Diabetes Voice GLOBAL PERSPECTIVES ON Issue 4 November 2016

WORLD DIABETES DAY 2016 ISSUE EYES ON DIABETES Over 400 million people currently live with diabetes. One in two is undiagnosed. Screening for is important to ensure early diagnosis and treatment to reduce the risk of serious complications. ACT TODAY TO CHANGE TOMORROW www.worlddiabetesday.org CONTENTS

13 THE GLOBAL CAMPAIGN 18 THE GLOBAL CAMPAIGN Why screen for type 2 diabetes? Diabetic retinopathy: from evidence and promise to real life obser vations

4 DIABETES VIEWS 13 Why screen for type 2 diabetes? Welcome to the World Diabetes Day David Cavan 2016 Special Edition Douglas Villarroel 18 Diabetic retinopathy: from evidence and THE GLOBAL CAMPAIGN promise to real life observations 6 WDD 2016 around the world Sehnaz Karadeniz

23 Regional report: racing to Beat Diabetes in 10 IDF School of Diabetes: Tackling Brazil diabetes through education Maria Tereza B. Lima EYES ON

International Diabetes Federation © International Diabetes Federation, 2016 - All rights reserved. No part Promoting diabetes care, prevention and a cure worldwide of this publication may be reproduced or transmitted in any form or by Editor-in-Chief: Douglas Villarroel any means without the written prior permission of the International DIABETES Editor: Elizabeth Snouffer Diabetes Federation (IDF). Requests to reproduce or translate IDF Over 400 million people currently live with diabetes. Editorial Coordinator: Lorenzo Piemonte publications should be addressed to [email protected].

One in two is undiagnosed. All correspondence should be addressed to: The material in this document is for information purposes only. IDF makes no representation or warrantires about the accuracy and reli- Screening for type 2 diabetes is important to ensure Elizabeth Snouffer, Editor International Diabetes Federation ability of any content in the document. Any opinions expressed are early diagnosis and treatment to reduce the risk of Chaussée de La Hulpe 166, 1170 Brussels, Belgium those of their authors, and do not necessarily represent the views of serious complications. Tel: +32-2-538 55 11 | Fax: +32-2-538 51 14 IDF. IDF shall not be liable for any loss or damage in connection with [email protected] your use of this document. Through this document, you may link to ACT TODAY TO CHANGE TOMORROW third-party websites, which are not under IDF’s control. The inclusion www.worlddiabetesday.org Diabetes Voice is available online at www.diabetesvoice.org of such links does not imply a recommendation or endorsement by IDF of any material, information, products and services advertised on third-party websites, and IDF disclaims any liability with regard to your access of such linked websites and use of any products or services advertised there. While some information in Diabetes Voice is about medical issues, it is not medical advice and should not be construed as such.

Volume 62 - Issue 4 November 2016 Diabetes Voice 3 DIABETES VIEWS WELCOME to the World Diabetes Day 2016 Special Edition

Douglas Villarroel Editor-in-Chief Diabetes Voice

World Diabetes Day (WDD) was first introduced WDD is led by thousands of volunteers and as a day to raise awareness of diabetes and professionals dedicated to improving the lives related complications in 1991. The International of people living with or at risk of diabetes. The Diabetes Federation (IDF) and the World Health IDF develops the WDD campaign each year and Organization developed the initiative in reaction awareness is disseminated with campaign support to the rise in cases of diabetes worldwide. and facilitation by IDF member associations November 14th was chosen as WDD because it worldwide, including the American Diabetes is the birthday of Sir , a medical Association, Diabetes UK, Diabetes Australia, the scientist who co-discovered and used the Canadian Diabetes Association, Diabetes South discovery to successfully treat a 14-year old boy Africa, Diabetes New Zealand and the Diabetic with type 1 diabetes. In 1923, Frederick Banting Association of India. These organizations arrange and John James Rickard Macleod received the events at international, national and local levels. Nobel Prize in Medicine for their discovery Typically, annual events leading up to and on the which forever changed the fate of millions of day of November 14th include: lives worldwide by increasing their chances for Conferences, workshops and seminars for survival. health and public policy professionals. WDD became an official United Nations Day on The distribution of information to encourage December 20, 2006 with the passage of United at risk individuals to be screened for diabetes. Nation Resolution 61/225. The official date aims to raise awareness of diabetes, its prevention and Events to highlight diabetes in local and the medical care that people with the condition national media, including television, need to avoid devastating complications. newspapers and Internet publications. Governments, non-governmental organizations WDD races to increase awareness of diabetes. and private businesses are encouraged to increase awareness of the disease, particularly among the general population and the media.

4 Diabetes Voice Volume 62 - Issue 4 November 2016 DIABETES VIEWS

Civil leaders around the world issue proclamations ‘Eyes on Diabetes’ campaign speaks directly to on WDD to raise awareness of diabetes in their the risk of eye disease leading to blindness. Of the communities. Many events aim to raise money 415 million adults worldwide living with diabetes for research into improved treatments for type (2015), over one third will develop some form of 1 and type 2 diabetes, and ultimately a cure for diabetic retinopathy – a complication of diabetes type 1 diabetes. that can lead to vision impairment and blindness. In addition, more than 93 million adults, or one in The theme of World Diabetes Day regularly three, currently living with diabetes have diabetic changes. For example, the WDD theme between retinopathy. Early detection and timely treatment 2009 and 2013 was focused on diabetes of diabetic retinopathy can prevent vision loss education and prevention. Other past WDD and reduce the impact of diabetes on individuals, campaign themes have included human rights, their carers and society. healthy eating, obesity, the disadvantaged and vulnerable, and children/teenagers with or at This November, IDF hopes to achieve 1 million risk for diabetes. These campaign themes are individual screenings through the Test2Prevent integrated into massive public events such as initiative. The year’s activities and materials will press events to discuss the increase in diabetes focus on promoting the importance of screening prevalence, sporting events, breakfasts, leaflet/ to ensure early diagnosis of type 2 diabetes poster campaigning, and lighting ceremonies. and treatment to reduce the risk of serious “Going blue” marks WDD with millions of complications. Many people who live with advocates proudly wearing blue hats, t-shirts and undiagnosed type 2 diabetes are not aware of even painted faces with the blue circle. Landmark their condition and are at a much greater risk of buildings and monuments around the world are complications. lit up in blue to help spread awareness of the day. By the time of diagnosis, diabetes complications In 2014-15, ‘Healthy Living and Diabetes’ was may already be present so early screening is very the theme of WDD. Diabetes education and important. The World Diabetes Day campaign prevention is critical to help the public understand ‘Eyes on Diabetes’ also stresses that screening diabetes warning signs and the risks associated for all diabetes-related complications is an with diabetes. Once a person is diagnosed with essential part of managing all types of diabetes diabetes it is critical that they are empowered for healthier, more productive and longer lives. to self-manage, and have access to care for best management practices and treatment. In this way, World Diabetes Day also aims to enhance diabetes education worldwide so it provides the information people need in order to live with the condition and treat it carefully. The theme for 2016 ‘Eyes on Diabetes’ focuses on the importance of early screening for diabetes. One in two people with diabetes remain undiagnosed, which makes them particularly susceptible to the complications of the condition, causing substantial disability and premature death. The

Volume 62 - Issue 4 November 2016 Diabetes Voice 5 THE GLOBAL CAMPAIGN

WDD 2016 AROUND THE WORLD 25TH ANNIVERSARY

World Diabetes Day (WDD) has been celebrated Today, the World Diabetes Day campaign isn’t as the official awareness day for diabetes for limited to just one day: 25 years, since 1991. IDF and the World Health WDD is a platform to promote IDF Organization created the initiative in response advocacy efforts throughout the year. to growing concerns about the escalating health threat posed by diabetes worldwide. World WDD is leading global efforts to promote Diabetes Day became an official United Nations coordinated and concerted actions to Day in 2006 with the passage of United Nation confront diabetes as a critical global Resolution 61/225. health issue.

6 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 7 THE GLOBAL CAMPAIGN

WDD is represented by IDF’s blue circle logo that November 11-13. was adopted in 2007 after the passage of the Rwanda UN Resolution on diabetes. The blue circle is the global symbol for diabetes awareness, signifying The Rwandan Diabetes Association has a week- the unity of the global diabetes community in long series of activities planned for World response to the diabetes epidemic. Diabetes Day. These include screening for type 2 diabetes, heart disease and eye complications The theme of World Diabetes Day (WDD) 2016 is on the occasion of Kigali Car Free Day on 6 ‘Eyes on diabetes’. WDD key campaign messages November; a Blue Half-Marathon on 13 November include: to increase diabetes awareness among the Rwandan population and promote the importance Screening for type 2 diabetes in of physical activity in helping to prevent type 2 communities worldwide is critical to diabetes and diabetes complications; the lighting modify the course of undiagnosed and of the Kigali Convention Center in Blue; and an untreated diabetes and reduce the risk of extensive media campaign through national, complications. community and private radio, national television and print media. Screening for diabetes complications, including retinopathy and other eye EUROPE diseases, is an essential part of managing all types of diabetes. Belgium In Brussels, the IDF European Region will be With over 230 national diabetes associations organizing a lunch debate on “Mobilising Political in 170 countries and territories, IDF represents Will” at the European Parliament on 8 November. the interests of the growing number of people The event will be hosted by Marian Harkin MEP and with diabetes and those at risk. The following Anne Hedh MEP to facilitate a discussion between compilation represents a snapshot of all the MEPs, the Commission and IDF Europe Members awareness activities organized by the IDF’s global on the development of a European strategy to diabetes community to mark World Diabetes Day prevent diabetes and diabetes complications. 2016. The partnership with the European Parliament includes an exhibition on diabetes, blood glucose Visit www.idf.org/wdd-events to see a more testing for MEPs and staff, as well as a ‘vitality’ comprehensive overview planned activities this healthy dish on offer for the whole week at the November. canteen of the Parliament. AFRICA Denmark The Danish Diabetes Association will be Ghana conducting type 2 diabetes risk assessments at approximately 200 venues throughout the Diabetes Youth Care will be organizing a two- country on November 14. In addition, landmarks day mini camp and eye screening session for such as Frederiksborg Castle in Copenhagen and young people living with diabetes in Ghana on the Energy Tower in Roskilde will be lit in blue for

6 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 7 THE GLOBAL CAMPAIGN

World Diabetes Day. In Beirut, the Chronic Care Center will attempt to form the world’s largest human blue circle. Germany Also in the city, 400 individuals will participate DiabetesDE has joined forces with German in the Beirut Marathon on November 13 to raise Diabetes Aid and the German online community diabetes awareness, with blood glucose testing #dedoc to conduct a country-wide type 2 diabetes being provided at the start. screening campaign – Germany Measures! – through online risk assessments and blood glucose United Arab Emirates screenings during the month of November. In Abu Dhabi, Sheikh Khalifa Medical City will Turkey conduct a community-based outreach programme to promote healthy lifestyles, prevention and early The Turkish Diabetes Association will be detection of diabetes, through raising awareness organizing a week-long series of awareness among public and health care providers. Over activities in Istanbul under the theme “Eat Healthy 2,000 people are projected to participate in - Be active - Prevent Diabetes”. These include screening for type 2 diabetes. screenings for type 2 diabetes in collaboration with the city administration, the distribution of NORTH AMERICA brochures and type 2 diabetes risk assessments to the general population. Diabetes awareness Guyana videos will be displayed on public trains, metros, buses, ferries and airplanes. The Guyana Diabetes Association will be organizing a cocktail reception and dinner MIDDLE EAST AND NORTH AFRICA in the capital Georgetown, involving local and international speakers and government Lebanon representatives.

8 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 9 THE GLOBAL CAMPAIGN

Trinidad and Tobago WESTERN PACIFIC The Girls Association of Trinidad and Tobago Australia has partnered with Caribbean Lifestyle Diabetes Centre to bring awareness to diabetes. On 14 Diabetes Queensland is organizing a fundraising November there will be a talk on diabetes and the event - SWIM10 SWIM-A-THON to support vital formation of human blue circles at 5 locations on research and support services for Queenslanders the island. living with all types of diabetes.

Hong Kong SOUTH AND CENTRAL AMERICA Youth Diabetes Action is organizing a Diabetic Brazil Eye Disease Seminar in Hong Kong on 26th November 2016. Attendees can meet with In São Paulo, a blue picnic (Piquenique Azul) will an ophthalmologist and learn how to prevent be held for people with diabetes and their friends diabetic eye disease. and families. The event will feature physical activity, talks about living with diabetes, music Malaysia and competitions with prizes. Students’ Club Tour De’Force of the Faculty of Hotel & Tourism Management, UiTM Sabah will Honduras be organizing an outdoor recreational event on A social media campaign will be conducted using Sunday 13 November 2016. The main highlight the hashtag #ojoconladiabetesHN to increase will be the formation of a human blue circle on diabetes awareness and promote the use of the top of the picturesque Bukit Tirig hill. Activities blue circle, the global symbol of diabetes. for local communities and participants will also include medical check-ups and general awareness SOUTH EAST ASIA about diabetes.

India In Lucknow, Uttar Pradesh, Lekhraj Diabetes Hospital & Medical College will organize a day- long event that will include a diabetes seminar and press conference, risk assessment for type 2 diabetes, random blood glucose testing for individuals identified as being at moderate to very high risk, and a diabetes walk with blue balloons handed out to all participants. Activities will culminate with the blue lighting of the hospital.

Maldives The Diabetes Society of Maldives will conduct free blood sugar testing at multiple locations across the country on 14 November.

8 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 9 THE GLOBAL CAMPAIGN

IDF SCHOOL OF DIABETES: TACKLING DIABETES THROUGH EDUCATION

World Diabetes Day 2016 on 14 November marks the launch of the International Diabetes Federation’s School of Diabetes, a flagship initiative of the Federation to help address the gaps that currently exist in the provision of quality care for people with diabetes around the world. Diabetes Voice spoke to IDF President Dr Shaukat Sadikot about the IDF School of Diabetes and what it will achieve.

Why is there a need for a School of Diabetes? providers, particularly primary care physicians, diabetes educators and people with diabetes. When the 5th edition of the IDF Diabetes Atlas came out in 2011, it had a significant amount of If we are to prevail against diabetes, we have to data but one statistic stood out in that year: one empower health professionals so that they are person died of diabetes related complications best equipped to address all aspects of diabetes. every SEVEN seconds. When the 7th edition of Education is our main strategy to tackle diabetes and a key focus area for IDF. the Diabetes Atlas was published in 2015, we learned—every SIX seconds one person dies from What are the main components of the IDF diabetes (5 million deaths). School of Diabetes? During this time, almost every association The IDF School of Diabetes is international had published new guidelines and consensus in scope and will provide a source of online statements, and a good deal of new information education and certified courses on various was published in a myriad of journals disseminated aspects of diabetes prevention and care. Certain through a variety of conferences and meetings. components will be open access and deal with Additionally, a variety of new medications were basic education and information for people with launched for the treatment of diabetes. Despite diabetes as well as their healthcare providers. all of these advances, the care and treatment of The certified courses have been developed for people with diabetes worldwide is not improving physicians, both specialists and primary care at an acceptable rate. physicians, and for diabetes educators. The online courses will use the continuing education format Today, we have a huge amount of knowledge so that participants will be able to update their about diabetes and we also have medications knowledge for a specific period of time. Some for treating diabetes, but too many people of the courses will be tutorials with access to living with diabetes today do not have access tutors and mentors from the seven regions of IDF. to information, care or treatment. The primary Initially, the courses will be available in English, aim of the activities of the International Diabetes and further languages will be added in future, Federation (IDF) is to improve the lives of people subject to funding. with diabetes and therefore, it is time to come out of the ivory towers of academia and look The School will also offer an open forum for at the ground reality. We have an obligation to discussion, linking to D-Net, where people increase diabetes knowledge among healthcare with diabetes and healthcare providers can ask

10 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 11 THE GLOBAL CAMPAIGN

questions and share their experiences. we anticipate will expand to as many countries as possible. In addition, individuals who complete It is important to make clear that the IDF School the certificate courses will be eligible to become of Diabetes will not issue degrees or diplomas Fellows of the IDF School of Diabetes. but only certify that individuals have undergone training in their field. A nominal fee will be charged for the certificate courses to ensure the future sustainability of the School.

How will the School be governed and structured? The School of Diabetes will be governed by a Board of Directors comprised of representatives from the seven IDF Regions. The the day-to- day management of the School will be the responsibility of an appointed Dean and Vice Dean who will head small committees that will oversee all content. A Science Audit group will specifically validate the content of the certified courses. An Honorary Faculty of around 250 experts from various fields will set up the courses, assist with updating them, and act as tutors and examiners. They will also be responsible for the open access education and lead the discussion groups in the open forum. The faculty will also work closely with IDF Centers of Education, which IDF President Dr. Shaukat Sadikot

10 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 11 THE GLOBAL CAMPAIGN

IDF SCHOOL OF DIABETES CERTIFIED COURSES*

1. IDF Certified Course for Diabetes • Diabetes care by primary care physicians and Educators establishing a diabetes clinic. • Hyperglycaemia in pregnancy. • Epidemiology, classification and diagnosis of • Diabetes and oral health. diabetes. • Infections in diabetes. • The role of the diabetes educator, team • Emergencies in diabetes. management, teaching and learning. • Diabetes in special populations. psychosocial and behavioural approaches. • Physical activity and nutrition therapy. 3. IDF Certified Course for Specialists • Insulin administration. • Self-management and sick-day management. • Physiopathology of type 2 diabetes. • Pre-diabetes. • Pharmacological treatment I: Metformin, SU, GL, • Community awareness, promotion and AGI, TZD. prevention, research, evaluation. • Pharmacological treatment II: Glitptin, GLP, • Diabetes in special populations. SGLT2I. • Insulin therapy: initiation, intensification and 2. IDF Certified Course for Primary Care newer . Physicians • Microvascular complications (retinopathy, nephropathy, DPN and DAN). • Epidemiology, classification and diagnosis of • Microvascular complications (nephropathy). diabetes. • Macrovascular complications (CVD, PVD, CV risks • Physiopathology of type 2 diabetes. and HF). • Pre-diabetes. • Hyperglycaemia in pregnancy. • Management guidelines. • Diabetes and oral health. • Non-pharmacological treatment of diabetes: • Infections in diabetes. diet, exercise and lifestyle modification. • Emergencies in diabetes. • Insulin therapy: initiation and intensification. • Sexual life and diabetes, • Physical activity and nutrition therapy. *The course modules will be made progressively available on www.idfschoolofdiabetes.org starting November 14. Further modules will also be added subsequently.

The IDF School of Diabetes is supported by an an unrestricted educational grant from AstraZeneca. Danilo Verge, Vice President CVMD, Global Medical Affairs, AstraZeneca, shares his thoughts on the partnership.

Please tell us why AstraZeneca is partnering with IDF on the School of Diabetes? “Diabetes continues to be one of the world’s most significant health challenges. While our focus at AstraZeneca includes the development of medicines that reduce the global burden and complications of diabetes, we’re also committed to developing and supporting programs that provide education and enable access to healthcare. The IDF’s School of Diabetes initiative fits perfectly with our ambition. With a public health challenge as great as the one we face with diabetes, we know we can’t act alone if we hope to address it effectively with a strong impact to reduce the global burden of diabetes. Partnerships working with organisations such as the IDF are key.“

12 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 13 THE GLOBAL CAMPAIGN

WHY SCREEN FOR TYPE 2 DIABETES?

David Cavan

It is well known that the number of people with diabetes is increasing rapidly across the globe such that in 2015, IDF estimated there were 415 million adults living with diabetes, the vast majority of whom have type 2 diabetes. What is not so well known is that almost half of all people living with diabetes do not know they have it.1

The key goal of management of type 2 particular risk from developing complications, diabetes is to help people with the condition because the signs and symptoms of diabetes achieve good glycaemic control through best are often not felt or detected for many years, p r a c t i c e f o r c a r e , t r e a t m e n t a n d e d u c a t i o n f o r even decades. Tragically, it is not uncommon self-management. Staying within near normal for people to be first diagnosed with diabetes blood glucose values improves current wellbeing after presenting with vision loss due to diabetic and minimises the risk of future complications. retinopathy, or a neuropathic foot wound that People with undiagnosed type 2 diabetes are at may require amputation. Given this predicament,

12 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 13 THE GLOBAL CAMPAIGN

there is a race against time to identify those with

TYPE 2 DIABETES RISK ASSESSMENT FORM WHAT CAN YOU DO undiagnosed type 2 diabetes, and to provide TO LOWER YOUR RISK OF DEVELOPING TYPE 2 DIABETES? Circle the right alternative and add up your points. You can’t do anything about your age or your genetic Early stages of type 2 diabetes seldom cause any predisposition. On the other hand, the rest of the fac- symptoms. If you scored 12–14 points in the Risk Test, 1. Age 6. Have you ever taken medication for high tors predisposing to diabetes, such as overweightness, you would be well advised to seriously consider your 0 p. Under 45 years blood pressure on regular basis? a diabetes treatment plan that incorporates abdominal obesity, sedentary lifestyle, eating habits physical activity and eating habits and pay attention 2 p. 45–54 years and smoking, are up to you. Your lifestyle choices can to your weight, to prevent yourself from developing 3 p. 55–64 years 0 p. No completely prevent type 2 diabetes or at least delay its diabetes. Please contact a public-health nurse or your 4 p. Over 64 years 2 p. Yes onset until a much greater age. own doctor for further guidance and tests. nutrition and exercise guidelines, often with 2. Body-mass index 7. Have you ever been found to have high blood If there is diabetes in your family, you should be care- If you scored 15 points or more in the Risk Test, you (See reverse of form) glucose (eg in a health examination, during an ful not to put on weight over the years. Growth of the should have your blood glucose measured (both fast- 0 p. Lower than 25 kg/m2 illness, during pregnancy)? 1 p. 25–30 kg/m2 waistline, in particular, increases the risk of diabetes, ing value and value after a dose of glucose or a meal) whereas regular moderate physical activity will lower the to determine if you have diabetes without symptoms. medication, before such complications arise. Not 3 p. Higher than 30 kg/m2 0 p. No risk. You should also pay attention to your diet: take care 5 p. Yes 3. Waist circumference measured below the ribs to eat plenty of fibre-rich cereal products and vegetables every day. Omit excess hard fats from your diet and fa- (usually at the level of the navel) 8. Have any of the members of your immediate vour soft vegetable fats. MEN WOMEN family or other relatives been diagnosed with only is this essential for the future wellbeing of 0 p. Less than 94 cm Less than 80 cm diabetes (type 1 or type 2)? 3 p. 94–102 cm 80–88 cm BODY-MASS INDEX 4 p. More than 102 cm More than 88 cm 0 p. No The body-mass index is used to assess whether a If your body-mass index is 25–30, you will benefit 3 p. Yes: grandparent, aunt, uncle or first person is normal weight or not. The index is calculated from losing weight; at least you should take care the individuals concerned, it also makes economic cousin (but no own parent, brother, sister by dividing body weight (kg) by the square of body that your weight doesn’t increase beyond this. If or child) height (m). For example, if your height is 165 cm and your body-mass index is higher than 30, the adverse 5 p. Yes: parent, brother, sister or own child your weight 70 kg, your body-mass index will be health effects of obesity will start to show, and it sense, as treating the complications of diabetes 70/(1.65 x 1.65), or 25.7. will be essential to lose weight. BODY-MASS INDEX CHART Total Risk Score

The risk of developing Height (cm) accounts for a substantial proportion of hospital type 2 diabetes within 10 years is Lower than 7 Low: estimated 1 in 100 will develop disease 4. Do you usually have daily at least 30 minutes 7–11 Slightly elevated: of physical activity at work and/or during leisure estimated 1 in 25 admissions and overall diabetes healthcare costs. time (including normal daily activity)? will develop disease 0 p. Yes 12–14 Moderate: estimated 1 in 6 2 p. No will develop disease 15–20 High: estimated 1 in 3 5. How often do you eat vegetables, fruit or will develop disease berries? Higher Very high: 0 p. Every day normal weight mild obesity marked obesity severe obesity morbid obesity How can we best identify people with than 20 estimated 1 in 2 1 p. Not every day will develop disease Weight (kg)

Please turn over undiagnosed diabetes? The answer of course Test designed by Professor Jaakko Tuomilehto, Department of Public Health, University of Helsinki, and Jaana Lindström, MFS, National Public Health Institute. The FINDRISC Diabetes Risk Score lies with screening. The WHO-IDF report on Screening for Type 2 diabetes (2003) defines screening as “the process of identifying those individuals who are at sufficiently high risk of a WHO IN 2011 RECOMMENDED specific disorder to warrant further investigation THAT HBA1C COULD BE USED or direct action.”2 Before exploring how screening AS A SCREENING TEST FOR should be undertaken, it is important to define who falls into the category of sufficiently high DIABETES WITH A CUT-POINT risk. Although type 2 diabetes is increasing OF 6.5% progressively across the world, there are large differences in prevalence between countries risk and whether they need further assessment. and so wider population-based screening might Those identified as high risk should have a be more appropriate in a country with high diagnostic blood test taken. These are shown in the prevalence such as Nauru (with estimated age- table. The ‘gold standard’ for diagnosis of diabetes adjusted prevalence of 24.1%) than in a country is an oral glucose tolerance test. This involves 1 such as Tanzania (4.1%). Known risk factors for having a blood sample taken for measurement type 2 diabetes are well accepted, and a number of glucose after an overnight fast, then taking a of risk assessment scores have been developed in drink containing 75 grams of glucose, followed order to help identify those at high risk. One of two hours later by another blood sample to the most well-known is FINDRISC, developed in measure glucose level. The advantage of this test 3 Finland. This has been validated in a number of is that it assesses both fasting and postprandial countries, and is available in an interactive form glucose in a standardised way. It is however quite 4 on the IDF website. A number of other countries inconvenient and time consuming for the person (including France, Canada, Germany, UK and taking the test, as well as for the staff conducting Australia) also have similar scores designed it. Alternatives are to measure just the fasting for their own populations, as listed on the IDF value (of necessity this still requires an overnight 4 website. The scores generally ask about age, fast and may miss postprandial hyperglycaemia) ethnicity, body mass index, waist circumference, or a random glucose value (but this may miss diet, physical activity, history of high blood fasting hyperglycaemia). pressure and family history of diabetes. A score is generated from the responses and this guides the In order to address these issues, an expert group person completing the form as to their level of convened by WHO in 2011 recommended that

14 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 15 THE GLOBAL CAMPAIGN

Table

Intermediate hyperglycaemia Diagnostic Test Diabetes (‘pre-diabetes’) 110-125 mg/dL ≥126 mg/dL Fasting Glucose (6.1-7mmol/L) (7.0 mmol/L) OR 6.0-6.4% ≥6.5% HbA1c (42-47 mmol/mol) (48 mmol/mol). OR 2-hour glucose following ingestion of 75g glucose load 140-199 mg/dL ≥200 mg/dL Or random plasma glucose (7.8-11.0 mmol/L) (11.1 mmol/L). WHO, 2006.

HbA1c could be used as a screening test for these studies also showed is that a proportion diabetes with a cut-point of 6.5% (48 mmol/mol) of people with pre-diabetes reversed to normal being diagnostic.5 The advantage is that this is a glucose tolerance.9 This is in stark contrast to the single test that can be taken at any time of day commonly-held belief up until the 1990s, which and does not require fasting. However, it is more was that if you had impaired glucose tolerance expensive than measuring glucose and therefore (as it was then called), there was a high chance less affordable in low-resource settings. It is you would develop type 2 diabetes and there important to be aware that a value below 6.5% was little that could be done to influence that does not conclusively exclude diabetes. While risk. One can imagine the psychological impact the finding of a high concentration of glucose in of such a diagnosis on an individual. Indeed, one the urine is likely to indicate diabetes, it is not of the potential risks of undertaking a screening recommended as a reliable screening test as a test is the impact on the person, quite apart from clear urine test does not exclude diabetes. the impact of the condition being screened for. These diagnostic tests will determine whether a person does indeed have diabetes, thus enabling them to receive appropriate lifestyle advice and medication, if necessary, to manage IT IS POSSIBLE TO PREVENT their type 2 diabetes and help reduce the risk PROGRESSION TO THE of complications. Importantly, these tests DEVELOPMENT OF TYPE 2 will also identify if they are in the category of intermediate hyperglycaemia, commonly DIABETES. known as pre-diabetes. The significance here is that, if people with pre-diabetes make lifestyle There is evidence from the ADDITION study10 changes, it is possible to prevent progression amongst others that screening for type 2 diabetes to the development of type 2 diabetes. This does not make people feel anxious or depressed, was demonstrated in a number of studies in the or falsely reassured if their screening test was early years of this century.6,7,8 What some of negative. However, in this study, people who

14 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 15 THE GLOBAL CAMPAIGN

The IDF online type 2 diabetes risk assessment, adapted from FINDRISC screened positive for diabetes were offered advised that individuals can reduce their risk of lifestyle advice and treatment. It is therefore type 2 diabetes by: essential, that regardless of the outcome of the Choosing water or unsweetened coffee or screening, the person being screened is offered tea instead of fruit juice, soda, and other appropriate advice on what to do with the result. sugar sweetened beverages. Many existing screening questionnaires, such as the FINDRISC, provide some basic information Eating at least three servings of vegetables appropriate to each individual’s score. It is every day, including green leafy vegetables even more important that those who undergo such as spinach, lettuce or kale. a diagnostic blood test receive information Eating up to three servings of fresh fruit every appropriate to the result. For those whose levels day. are normal, this could be as simple as some basic written information about maintaining a Choosing nuts, a piece of fresh fruit or sugar- healthy lifestyle and avoiding weight gain. For free yoghurt for a snack. those with pre-diabetes, this should include Limiting alcohol intake to a maximum of 2 more specific information about measures that standard drinks per day. individuals could take to help reduce their risk of developing type 2 diabetes. These will need to be Choosing lean cuts of white meat, poultry culturally appropriate, but should at least focus and seafood instead of processed meat or red on encouraging increased physical activity and on meat. reducing intake of sugar and processed foods that Choosing peanut butter instead of chocolate are high in fat, sugar and salt. Such information spread or jam. could be based on the IDF healthy eating advice published for World Diabetes Day 2014, which Choosing whole-grain bread instead of white

16 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 17 THE GLOBAL CAMPAIGN

bread, brown rice instead of white rice, whole References grain pasta instead of refined pasta. 1. International Diabetes Federation. IDF Diabetes These same messages will also be appropriate for Atlas, 7th edn. Brussels, Belgium: International those diagnosed with type 2 diabetes; however, Diabetes Federation, 2015. www.diabetesatlas. these individuals should also be encouraged to org. visit their doctor for a full assessment to determine 2. World Health Organization. Screening for type whether additional treatment is needed and 2 diabetes. Geneva: World Health Organization; whether their diabetes has already led to any 2003. www.who.int/diabetes/publications/en/ complications that need to be addressed. screening_mnc03.pdf 3. Lindstrom J, Tuomilehto J. The diabetes risk score: In conclusion, there are accessible tools for a practical tool to predict type 2 diabetes risk. identifying people at high risk of developing Diabetes Care 2003; 26: 725–731. diabetes and of diagnosing them with either pre- 4. IDF online type 2 diabetes risk assessment, www. diabetes or type 2 diabetes. IDF encourages the idf.org/type-2-diabetes-risk-assessment global community to screen for diabetes because 5. World Health Organization. Use of Glycated early lifestyle intervention and treatment in both Haemoglobin (HbA1c) in the Diagnosis of Diabetes groups can protect future health and reduce Mellitus. Geneva: World Health Organization; healthcare costs required to treat complications. 2011. http://www.who.int/diabetes/publications/ report-hba1c_2011.pdf David Cavan, MD, is Director of 6. Li G, Zhang P, Wang J, et al. The long-term effect of Policy and Programmes at IDF. lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20- year follow-up study. Lancet 2008; 371: 1783–9. 7. Lindstrom J, Louheranta A, Mannelin M, et al. The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 2003; 26: 3230–6. 8. PP Research Group. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. N Engl J Med 2002; 346: 393–403. 9. Perreault L, Pan Q, Mather KJ et al. Effect of regression from prediabetes to normal glucose regulation on long-term reduction in diabetes risk: results from the Diabetes Prevention Program Outcomes Study. Lancet 2012; 379: 2243-51. 10. Lauritzen T, Borch-Johnson K, Davies M et al. Screening for diabetes: what do the results of the ADDITION trial mean for clinical practice? Diabetes Manage 2013; 3: 367-378.

16 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 17 THE GLOBAL CAMPAIGN DIABETIC RETINOPATHY: FROM EVIDENCE AND PROMISE TO REAL LIFE OBSERVATIONS

Dr. Sehnaz Karadeniz

Diabetic retinopathy is one of the most feared complications of diabetes and one of the leading causes of preventable blindness in the working age population in developed countries. As the number of people with diabetes increases worldwide, the number of people who are at risk for developing retinopathy increases, too.

Additionally, there are approximately 193 million diabetic retinopathy; the first article in PubMed, people worldwide with undiagnosed diabetes an index of reputable medical journals, dates according to the IDF estimates which is close back to 1946 and more than 28,700 articles have to half of all people with diabetes.1 People appeared since then in PubMed only. with undiagnosed diabetes are more prone to What is the current evidence-base in the field diabetes complications like retinopathy leading of diabetic retinopathy, and the research that to blindness because living with uncontrolled and further raises our hopes for the future? untreated diabetes for many years, if not decades, is a well known consequence. For nearly the last three decades, studies have clearly shown the long-term benefits of good Today, it is long overdue for all multi-stakeholders glycaemic control, delay and slow down the involved in the prevention and care of people at progression of diabetic retinopathy. A clear risk for or living with diabetes to have their eyes and an accepted evidence base comes from on diabetic retinopathy and other long-term the Diabetes Control and Complications Trial (a diabetes complications. controlled clinical trial in T1DM that ran from Seeing is believing: current evidence-base 1983-1989), and the Epidemiology of Diabetes Interventions and Complications (a long-term Every person with diabetes is at risk for observational follow-up study). After a diabetes developing diabetic retinopathy, and the risk duration of 30 years, the cumulative incidence increases with the duration of diabetes. In the of proliferative diabetic retinopathy was 50% 1930’s many scientists thought that middle-aged in the conventional treatment group with less overweight people with type 2 diabetes were tight glucose control, and 21% in the intensive the only phenotype to have diabetic retinopathy. treatment group—a differential that reflects After the discovery of insulin in 1921, doctors the powerful effect of intensive blood glucose and researchers witnessed that younger people control over time.3 with type 1 diabetes (T1DM) started living longer and that they also were developing retinopathy.2 In addition, many treatment advances that began Since the early decades of 1900, a growing as compelling, are today the practice standard. number of studies have been published on For nearly four decades, laser photocoagulation

18 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 19 THE GLOBAL CAMPAIGN

has been the effective approach for the treatment in 2014, and another anti-VEGF, aflibercept, was of sight-threatening retinopathy. The strongest approved in 2015 with similar indications. Other evidence came from two landmark trials in the molecules are also on the way. 1970s and 1980s; the Diabetic Retinopathy- The question is whether these favourable and the Early Treatment Diabetic Retinopathy research outcomes in closely-followed up and Studies. These studies showed how pan-retinal highly motivated individuals with diabetes are laser photocoagulation can reduce the risk of translated into the real lives of people with moderate to severe visual loss at least by 50%, if diabetes? timely intervened. The relationship between the period of diagnosis In 2012, the FDA approved ranibizumab (an anti- of T1DM and the changes in visual impairment VEGF) for the treatment of diabetic macular was examined in a population-based longitudinal edema. Ranibizumab was the first approved study. The prevalence of visual impairment was treatment in nearly 30 years for intraocular use to lower in those persons who were diagnosed treat diabetic retinopathy in people with severe more recently than in those diagnosed earlier. diabetic macular edema. A dexamethasone For example, the prevalence of visual impairment intravitreal implant (corticosteroid) was approved in people with duration of T1DM between 15-19

18 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 19 THE GLOBAL CAMPAIGN

years was 13% among those diagnosed in 1960- they develop visual loss, which, by then is often 69, and 4% among those diagnosed in 1975-79.4 too late. Quality of life, and often income, can be Although there is a huge improvement, it is still severely impacted. beyond what we desire, and diabetic retinopathy Therefore, the case for retinopathy screening is is still among the leading causes of preventable widely recognized, and it also satisfies the classic blindness. screening criteria for a disease, as defined by Wilson and Jungner, back in 1968. These criteria are still valid today: IF PEOPLE WITH DIABETES It is an important health problem; there DO NOT HAVE THE is an accepted treatment for patients with recognized disease, facilities for RECOMMENDED SCREENING diagnosis and treatment are available. AND FOLLOW-UP, THEY There is an early asymptomatic stage. MAY NOT BE AWARE OF There is a suitable examination; THEIR PROBLEM UNTIL THEY the test for retinal examination is acceptable. The natural history of the DEVELOP VISUAL LOSS disease is more or less understood; we know whom to treat. It is cost- Keeping our eyes on diabetes effective. The patients need to be regularly screened.6 Education of people with diabetes is very important. This is the only way that they become The International Diabetes Federation together part of the care team, get involved in decision- with the Fred Hollows Foundation have making as informed people and take responsibility published “Diabetes eye health. A guide for of their own care. Unfortunately, availability and health professionals” with a special emphasis access to diabetes education is a major problem on screening and integration of health services, in many countries. Just recently, the Diabetes in order to improve the eye care of people with Attitudes, Wishes and Needs 2 study (DAWN2™) diabetes, and to prevent the burden of diabetes which ran across 17 countries showed that related visual loss. only 48.8% of respondents had participated in Sadly, in our world today the number of people diabetes educational programs and/or activities with diabetes who have recommended eye to help manage their diabetes.5 examinations and follow-up are much less than A very striking feature of diabetic retinopathy the numbers desired. This disparity constitutes is that it may not cause any complaints until many lost opportunities for saving sight and late stages. This is a significant opportunity for preventing moderate or severe visual loss in the people who have their recommended fundus majority of cases. examination regularly. If sight-threatening Improving our vision for healthcare today, retinopathy is diagnosed early it gives the ensures a healthier tomorrow opportunity for timely treatment, and to preserve vision. In contrast, if people with diabetes do not There is a clear gap between the available evidence have the recommended screening and follow- and its translation into the lives of people with up, they may not be aware of their problem until diabetes. Diabetic retinopathy remains one of the

20 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 21 THE GLOBAL CAMPAIGN

leading causes of preventable blindness despite References the tremendous advances in medical technology, 1. International Diabetes Federation. IDF Diabetes medicine, and medical devices. Atlas, 7th ed. Brussels, Belgium: International Diabetes Federation, 2015. These gaps may exist due to several factors; 2. No authors listed. Discussion on diabetic ranging from inadequate healthcare systems, retinopathy. Proc R Soc Med 1951; 44(8): 742-54. uneducated or under-resourced healthcare 3. Diabetes Control and Complications Trial/ providers and finally, to people with diabetes Epidemiology of Diabetes Interventions and themselves who cannot access information Complications (DCCT/ EDIC) Research Group, or treatment. We can bridge these gaps by Nathan DM, Zinman B, Cleary PA, et al. Modern- transforming our healthcare systems from day clinical course of type 1 diabetes mellitus reactive to proactive and from being disease- after 30 years’ duration: the diabetes control and centered to patient-centered. We can provide complications trial/ epidemiology of diabetes better integration of health services, by interventions and complications and Pittsburgh improving the coordination and collaboration epidemiology of diabetes complications between the health disciplines, and by making experience (1983–2005). Arch Intern Med healthcare services, medicines and medical 2009;169:1307–1316. devices accessible, available and affordable. 4. Klein R, Lee KE, Knudtson MD et al. Changes in visual To achieve all of these, we need comprehensive impairment prevalence by period of diagnosis of nationwide diabetes planning. Retinopathy diabetes: The Wisconsin Epidemiologic Study of screening and management should be part of Diabetic Retinopathy. Ophthalmology 2009; 116: this strong, coordinated and comprehensive 1937-42. response. To have a positive change in ‘real 5. Nicolucci A, Kovacs Burns K, Holt RI, et al. life’ for successful implementation, a strong, Diabetes, Attitude, Wishes and Needs second coordinated and comprehensive plan can only be study (DAWN2): Cross-national benchmarking realized with measurable goals, monitoring and of diabetes-related psychosocial outcomes for allocation of adequate financing. people with diabetes. Diabet Med 2013; 30: 767- 77. Today, we cannot definitively prevent the 6. Wilson JMG, Jungner G. Principles and practice development of diabetic retinopathy, but of screening for disease. Geneva: WHO; 1968. prevention of related moderate to severe visual http://www.who.int/bulletin/volumes/86/4/07- impairment is in our hands. We all have to work 050112BP.pdf. together in order to save the sight and maintain the quality of life in people with diabetes.

Dr. Sehnaz Karadeniz is IDF Europe Regional Chair, Professor in Ophthalmology at Istanbul Science University and Founding Member of the Turkish Diabetes Foundation. She lives in Istanbul, Turkey.

20 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 21 22 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 23 THE GLOBAL CAMPAIGN REGIONAL REPORT: RACING TO BEAT DIABETES IN BRAZIL

Maria Tereza B. Lima

The Race to Beat Diabetes, an annual promotion by the Institute for Children with Diabetes (ICD), reached its 18th milestone in 2016. Thousands of people gathered at the Moinhos de Ventos Park in Porto Alegre, Brazil on June 5, 2016. Approximately 20 thousand people partic- ipated in the event; many ran the course while others cheered on and donated to the event by buying a t-shirt for a noble cause - to help children and adolescents with type 1 diabetes live better lives. In addition to promoting healthy physical exercise and volunteer work within the community, the Race to Beat Diabetes brings much needed public awareness about diabetes. Moreover, the race raises funds for the benefit of the 3,188 children and adolescents assisted by ICD with the help of the Conceição Hospital Group and the Brazilian Ministry of Health.

The Race to Beat Diabetes was originally inspired participants that finish the race as a token of by the successful and hugely popular races in appreciation for their achievement and solidarity, Europe and the US focused on raising funds for all and prizes are also distributed. At the final types of diabetes. The first Race to Beat Diabetes ceremony, trophies are given to ICD sponsors was held in 1999 with a special fundraising and to those participants who raised the most purpose: to build the actual center for ICD. The money, often from the activity of selling t-shirts ICD building project started as a dream but was to friends, companies and schools. financially achieved with the help of community Generating excitement for the race donors. From 1999–2004, all Race to Beat Diabetes fundraising activities and donations This year the theme chosen for the 18th race were dedicated to the ICD building. was to show the great rivalry between the most beloved soccer teams of the region. As many Since 2005, all financial resources raised from people from other parts of the world may know, the Race to Beat Diabetes have been used to soccer is a very significant part of Brazilian culture. maintain ICD’s infrastructure and to fund and Race organizers created the #vesteacamisa maintain services and projects for the benefit of ICD patients. The race relies on the sponsorship of companies and the support of municipal public agencies. For awareness and promotion, the race receives communications support from the state government. The Race to Beat Diabetes has raised 1,597,378 US dollars over the past 18 years.

The total distance of the Race to Beat Diabetes is four kilometers and throughout the event, organizers hand out free water and fruit to the race participants. The ICD awards medals to all

22 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 23 THE GLOBAL CAMPAIGN

(#wearthejersey) #hashtag event on social media including many photo opportunities, generated to get participants and the public excited about nationwide and social media enthusiasm which the race. #Vesteacamisa is based on Brazil’s love put the race and diabetes at the center of public of soccer, mimicing how soccer players exchange attention. team jerseys at the end of each game. The player’s The Institute for Children with Diabetes exchanges are typically photographed or filmed and due to fan excitement, become viral on the ICD has been working for nearly 13 years to Internet. To participate in ICD’s event this year, give children living with diabetes the care individuals simply had to wear a jersey from an and treatment necessary to prevent diabetes opponent’s team, take a picture or shoot a video, complications, such as neuropathy, kidney and publish it on social media, challenging friends disease and retinopathy. Currently, ICD’s work to participate also. has shown a 91% reduction in patient hospital stays. This superior achievement is a result of ICD’s In 2013, ICD created a very successful Race to Beat commitment to continuous education programs Diabetes with the help of Usain Bolt, the Jamaican in diabetes, proper treatment with access to new sprinter and Olympic champion. In 2013, Usain, technologies and also social assistance offered who participated in an exhibition event in Brazil to children and adolescents living with diabetes. that year, appreared and was given a Race to Beat ICD’s technical team includes endocrinologists, Diabetes t-shirt. The Olympian’s participation,

24 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 25 THE GLOBAL CAMPAIGN

programs, carbohydrate counting workshops, insulin administration workshops, oral health treatment and guidelines assistance, and a ICD’S WORK HAS SHOWN toy library. A 91% REDUCTION IN The institutional model adopted by ICD and the PATIENT HOSPITAL STAYS. ICD management team has also made it possible to develop a superb team of professionals in charge nurses, nutrionists, dentists, social workers and of fundraising, marketing and administrative experts in nephrology, ophthalmology, psychiatry, work. These professionals and volunteers have and physical education. Our professionals made it possible to secure financial resources for provide comprehensive care to the children and the projects that promote the health and quality adolescents we serve. ICD operates from 8 am to of life for children and adolescents with diabetes. 5 pm with ambulatory care, a day hospital and a Maria Tereza B. Lima is Manager of the hot-line. Institute for Children with Diabetes (ICD) in Examples of ICD’s programs and activities include: Porto Alegre, Brazil. • A type 1 diabetes education program providing 15 video classes, recorded by ICD’s For more information: medical and technical teams, and aimed at ICD: www.icdrs.org.br expanding knowledge on type 1 diabetes ICD Facebook: facebook.com/icdrs where there is a need. Through the site www.educacaodiabetestipo1.com.br health professionals can register, have access to ICD classes, and deliver the information to patients and their families. • A quality of life program – called PAQ Life targets adolescents that have very high

glucose levels (HbA1c > 11%). The idea is to listen and identify issues from patients and family members and to help improve diabetes treatment, which often includes specific solutions to deal with daily difficulties. ICD professionals help to establish realistic goals

to decrease HbA1c averages and usually are

able to decrease HbA1c by at least 1% over the period of three to four months. • Other ICD programs include a medical necessities program which supplies insulin, syringes, test strips, and other necessary medication. ICD also provides sports incentive

24 Diabetes Voice Volume 62 - Issue 4 November 2016 Volume 62 - Issue 4 November 2016 Diabetes Voice 25 EYES ON DIABETES Over 400 million people currently live with diabetes. One in two is undiagnosed. Screening for type 2 diabetes is important to ensure early diagnosis and treatment to reduce the risk of serious complications. ACT TODAY TO CHANGE TOMORROW www.worlddiabetesday.org