Editorial
Today’s Lancet continues our long-standing commitment to diabetes with content chosen to coincide with the 74th scientific sessions of the American Diabetes Association (ADA) on June 13–17, in San Francisco, CA, USA. In keeping with the ADA’s mission “to prevent and cure diabetes and to improve the lives of all people affected by diabetes”, this issue considers factors that contribute to the unacceptably high prevalence of type 2 diabetes and some of the major diseases that kill people who have it. Driving the increase in prevalence of type 2 diabetes is a change in human societies that has altered food production worldwide. Resource-intensive animal husbandry has increased, as has the further refinement of grains. Other changes in society have promoted urbanisation with greater access to highly processed, energy-dense foods and decreased physical activity. An inevitable consequence of the resulting obesogenic environment is the rapid increase in diabetes, which now affects 382 million people (a worldwide adult prevalence of 8·3%), the majority of whom are in low-income and middle-income countries. The number of individuals affected is predicted to approach 600 million by 2035. Prevention is fundamental to managing the diabetes crisis.
Just as climate change cannot be limited until CO₂ emissions are reduced, type 2 diabetes cannot be controlled until its major predisposing risk factor— obesity—is addressed. Hampering this effort (as shown by the timid NICE guidance issued on May 28) is the widely held attitude that obesity is a problem for individuals. It is not. With 25% of the UK adult population now obese, obesity is a social problem, as the Profile of Linong Ji in this issue makes clear. Therefore, to effect and sustain meaningful change requires society-wide solutions and policies—and politicians with sufficient wisdom and courage to implement them. Reliable information is needed to empower people to make informed lifestyle changes and to support wider efforts to reduce obesity and diabetes. Although information is limited, the 23 year follow-up of the Da Qing Diabetes Prevention Study, reported this month in The Lancet Diabetes & Endocrinology, shows that a time-limited diet and exercise intervention in people with impaired glucose tolerance can reduce subsequent diabetes and cardiovascular mortality. Such www.thelancet.com Vol 383 June 7, 2014
low-technology interventions have great potential, especially for developing countries in which diabetes is increasing most rapidly. Although diet is the cornerstone of treatment for diabetes, and there is broad consensus that many diets— appealing to a range of palates and cultures—can be effective, Sylvia Ley and colleagues point out in the first Lancet Series paper that there is scant applied evidence for what works in diets and little condemnation of what does not work. Inconsistency between dietary guidelines adds to confusion, creating an ideal environment for inaction. Robustly designed, properly funded research is needed to examine nutrition quality and clarify interventions that can be widely adopted to improve long-term public health, bearing in mind that, like Da Qing, benefits may accrue over decades. Just as the catastrophic effects of unchecked climate change can be anticipated, so too can the likely health outcomes of people with type 2 diabetes, who are at increased risk for premature death from cardiovascular disease and cancer. These risks are elaborated in the Article by Sanne Peters and colleagues, the Comment by Yuankai Shi and Frank Hu, and the second Series paper by Rury Holman and co-authors. These contributions, like that on DNA methylation and body-mass index (BMI) by Katherine Dick and colleagues, point the way to research agendas that could make a real difference for people with diabetes: reduction of BMI, more aggressive stroke prevention, and better understanding of the cardiovascular endpoints related to different antidiabetic drugs. Particularly important is the suggestion of sexspecific susceptibility to adverse outcomes in diabetes and the need for prespecified subgroup analysis by sex as a standard feature of future research. The prevention of type 2 diabetes presents a complex challenge that involves both individual actions and external forces. Without a concerted society-wide effort to reduce risk factors and support individuals at risk, the burden of diabetes, health-care costs, and adverse population outcomes will inevitably increase. Like climate change, the rampage of type 2 diabetes challenges a society’s priorities: just how bad do things need to get before effective action is taken, knowing full well that each year’s delay condemns another 10 million people to diabetes? The Lancet
Matt Hess/Golden Pixels LLC/Corbis
Back to basics for diabetes
See Comment page 1947 See Perspectives page 1961 See Articles pages 1973 and 1990 See Series pages 1999 and 2008
For the NICE guidance on obesity see www.nice.org.uk/ CG43 For the Da Qing Diabetes Prevention Study see Articles Lancet Diabetes Endocrinol 2014; 2: 474–80
1945
Today’s Lancet continues our long-standing commitment to diabetes with content chosen to coincide with the 74th scientific sessions of the American Diabetes Association (ADA) on June 13–17, in San Francisco, CA, USA. In keeping with the ADA’s mission “to prevent and cure diabetes and to improve the lives of all people affected by diabetes”, this issue considers factors that contribute to the unacceptably high prevalence of type 2 diabetes and some of the major diseases that kill people who have it. Driving the increase in prevalence of type 2 diabetes is a change in human societies that has altered food production worldwide. Resource-intensive animal husbandry has increased, as has the further refinement of grains. Other changes in society have promoted urbanisation with greater access to highly processed, energy-dense foods and decreased physical activity. An inevitable consequence of the resulting obesogenic environment is the rapid increase in diabetes, which now affects 382 million people (a worldwide adult prevalence of 8·3%), the majority of whom are in low-income and middle-income countries. The number of individuals affected is predicted to approach 600 million by 2035. Prevention is fundamental to managing the diabetes crisis.
Just as climate change cannot be limited until CO₂ emissions are reduced, type 2 diabetes cannot be controlled until its major predisposing risk factor— obesity—is addressed. Hampering this effort (as shown by the timid NICE guidance issued on May 28) is the widely held attitude that obesity is a problem for individuals. It is not. With 25% of the UK adult population now obese, obesity is a social problem, as the Profile of Linong Ji in this issue makes clear. Therefore, to effect and sustain meaningful change requires society-wide solutions and policies—and politicians with sufficient wisdom and courage to implement them. Reliable information is needed to empower people to make informed lifestyle changes and to support wider efforts to reduce obesity and diabetes. Although information is limited, the 23 year follow-up of the Da Qing Diabetes Prevention Study, reported this month in The Lancet Diabetes & Endocrinology, shows that a time-limited diet and exercise intervention in people with impaired glucose tolerance can reduce subsequent diabetes and cardiovascular mortality. Such www.thelancet.com Vol 383 June 7, 2014
low-technology interventions have great potential, especially for developing countries in which diabetes is increasing most rapidly. Although diet is the cornerstone of treatment for diabetes, and there is broad consensus that many diets— appealing to a range of palates and cultures—can be effective, Sylvia Ley and colleagues point out in the first Lancet Series paper that there is scant applied evidence for what works in diets and little condemnation of what does not work. Inconsistency between dietary guidelines adds to confusion, creating an ideal environment for inaction. Robustly designed, properly funded research is needed to examine nutrition quality and clarify interventions that can be widely adopted to improve long-term public health, bearing in mind that, like Da Qing, benefits may accrue over decades. Just as the catastrophic effects of unchecked climate change can be anticipated, so too can the likely health outcomes of people with type 2 diabetes, who are at increased risk for premature death from cardiovascular disease and cancer. These risks are elaborated in the Article by Sanne Peters and colleagues, the Comment by Yuankai Shi and Frank Hu, and the second Series paper by Rury Holman and co-authors. These contributions, like that on DNA methylation and body-mass index (BMI) by Katherine Dick and colleagues, point the way to research agendas that could make a real difference for people with diabetes: reduction of BMI, more aggressive stroke prevention, and better understanding of the cardiovascular endpoints related to different antidiabetic drugs. Particularly important is the suggestion of sexspecific susceptibility to adverse outcomes in diabetes and the need for prespecified subgroup analysis by sex as a standard feature of future research. The prevention of type 2 diabetes presents a complex challenge that involves both individual actions and external forces. Without a concerted society-wide effort to reduce risk factors and support individuals at risk, the burden of diabetes, health-care costs, and adverse population outcomes will inevitably increase. Like climate change, the rampage of type 2 diabetes challenges a society’s priorities: just how bad do things need to get before effective action is taken, knowing full well that each year’s delay condemns another 10 million people to diabetes? The Lancet
Matt Hess/Golden Pixels LLC/Corbis
Back to basics for diabetes
See Comment page 1947 See Perspectives page 1961 See Articles pages 1973 and 1990 See Series pages 1999 and 2008
For the NICE guidance on obesity see www.nice.org.uk/ CG43 For the Da Qing Diabetes Prevention Study see Articles Lancet Diabetes Endocrinol 2014; 2: 474–80
1945
