the United States of America.
  • Intangible costs: Diabetes influences the quality of life of patients (suffering, anxiety, and discrimination sometimes). It can also affect their social life and their leisure time. Their mobility can also be reduced because of the disease.

Diabetes complications require hospitalisation most of the time. 50% of people with diabetes suffer from at least one complication. Hospitalisation represents the biggest proportion of the direct costs. It implies admission to hospital, laboratory analysis, the work of a medical staff, specific therapies, and investments to assure the best quality of care for affected people. The length and the frequency of this hospitalisation also increase the charges for health systems. By contrast, drug costs (insulin, anti-diabetic drugs) to treat type 2 diabetes are relatively low. To sum up, diabetes complications represent a huge cost for health care systems.

See European comparison on cost of diabetes as percentage of total health expenditurepdf(17 KB)

The World Diabetes Day

The World Diabetes Day, celebrated every year on November 14, was established by the IDF and the WHO in 1991 with the aim of coordinating diabetes advocacy worldwide. Since then, it has become the primary global awareness campaign of the diabetes community. Officially supported by the World Health Organization (WHO) and the International Diabetes Federation (IDF), World Diabetes Day is an annual awareness campaign aiming to raise public awareness of the causes, symptoms, treatment and complications associated with diabetes.

Diabetes Education and Prevention is the World Diabetes Day theme for the period 2009-2013.