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Complicat ions-macrovascular 2
Fahrudin Vojic

Comparison of blood glucose level in male and female st udy subject s

Part ha Sarker

Diabet es-in-Childhood-and-Adolescence-Guidelines 2011

Aris Fazeriandy
September 2004 I Volume 49 I Issue 3 12.00 EUR G30956

Diabetes care
in need

Bulletin of the International Diabetes Federation

 Contents

IDF | The global advocate for

people with diabetes

Diabetes Voice is available

online at www.diabetesvoice.org

Editor-in-Chief © mauritius © dpa

Philip Home, UK
philip.home@idf.org
DIABETES VIEWS FUTURE DIRECTIONS
Managing Editor Diabetes in times of crisis .......................... 2 New treatments for diabetes:
Catherine Regniers, IDF
catherine@idf.org Pierre Lefèbvre generating new insulin-
producing cells ....................................................... 34
Editor
Tim Nolan, IDF
Diabetes care in need ....................................... 3 Denise L Faustman
tim@idf.org Philip Home
DIABETES IN SOCIETY
Layout/Production Manager
Kristina Hawthorne, NEWS IN BRIEF .................................................... 5 The nutrition transition
Kirchheim Publishers & Co and the global shift
hawthorne@kirchheim-verlag.de
H E A LT H D E L I V E RY towards obesity ..................................................... 38
Advisory Group The human perspective on Barry M Popkin
Patricia Fokumlah, Cameroon health-care reform: coping
Attila József, Hungary
Rob James, Canada with diabetes in Kyrgyzstan ............... 10 Reviving the St Vincent
Pablo Aschner, Colombia Botagoz Hopkinson, Dina Balabanova, Declaration .................................................................. 42
Viswanathan Mohan, India
Juliana Chan, People’s Republic of China
Martin McKee, Joseph Kutzin Michael Hall, Itamar Raz,
Lex Herrebrugh
Publisher Diabetes under fire .......................................... 14
Manuel Ickrath,
Kirchheim Publishers & Co Itamar Raz Diabetes-related websites:
are they readable? ........................................... 46
Correspondence should be addressed
to the Managing Editor:
Socio-economic determinants Sanja Kušec
International Diabetes Federation of the cost of diabetes in India 18 ......

Avenue Emile de Mot 19 Anil Kapur, Stefan Björk, Jyotsna Nair, MEDIA AND EVENTS
1000 Brussels
Belgium Sanjeev Kelkar, Ambady Ramachandran Karachi, 2004: Diabetes
Phone: +32-2-5431627 in Asia ................................................................................ 49
Fax: +32-2-5385114
diabetes.voice@idf.org
Cost and availability of insulin Fatema Jawad
and other diabetes supplies:
Advertising enquiries: IDF survey 2002-2003 24 ................................. C A L E N DA R ............................................................... 52
Production Manager
Kirchheim Publishers & Co Ron Raab, Léopold Fezeu,
Kaiserstrasse 41 Jean-Claude Mbanya
55116 Mainz
© International Diabetes Federation, 2004

Germany
Phone: +49-6131-9607031 How to procure insulin in times
Fax: +49-6131-9607061 of emergency 28
.............................................................

IDF Task Force on Insulin, Test Strips

and Other Diabetes Supplies

The impact of low health

literacy on diabetes outcomes ......... 30
This publication is also available in Lisa D Chew
French and Spanish

ISSN: 1437-4064 1
Cover photo © Deutsche Presse Agentur
September 2004 Volume 49 Issue 3
 Diabetes Views

Diabetes in times of crisis

The day-to-day challenges faced by people with diabetes actions help to reduce the financial
in the management of their condition are compounded by burden of living with diabetes
poverty and conflict. During times of hardship, acquiring in the poorest countries.
basic diabetes supplies becomes quite literally a struggle for
survival. Since its creation in 1950, the International Diabetes In a decision which brings
Federation (IDF), together with its Member Associations, has to mind the legacy of the
given priority to the support of people with diabetes through dedicated volunteers of the last
periods of difficulty. Indeed, in the diabetes community the century, it has been agreed that
tradition of solidarity and co-operation to help those most the theme of the World Diabetes
in need dates back to the first half of the last century. Day campaign 2006 will be
‘Diabetes in low-resource and
The Associaçao Protectora dos Diabéticos Pobres de Portugal under-served communities’. Pierre Lefèbvre is IDF
was founded in 1926. The Association – known since 1973 President. He is also
as the Associação Protectora dos Diabéticos de Portugal – was In the previous issue of Diabetes Emeritus Professor
set up to help particularly the poorest people with diabetes Voice, we published an article of Medicine at the
in Portugal to cope with the nightmare of life during the describing life with diabetes in University of Liège,
great depression. In 1942, the Belgian Diabetes Association the Gaza Strip, reported by a Belgium, and Doctor
was founded in an effort to guarantee supplies of insulin doctor working with Médecins Honoris Causa in five
to people with diabetes during the Second World War. Sans Frontières. Although the universities in Europe
article ended with an expression and North America.
Over the years, IDF bodies have been established to help of hope and made a call for
those in need. The Task Force on Insulin, Test Strips and improved diabetes care in the
Other Diabetes Supplies – formerly the Insulin Task Force region, it was preceded by a few
– intervenes regularly and effectively to facilitate the sentences of an inappropriately political tone – not written
delivery of insulin and test strips and other monitoring by the author. In this issue, Itamar Raz, President of the
equipment in times of catastrophe – natural or otherwise. Israel Diabetes Association, expresses his point of view and
describes the support for people with diabetes in Palestine
This was the case when, during the last Triennium, the collapse provided as a result of under-reported cross-border
of the economy in Argentina and skyrocketing inflation co-operation. He also identifies pathways for enhancing
provoked an acute shortage of insulin. The IDF President the care of those most in need and – most importantly
wrote a letter to the President of the Republic of – he sees medicine as a possible channel for communication
Argentina in which his attention was drawn to the and co-operation between Israelis and Palestinians.
critical situation of many of his nation’s citizens; the rapid
action of the Task Force resulted in the shipment to In IDF, we recognize that there are people with diabetes in
Argentina of insulin and other diabetes supplies from many regions in the world, such as Palestine, who urgently
IDF corporate partners and Members Associations. require help. The task of reaching these people is not an
easy one; but it is essential that we do so. Indeed, it is
In 2002, the Task Force worked with IDF–Africa and Insulin for our obligation – to which we are firmly committed.
Life to urgently transport insulin and insulin syringes to Goma,
Democratic Republic of Congo, where the eruption of a volcano
affected some 400 people with diabetes. Furthermore, on an on-
going basis, the Task Force negotiates the pricing and distribution
of diabetes supplies with the pharmaceutical industry. Their

2
September 2004 Volume 49 Issue 3
 Diabetes Views

Diabetes care in need

In some ways this is a depressing issue of Diabetes Voice. Ever colleagues details, ensuring a
the optimist, your Editor-in-Chief (but see below) cannot help systematically high quality of care
nevertheless being moved by the depth of need that the articles in the European Region remains
in this issue expose. Around the world, in too many places, I a dream.
have seen some of the results of parents giving their children
half the ordered insulin dose, whether due to cost or insecurity Diabetes care prides itself on
of supply. Those children grow up stunted, mentally and being at the front of developments
physically, if they are lucky enough to survive at all. Sometimes in health-care education.Yet two
their hands are cruelly deformed due to sugar damage. articles, by Sanja Kušec and by Lisa
Chew, remind us that we do not
Kyrgyzstan is a beautiful country – and my first visit yet know how to communicate
enjoyed the spirit of hope that goes with the first day – particularly with those whose Philip Home
of a newly independent state. May I just ask you to read social position means they have is Professor of
what Botagoz Hopkinson and colleagues now have the greatest need for information Diabetes Medicine
to write about that little country’s diabetes care. and advice. Perhaps ‘do not know’ at the University of
here is wrong. As with diabetes Newcastle upon Tyne,
These problems are not confined to one part of our world, care in Europe we know how and Chair of the IDF
as emphasized in the article by Ron Raab and colleagues from to do it; we just do not do it. Clinical Guidelines
one of IDF’s task forces. What exactly would you or I do if the Task Force.
cost of a life-saving drug for our child exceeded our family’s Perhaps I am being too
income? The article emphasizes that it is not just insulin – insulin bleak. The article by Itamar
delivery devices and meters for glucose checks are necessary Raz, like that of Panagiotis
parts of the technology to maintain health, and just as costly. Tsapogas in our last issue, makes clear the efforts some
How perverse of nature to make insulin the hormone which is people are making, at personal cost and risk, to cope with
most difficult to replace artificially, yet the most essential to life. the underlying economic and political issues which make
many of the diabetes care problems so difficult to handle.
Even in adults, diabetes can be economically crippling when it For myself I have a particular aversion to inter-community
occurs in the context of poverty and deprivation, as described conflict and to the promotion of such problems by leaders
from the results of the survey by Anil Kapur and colleagues. who are seemingly oblivious to the consequences for health
The costs of care of diabetes complications are high – if care and education. Perhaps it was in that spirit that I missed the
can be accessed at all – and out of range when viewed against political significance of the scene-setting paragraph added to
a typical annual income. A colleague described to me recently the Gaza article in our last issue, the background to my
the deep ulceration of the feet of a child with diabetes, a result offering my resignation as Editor-in-Chief of Diabetes Voice
of poor glucose control and deformity, the sores dragging along to IDF.
in the dirt. She paid for the child to get surgical help – what
else could she have done; but how many others are there?

Back in Europe it is 15 years this October since IDF-Europe

and WHO (European Region) got together to work on an
initiative founded on the St Vincent Declaration. It is true that
the changes since then are impressive to anyone who has
followed its course, but, as the article from Michael Hall and

3
September 2004 Volume 49 Issue 3

Industry
New insulin for diabetes
now available
Insulin detemir (Levemir, Novo Nordisk)
was recently launched commercially,
after European approval was granted.
Insulin detemir was approved by the
European Commission for marketing in
the European Union for the treatment of
diabetes in June 2004. In the USA, Novo
Nordisk received overall approval from
the US Food and Drug Administration
for insulin detemir in October 2003.
Drug trials on mice point to
obesity treatment
© dpa
A drug under development by
GlaxoSmithKline (GSK) to treat high
levels of blood fat has been shown to
produce important reductions in weight
gain in mice when they are fed a high-
fat diet (The Guardian 25/8/2004).
The results from an independent study
by US scientists indicate that the
drug, GW501516, will be investigated
as a treatment for obesity by the
British pharmaceutical company.
News in Brief
The drug is in mid-stage clinical trials
to treat high blood fat (dyslipidaemia).
It is some years away from sale;
potential side-effects of increasing
cancer risk and oedema (fluid
build-up) require further investigation.
Exenatide steps slowly toward the
marketplace
Amylin Pharmaceuticals and Eli Lilly
and Company have submitted the
drug exenatide to the US Food and
Drug Administration for approval. The
progress of exenatide – structurally
derived from the saliva of the giant
American lizard, the Gila monster
(Heloderma suspectum) – was reported
in the June issue of Diabetes Voice in an
article by El-Ouaghlidi and Nauck. The © dpa
drug is one of a new class of medicines
derived from gut hormones and known from skin cells into eggs which have
as incretin mimetics, which are under had their own genetic material removed.
investigation for the treatment of Nurturing the eggs for six to eight days
Type 2 diabetes. In clinical trials, produces a tiny ball of around 100 cells
exenatide has demonstrated reductions from which stem cells can be extracted.
in blood sugar and improvements
in markers of beta-cell function. In theory, skin DNA from a person
with diabetes can be developed into
embryonic stem cells which could be
Research nurtured to produce new pancreatic
tissue. This could then be transplanted
Major step forward in human back into the person with no risk
embryo research in the UK of rejection. For more about new
The UK Human Fertilisation and biologically based treatments for
Embryology Authority recently gave a Type 1 diabetes, see the article
team at Newcastle University the first by Denise Faustman in this issue
licence to create embryos and extract and by James Shaw (Diabetes
stem cells from them for research. Voice 2002, issue 1).
Diabetes is known to be the group’s
first intended target of such work. Statins recommended – with or
without high cholesterol
It is believed stem cells hold the key to The results of a recent trial suggest
treating conditions such as Parkinson‘s that people with Type 2 diabetes could
and Alzheimer‘s diseases and diabetes. benefit from cholesterol-lowering
The Newcastle team plan to insert DNA treatment with statins – even when
5
September 2004 Volume 49 Issue 3
 News in Brief
they do not have high levels of blood
cholesterol (Lancet 2004; 364: 685-96).
Researchers in Dublin, Ireland assessed
the effectiveness of atorvastatin for
the prevention of major cardiovascular
events in people with Type 2 diabetes
without high levels of LDL (bad)
cholesterol. Acute coronary heart
disease events were reduced by around
30% among people given atorvastatin,
compared with those given a placebo.
Atorvastatin reduced the death rate by
27% compared with placebo. Strokes
were reduced by 48%. The results are
consistent with those of the Heart
Protection Study (see article by Roger
Lehmann, Diabetes Voice 2002, issue 3).
Obesity the main threat from a
mother – not diabetes
© mauritius
A study of more than 2000 children
born to mothers with gestational
diabetes found that the level of
maternal obesity rather than the
severity of the diabetes was the
“main predicating factor” for defects
September 2004 Volume 49 Issue 3
of the heart, kidney and urinary
tract (Diabetologia 2004; 47: 509-
514). Women with diabetes before
pregnancy have an increased risk of
giving birth to babies with congenital
abnormalities. High levels of blood
sugar passing through the placenta
to the developing baby are known to
cause defects in the crucial early few
weeks while organs are forming.
Obesity is an indicator of the nutrients
available to a baby in the womb. The
researchers from Barcelona, Spain
were surprised to find that it was the
excess of these nutrients, and not the
excess of blood sugar, which may be
connected to malformations at birth.
The researchers said that while women
planning a family should consider
their weight and its possible effects,
it is not advisable for a woman to lose
weight quickly before pregnancy.
‘Wonder drug‘ closer to reality
A tablet that could help people lose
weight, stop smoking and thus possibly
reduce the risk of heart disease could
be available within two years. Results
from the first 12 months of a two-year
trial into rimonabant show that 40% to
45% of the overweight and obese people
in the trial lost 10% of their weight.
The drug also reduced levels of blood fat
and the development of the metabolic
syndrome, a cluster of risk factors –
including abdominal fat, high blood fat
and low HDL (good) cholesterol – which
leads to diabetes. Rimonabant works
on a system in the brain (blocking
binding of natural cannabinoids to
their receptors) which is involved in
motivation and control of appetite as
well as the urge to smoke. The drug
6
© mauritius
was derived, in part, from observing
the way in which cannabis smokers
develop an overwhelming urge to snack.
Islet transplantation: pros and cons
The results of recently published
research demonstrate that islet
transplantation can deliver stable
glycaemic control, relief from recurrent
severe low blood sugar (hypoglycaemia),
and insulin independence (Curr Diab
Rep 2004; 4: 304-9). However, this
approach carries the risk of bleeding
and portal vein thrombosis.
Common long-term minor problems
with immunosuppression include mouth
ulcers, diarrhoea, and acne. Longer-
term risks include cancer and serious
infection, although both are rare to
date in clinical islet transplantation.
The researchers in Canada reported
that although progression of long-term
diabetes complications may stabilize,
as yet little is known of this aspect.
Short-term problems included rises in
levels of blood cholesterol and blood
pressure; in some people there was a
decline in kidney function; and in a

few, acute bleeding into the eye. For a
further discussion on the benefits and
drawbacks of islet transplants, see the
article by Denise Faustman in this issue.
New diabetes gene discovered
Researchers in Houston, USA have
identified a new gene, a mutation of
the SUMO-4 gene, which is associated
with Type 1 diabetes (J Biol Chem
2004; 279: 27233-8). SUMO-4 plays a
role in regulating the immune system.
According to the researchers, when
this gene is mutated, it functions
abnormally. This may affect the
inflammatory process in the body
and increase susceptibility to
the development of diabetes.
A number of genes have been
discovered which contribute to
the risk of developing diabetes,
such as those in the ‘HLA’ region,
which regulate the immune system
and help in the differentiation of
immune cells. The genes in the
HLA region account for as much
as 40% of the genetically inherited
risk of developing Type 1 diabetes;
SUMO-4 contributes to the overall
risk. However, SUMO-4 is important
due to the role it plays in controlling
the immune and inflammatory
response of the body.
Heart medication can provoke
build-up of potassium
Researchers in Texas, USA have found
that around 10% of people being
treated with heart/kidney drugs such
as angiotensin-converting enzyme
(ACE) inhibitors and angiotensin-
receptor blockers have increased
potassium levels (N Engl J Med
2004; 351: 585-92). High potassium
levels can provoke disruptions to
the heart’s normal rhythm.
It was reported that a large proportion
of people being treated with these
drugs are at increased risk for high
potassium because between 30-50%
of people with heart failure (reduced
ability to pump blood efficiently)
have kidney complications already.
The researchers recommended that
a person’s medical profile should be
reviewed and other drugs that impair
the ability of the kidney to excrete
potassium, such as ibuprofen and
naproxen, should be discontinued.
Dietary care should also be taken by
those at risk: the consumption of
certain foods, such as bananas, melon,
beef, liver, and orange juice, can
increase levels of potassium in the body.
Society
Eating disorders sadly more
common in girls with diabetes
Researchers in Toronto, Canada
compared the prevalence of eating
problems in girls between 9-14 yr
with Type 1 diabetes and girls of
the same age without diabetes.
The results suggest that girls
with diabetes experience eating
disturbances significantly more often
than do those without the condition
(Diabetes Care 2004; 27:1654-9).
Compared with the girls without
diabetes, those with the condition
had more disturbed eating behaviours.
The girls with diabetes were more
likely to use intense, excessive exercise
to control their weight. Furthermore,
7
News in Brief
binge eating was significantly more
prevalent in the girls with diabetes.
The researchers recommended
that “screening and prevention
programmes for this high-risk group
should begin in the pre-teen years.”
US swimmer with diabetes wins
Olympic gold medal
© dpa
Gary Hall, Jr recently won the gold
medal for the 50 metres free-style at
the Olympic Games in Athens. Gary
Hall, Jr, who was diagnosed with
Type 1 diabetes while he was already an
Olympic champion with two gold medals
from the 1996 Games in Atlanta, USA,
was told twice in one day that he would
never swim again at the world-class
level – first by the general practitioner
who diagnosed him, and then again
that afternoon by an endocrinologist!
To read more about Gary Hall Jr, visit
his website at www.garyhalljr.com.
Liposuction: a limited
health option
While liposuction may increase
a person’s ability to exercise and
September 2004 Volume 49 Issue 3
 News in Brief
reduce stress on joints, new evidence
demonstrates that the surgical
removal of body fat has no effect on
insulin action and risk factors for
cardiovascular disease (N Engl
J Med 2004; 350: 2549-57).
Furthermore, people who undergo
liposuction are at increased risks
of infections and blood clots.
The researchers followed up liposuction
in 15 obese women – including seven
with Type 2 diabetes – which involved
the removal of around 10 kg (22 lb) of
fat. The surgery produced little change
in several measures of heart disease
© dpa
September 2004 Volume 49 Issue 3
and metabolic risk, including levels of
blood pressure, cholesterol and insulin
sensitivity. Levels of C-reactive protein,
which is an indicator of inflammation in
the blood vessels, were also unchanged.
The researchers concluded that the
most effective method for improving
metabolism and heart health is to
burn more calories through physical
exercise than are ingested in food.
UK guidelines provide blueprint
for standardized care
Care guidelines for adults and
children with Type 1 diabetes were
launched recently in the UK. Visit
www.nice.org.uk. These will be
published in full in September 2004
by the UK National Institute for
Clinical Excellence and Royal College
of Physicians. Included among the
measures recommended in the
guidelines are: annual checks to
detect diabetes eye damage, kidney
complications, and nerve and foot
problems; a 24-hour telephone
helpline; and a team-based approach
to diabetes care. It is hoped that
these measures will standardize the
optimum care of diabetes in the UK.
The use of a trained team of specialists
will cover all aspects of diabetes care
including foot care, counselling and
psychological care, education, nutrition,
and the management of diabetes
complications. The guidelines make
specific recommendations for the care
of children and young people with
diabetes. These include a choice of
home-based or in-patient management,
a 24-hour telephone helpline, and the
provision of consistent and accurate
information on the condition.
8
Bursting the bubble on fizzy drinks
Colas, lemonade and fruit drinks with
added caloric sweeteners are implicated
as a major cause of obesity and
linked to a rise in diabetes according
to the results of a recent US study
(JAMA 2004; 292: 978-9). Researchers
reported that although the drinks are
loaded with calories they do not
make us feel full. People continue to
consume these potentially harmful
drinks in large quantities without
realizing the risks to health.
© mauritius
A can may contain 40-50 g (1.4 oz) of
sugar. It was calculated that a person
who drinks one can a day could gain
7 kg (15 lb) over a year. The authors
reported that the consumption of soft
drinks in the USA increased in adults by
61% from 1977 to 1997 and more than
doubled in children and adolescents
between the late 1970s and mid-1990s.
Neville Rigby of the International
Obesity Task Force said recently that
sweetened soft drinks continue to be
marketed to children “as if the industry
was unaware there was a problem.“
For more information or to contribute News
In Brief items to future issues of Diabetes
Voice, please contact the Managing Editor,
(fax: +32-25385114; catherine@idf.org).
 Health Delivery

The human perspective on

health-care reform: coping with
diabetes in Kyrgyzstan
ִ Botagoz Hopkinson, Dina Balabanova, Martin McKee, Joseph Kutzin

Kyrgyzstan is a small mountainous country with The policy makers’ perspective

a predominantly agricultural economy; it gained Since 1991, the City Endocrinology
Dispensary (clinic) in Bishkek has
independence with the break-up of the Soviet Union in been responsible for the provision
1991. For a significant sector of the Kyrgyzstani population, of outpatient care to local residents,
as well as the development of health
economic difficulties at national level translate into high
policy, and the implementation of
unemployment and widespread impoverishment. Kyrgyzstan diabetes services nationally. Despite
its expanded responsibilities, the
inherited an extensive but basic health-care system, with a
City Dispensary has received no
functioning – albeit fragmented – structure for managing additional funding. Equipment is
chronic diseases.1 The authors of this article report on the obsolete and there is a lack of basic
laboratory supplies. With some
findings of a rapid appraisal study which uses the St Vincent exceptions, diabetes care outside
Declaration as a gold standard to assess the performance of the capital is provided in regional
and district hospitals that have few
diabetes care in Kyrgyzstan.
links with national-level institutions.

>> The City Dispensary is responsible

Kyrgyzstan is a landlocked
country, trapped between the high
mountains of the Pamirs and the
Tien Shan and its larger neighbours
Kazakhstan and Uzbekistan. Since
independence in the early 1990s,
health has been a significant issue
for the new government. For
people with diabetes for example,
deaths attributed to the condition
have almost doubled (from 6.5 per
100 000 in 1990 to 11.3 per 100
000 in 2002), with a larger increase
in Chui oblast (region). In a study
of the situation, data from multiple
sources were collected from the
capital, Bishkek, and from Chui
oblast, a mainly rural area.
for managing data on people with
diabetes throughout the country
and their insulin needs. In practice,
however, these data are gathered by
the chief endocrinologist, who calls
regional colleagues by telephone
and manually compiles the results.
Although a national register of
people with diabetes is maintained,

10
September 2004 Volume 49 Issue 3

it is not effectively used. The number
of registered people with diabetes
remained constant throughout the
1990s. This translates into a seemingly
very low diabetes prevalence of 3.4
per 1000 in 2002; in 2001, of 16 295
people registered, 1693 (10%) had Type 1
diabetes. The level of complications is
high: over 40% of people with diabetes
suffer foot problems and over 30% have
renal problems. While these figures
for late-developing complications are
considered underestimates, they are
considerably higher than those in
Western Europe and North America.
( National diabetes
data are gathered
manually by the
)
chief endocrinologist
through telephone
calls to regional
endocrinologists.
A comprehensive national diabetes
programme (1999-2004) envisages
the training of primary care providers
(family physicians), improvements in
the distribution of insulin and essential
supplies, and enhanced clinical practice
including education for people with
diabetes, and self-management.
However, despite approval by an inter-
Ministerial committee, this has not
been linked to designated funding.
The health professional’s
perspective
Insulin and diabetes supplies
According to the health professionals
interviewed, the shortcomings of a
fragmented, poorly functioning health-
care system that lacks physical and
financial resources are exacerbated by
low motivation among health carers –
© mauritius
a result of low salaries, long working
hours, and an inadequate infrastructure.
Primary care physicians reported a
frequent lack of access to essential
diabetes supplies. The endocrinology
departments of the National Hospital
and National Children’s Hospital
– both national referral centres for
diabetes – lacked test strips and blood
glucose meters, and experienced
irregular supplies of insulin.
The hospitals in Kyrgyzstan are not
permitted to provide insulin to people
with diabetes after discharge from in-
patient care – with inevitable adverse
consequences. Staff report an increase
in the number of people with diabetes
admitted in coma (ketoacidosis)
and with severe complications.
The Kyrgyz Ministry of Health
11
Health Delivery
purchases insulin by tender,
based on the number – obtained
from the City Dispensary – of
registered people with diabetes.
Often procured with substantial
delays, these supplies are
then distributed via the City
Dispensary to regional facilities.
Although the retention of state
control over the distribution of
insulin is intended to protect
supplies, this has been compromised
by the failure of budgets to keep pace
with prices; and by logistical difficulties
in ensuring that the medication actually
reaches the people with diabetes.
Human resources, training
and infrastructure
An inadequate capacity for
the management of diabetes
complications was widely
reported. Health professionals
at the City Dispensary were
familiar with the principles of the
St Vincent Declaration, which
sets out internationally accepted
recommendations for the detection
and management of diabetes. In
practice, however, they were financially
and organizationally constrained from
implementing its recommendations.
The decentralization process that
was initiated in the late 1990s was
not accompanied by sufficient
training and investment in
communication and infrastructure.
Although in 1998 the Bishkek City
Dispensary transferred responsibility
to local clinics for the care of 2627
people with Type 2 diabetes, contrary
to expectations, by 2001 the use
of the Dispensary had increased
markedly as people with diabetes
September 2004 Volume 49 Issue 3
 Health Delivery
from outside the capital returned to
the city to seek what they perceived
to be better quality care.2
Family physicians in rural areas were
largely unaware of the presence of
diabetes in the people under their
care, and assumed that diabetes
care was being provided by the
City Dispensary. These primary
care professionals reported their
own inability to help anyone with
a diabetes emergency; all primary
care physicians reported a lack
of training in the assessment of
diabetes foot complications.
( )
Family physicians in
rural areas reported
their own inability to
help anyone with a
diabetes emergency.
Furthermore, poor communications
networks impede the effective
functioning of the health-care system:
care is provided by different specialists
in various locations often not sharing
information; endocrinologists reported
that they were uncomfortable with
the management of common
diabetes complications such as
foot problems; people are often
transferred to general hospitals,
where the specialized skills needed
to manage their condition were absent.
The perspective of
people with diabetes
The consistent underfunding of the
Kyrgyz health-care system since
independence has created a situation
in which people with diabetes are
required to make significant out-of-
pocket contributions for the treatment
September 2004 Volume 49 Issue 3
of severe complications, such as
diabetes eye damage (retinopathy)
or nerve damage (neuropathy).
Consistent with other studies,
interviewees reported that informal
payments to medical staff and
hospitals for essential diabetes
supplies were endemic.3
Legislation which was designed to
ensure free medical treatment is often
disregarded outside the capital. While in
hospital people with diabetes are often
expected to bring their own diabetes
drugs and equipment, and food.
The mainly hospital-based services
for people with diabetes often involve
invasive therapies. There is little use
of self-management or conservative
techniques. Thus minor foot ulcers
are routinely referred to surgical
departments where the standard
treatment is an above-knee amputation
– a last resort in Western Europe.
Of the 27 people interviewed, only
three had access to blood glucose
meters and test strips in order to
help manage their condition.
( )
Minor foot ulcers are
routinely referred to
surgical departments
where the standard
treatment is an above-
knee amputation.
Inadequate supplies
The inability to obtain consistent
supplies of a prescribed type of
insulin was the most frequently
reported problem for people with
diabetes in Kyrgyzstan. As a result,
people with diabetes are continually
forced to take life-threatening
12
risks, using products of varying
strengths or duration of action. It
is illegal for the state pharmacies
to sell insulin; people with diabetes
often buy their diabetes supplies
at market stalls or from abroad.
Newly diagnosed people with
diabetes in rural areas face
particular problems. The study
found that health facilities outside
Bishkek rarely held sufficient insulin
for new cases of the condition and
often lacked even basic equipment
to perform blood and urine tests.
As a result, people often had to go
without treatment for several days
until supplies could be obtained. Most
interviewees reported bypassing
local health centres when possible.
Fear and frustration
Currently, people with diabetes are
entitled to a small disability pension
from the Ministry of Social Protection
and Labour. However, to obtain this
pension, an annual in-patient medical
assessment lasting 10-12 days is
required – a hang-over from Soviet
days. The process involved in this
assessment caused anxiety among
people with diabetes due to the
inflexibility of timing of admission,
the expense incurred, and the
potential loss of financial support.
Young people with diabetes are
often educated in separate schools
from their peers and excluded from
routine physical activities – provoking
feelings of isolation and frustration.
Sadly, there were reports of children
with no hope for the future who
were unwilling to take insulin. Many
adults reported accepting that their

children would die prematurely.
Although seven of the people
interviewed were attending a
diabetes education programme
in Bishkek, the majority reported
a lack of such support from health-
service agencies. Other than a
basic idea of the relationship
between food intake and insulin
use, few of the people interviewed
had any knowledge of how to
manage their condition.
Over half of those interviewed
complained about the late diagnoses
of diabetes, inadequate management
of complications, and inappropriate
referrals. Of the 27 respondents,
23 reported pain in their feet
and feared a possible amputation.
Moreover, medical professionals
were perceived as lacking
in interpersonal skills and
unsympathetic to the needs
of people with the condition.
Messages from the study
Important efforts are being made to
improve diabetes care in Kyrgyzstan.
However, despite the large number of
health professionals per capita and the
ambitious training of family physicians,
the study highlighted a significant lack
of functional capacity – especially in
rural areas – resulting in the ineffective
management of diabetes at local level.
Investment in a number of areas
appears to be imperative.4 There
is a need to improve access to
physical resources, such as glucose
meters and test strips. The stable
supply of insulin must be ensured
– especially in rural areas. The system
for procurement and distribution
of insulin should be re-evaluated.
An emphasis should be placed on
evidence-based practice, with a
particular emphasis on self-care. Given
the shortage of basic resources, the
annual in-patient assessments discussed
above are wasteful as well as serving
no purpose. Doing away with these
requires changes in the regulations
regarding social protection. National
guidelines on the appropriateness
of interventions – such as widely
used amputations – should be
formulated, and staff trained in simple
conservative management. Links
between the different levels of the
health system should be established
in order to ensure continuity of
care for people with diabetes.
These different requirements are
interlinked. Investment in one
without attention to the others is
likely to fail, as demonstrated by the
experience of the foot specialist who,
having received expensive training,
received no resources to use it.
ִ Botagoz Hopkinson,
Dina Balabanova, Martin McKee,
Joseph Kutzin
Botagoz Hopkinson is a Research Fellow at
the European Centre on Health of Societies
in Transition, London School of Hygiene
and Tropical Medicine, London, UK.
Dina Balabanova is a Lecturer in
Health Policy at the European Centre
on Health of Societies in Transition,
London School of Hygiene and
Tropical Medicine, London, UK.
Martin McKee is a Professor of European
Public Health at the European Centre
13
Health Delivery
on Health of Societies in Transition,
London School of Hygiene and
Tropical Medicine, London, UK.
Joseph Kutzin is a Senior Resident
Advisor, MANAS Health Policy Analysis
Project which is based at the World Health
Organization, Regional Office for Europe,
Division of Country Support, Scherfigsvej,
Copenhagen, Denmark. He is a Visiting
Fellow of the Imperial College Centre
for Health Management, London, UK.
Acknowledgements
The UK Department for International
Development (DFID) supports policies,
programmes and projects to promote
international development. DFID provided
funds for this study as part of that
objective, but the views and opinions
expressed above are those of the author(s)
alone. The authors extend their thanks to
Gerry Stimson, Jan Bultman, Armin Fidler
and Richard Coker for their assistance
with this article.
The material contained in this article was
reproduced with permission. Copyright
John Wiley & Sons Limited. Hopkinson B,
Balabanova D, McKee M, Kutzin J. The
human perspective on health care reform:
coping with diabetes in Kyrgyzstan. Int J
Health Plann Mgmt 2004; 19:43-61.
References
1 McKee M and Healy J and Falkingham J (2002).
Health care in Central Asia. Open University
Press, Buckingham.
2 Bishkek City Endocrinology Dispensary (2002).
Report on diabetes services in Kyrgyzstan. City
Dispensary, Bishkek.
3 Kutzin J. (2003). Health expenditures, reforms
and policy priorities for the Kyrgyz Republic.
Policy Research Paper 24, MANAS Health Policy
Analysis Project. MANAS, Bishkek: Kyrgyz
Republic.
4 McKee M and Healy J (ed) (2002). Hospitals
in a changing Europe. Open University Press,
Buckingham.
September 2004 Volume 49 Issue 3
 Health Delivery

Diabetes under fire

ִ Itamar Raz

In the last issue of Diabetes Voice Panagiotis Tsapogas trained at our Diabetes Centre. One
of our leading researcher-physicians
presented a view of diabetes care in Gaza from the perspective
is Palestinian, and our hospital has a
of his work with Médecins Sans Frontières. Here, Itamar Raz, large percentage of Palestinian doctors
and nurses. To this day, we actively
President of the Israel Diabetes Association (IDA), presents
co-operate with Palestinian doctors
a view from the perspective of an Israeli person living in the in the West Bank and Gaza, and
region, and from the leading Palestinian physicians with people from both areas come to us
in Jerusalem and get the best medical
whom he collaborates. Together they struggle in the midst care we can offer, free of charge.
of the disruptions to deliver diabetes health care across the
Our political viewpoints are of
political divide. The message is of the desire of many in
course often radically different, but
Israel to contribute to the Palestinian health-care system in this does not interfere with warm
personal interactions or optimal
regard of diabetes, and that such co-operative efforts by good-
diabetes management. Medicine can
willed health-care workers on both sides have already made a thus be a channel for communication
significant contribution which deserves to be recognized. between Israelis and Palestinians
that can override the hostility of
some sectors of our populations.
>>
The continuing Israeli-Palestinian
conflict is an illustration of the
damage that populations can
suffer when secular and religious
My great-grandfather, a leading
scholar of the Hebrew language,
migrated to the land of Israel in
1880. His son, a journalist, wrote
( )
Often, the media view
of the conflict can
make it seem polarized
beyond reconciliation.

authorities fail in their leadership
of peoples of similar cultures
with similar thoughts. What
seems clear and simple can
become hostile and threatening
once militant parties interfere with
the integration of communities.
And health-care delivery suffers
along with the other social
structures that depend
on a stable society.
extensively about the need to live
together with the Palestinians.
Conflict and co-operation
Over 75 years later, the view of the
conflict often presented in the media
can make it seem polarized beyond
reconciliation.Yet in my own Diabetes
Centre in Jerusalem, health care bridges
the gap. Indeed, many of the doctors
practising in the West Bank and Gaza
The avenue of co-operation opened
for us in the years 1988-2000, when
political healing between Israelis and
Palestinians seemed really possible
at last. With no borders between
Israeli and Palestinian diabetes
teams or people with the condition,
our Diabetes Center was asked to
assist in this cause. Within weeks,
relations were established with the
Palestinian Deputy Minister of

14
September 2004 Volume 49 Issue 3
 Health Delivery

Medicine can be
a channel for
communication
between Israelis and
Palestinians.

Health and leading diabetes doctors.

A joint diabetes screening initiative
began, funded and equipped by
IDA and diabetes centres in
Israel – which are themselves
not particularly well funded.
Additionally there were many
jointly staffed educational initiatives.

Hope, hostility, ... and hope

The European Association for
the Study of Diabetes (EASD)
meeting in Jerusalem in 2000
was both a milestone of co-operation,
friendship and hope, and the point
of breakdown in many of our
joint efforts.
Large symposia were scheduled to
take place including in the West Bank
in Jericho and Ramallah. However, with
the Intifada imminent, communication
with our Palestinian colleagues ceased,
and the organizers were forced to
cancel those symposia. The main
meeting went ahead with nearly
10 000 participants, but within a
week conflict had brought terrible
suffering. The violence which
followed had a very negative effect
on many programmes of assistance
and co-operation which Israelis
were trying to develop to benefit
Palestinians with diabetes.
Nevertheless, the violence and
hostility of some could not cut the
ties between well-meaning people.
At Hadassah hospital in Jerusalem, for
example, approximately 150 Palestinian
children underwent cardiac surgery in
2003-2004, funded jointly by Tuscany
(Italy) and the hospital itself. Other
hospitals have similar projects.
( )
EASD 2000 was both a
milestone of friendship
and hope and the
point of breakdown in
many of our efforts.
Hadassah continues to establish
training programmes for professionals
from the West Bank and Gaza in a
wide range of specialties. We would
like to be able to do more. A group of
Israeli doctors, members of Physicians
for Human Rights – Israel, heads out
almost every weekend to Palestinian
villages. This group of volunteers
includes specialists in diabetes care.
Logistical and resource problems
The United Nations Relief and Works
Agency for Palestine Refugees in the
Near East (UNRWA) also contributes
substantially to diabetes treatment,
especially in Gaza, and under its
auspices, diabetes clinics there
treat the majority of those in need,
providing counselling, insulin therapy,
kidney-protection drugs, and the like.
But some basic elements of care, such
as glycated haemoglobin tests, self-
monitoring equipment, and heart-
protection drugs such as statins, are
still not available to Palestinian people
in Gaza. Obesity is a big problem for
Palestinian populations – and is as yet

15
September 2004 Volume 49 Issue 3
 Health Delivery

IDA has launched

initiatives to strengthen
ties between Israeli and
Palestinian doctors.

Although I would strongly question

the political balance in the recent
article in Diabetes Voice on diabetes
care in Gaza, it usefully highlights the
role of the political conflict that has

“I would like to introduce Diabetic

barely tackled. Thus their diabetes
problem can only grow larger.
and the disheartening loss of
donated funds through corruption,
a large part of the population is
Friends Society of Bethlehem,
which was established in 2001
in order to provide diabetic
patients with services that are
lacking in our area. Even though
we are still at the beginning

( A group of Israeli getting access to a basic level of care. of our humanitarian road,
doctors, members of we were able to assist many
Guidelines and statistics people with essential needs, in

)
Physicians for Human
Rights, heads out
almost every weekend
to Palestinian villages.
Paradoxically, the situation in the
West Bank is even worse due to the
difficulty in reaching those people
with diabetes living in remote villages
which are hard enough to reach in
times of peace – and much more so
with the checkpoints that are installed
during times of conflict. As a result,
the population in the refugee centres
receives better care than those living
In 2003 the Palestinian Medical
Society published excellent
guidelines for the treatment of
diabetes, and a recent statement
from the Palestinian Authority
was far from pessimistic. Indeed,
official statistics do not show the
unusually high rates of cardiovascular
events, or of the late-developing
diabetes complications such as
blindness, renal insufficiency or
limb amputations. Interviews
with physicians from Gaza speak
of real progress in these areas
addition to conducting various
activities with children and adults.
We also have many projects,
especially for children, that
we hope to implement in the
near future. The purpose of this
letter is to make our society
familiar to you, and hopefully,
if you see it suitable, we can
co-operate together in the future
as well as benefit from your
expertise in the diabetic field.”
Letter to IDA, August 2004

in the villages. My impression is that – efforts by many individuals do

despite the aggression, the checkpoints seem to be making a difference.

16
September 2004 Volume 49 Issue 3

led to destruction, hatred, and harm
to individuals. But can we do more in
these circumstances to help in Gaza,
despite the hostile environment?
New ventures to tackle
the problems
Undoubtedly, there are thousands of
Palestinian people with diabetes who
are severely affected by a situation
for which they are not to blame. We
Israelis, suffering real terror on our
side of the conflict, sometimes do not
rise far enough above the day-to-day
difficulties to search for the means to
bridge the gap and provide more help.
There is a sense of the same short-
comings in the article from Panagiotis
Tsapogas. How can we motivate the
diabetes community in Israel to work
to improve the support for Palestinian
people with diabetes? What tactics can
be used to effect such improvement?
We have launched several ventures:
Y strengthening the severed ties
with leading Palestinian doctors
in the West Bank and Gaza
Y asking these doctors to provide
accurate situational reports, so that
help can be directed more efficiently
Y allocating resources from the
budgets of IDA and its supporting
pharmaceutical companies
Y organizing conferences for
health carers and people with
diabetes in the West Bank and
Gaza with input from IDA
Y encouraging clinical research,
including that conducted
in collaboration with
pharmaceutical companies
Y trying to integrate Palestinian
doctors in international
activities and in organizations
Health Delivery
such as the International many in need of help. We must
Diabetes Federation (IDF). find ways to reach out to them.
( )
Physicians from
Gaza speak of real
progress – everyone’s
efforts do seem to
make a difference.
ִ Itamar Raz
In summary, we must rise above Itamar Raz is a Professor of
the tough daily realities. Those of Medicine in Jerusalem. He is President
us in Israel must remember that of the Israel Diabetes Association.
the Palestinian people who come
to us in the hope of receiving best
care are only a fraction of the
Editor’s note – an apology
Following comments from Itamar Raz and others, the International Diabetes Federation
issued an apology to the readers of Diabetes Voice, published on the IDF website on
2 August 2004. The apology included the following text:
In the June 2004 issue of Diabetes Voice, Panagiotis Tsapogas, Medical Co-ordinator of MSF
(Médecins Sans Frontières) in Gaza 2002-2003, reported on the challenges of living with
diabetes in the Gaza Strip, expressed hope, and called for help. Sadly, this article was
preceded by an introductory paragraph, not written by Dr Tsapogas, which was intended to
‘set the scene’. The paragraph, which had also been posted on the IDF website together with
the Table of Contents of the said issue, expressed views which were not those of IDF and
was immediately removed from the website.
We regret the political tone of this introductory paragraph, which in no way represents
the views of the Federation. On behalf of IDF and Diabetes Voice, we offer our unreserved
apology to those who have been offended.
As bearing responsibility for the content of Diabetes Voice, the Editor-in-chief has offered
his resignation which IDF has accepted.
We wish to affirm that IDF as a Federation of 185 associations in 142 countries does not
represent any political views and that its mission is to “promote diabetes care, prevention
and a cure worldwide”.
Pierre Lefèbvre, President, IDF
Martin Silink, President-Elect, IDF
Philip Home, Editor-in-Chief, Diabetes Voice
17
September 2004 Volume 49 Issue 3
 Health Delivery

Socio-economic
determinants of the
cost of diabetes in India
ִ Anil Kapur, Stefan Björk, Jyotsna Nair, Sanjeev Kelkar, Ambady Ramachandran

Diabetes is rapidly emerging as a major health-care problem in this problem. Many sociological factors
determine the long-term outcome of
India, especially in urban areas where the prevalence of Type 2
health conditions: the ability of people
diabetes has been reported as 12% of the adult population.1 to access treatment is dependent on
Furthermore, there is an equally large pool of people with their proximity to health facilities, the
resources necessary to travel to these,
impaired glucose tolerance (IGT), many of whom will go and even knowledge of their existence.
on to develop Type 2 diabetes in the future. The World Health
Organization (WHO) estimates the number of people with
diabetes in India in 2000 to be 31.7 million, which is likely to
2
rise to 79.4 million by 2030. In this article the authors report
( )
Poverty and the lack
of health education
exacerbate the
problem of limited
health care in India.
on the socio-economic factors affecting the costs of diabetes
care in India. The wider consequences
Long-term consequences

>> An illness affecting the wage-earning

The need to prioritize distribution of
limited resources in India has resulted
in a public health-care system that
tends to concentrate on the care of
people with acute illness. Diabetes care
provided in government health centres
is free or of low cost. However, given
the limited funds and infrastructure
for chronic progressive conditions like
diabetes, the quality of care suffers:
public hospitals and clinics are crowded
and ill-equipped. Insurance cover and
cost-reimbursement for treatment in
the private sector is marginal or non-
existent; here too the infrastructure
for chronic care is limited. The lack of
adequate facilities and financial capacity
indirectly worsens long-term prognosis.
Prevailing poverty and illiteracy, and the
lack of health education exacerbate
member of a family often also has
a significant effect on others. In the
absence of protection during illness
or bad times through an effective
social-security system, many people in
India rely on the physical and financial
support of their family in order to
overcome medical crises or other
social problems. As a result, children
and adolescents may be forced to
start work prematurely and at low
wages – significantly reducing their

18
September 2004 Volume 49 Issue 3
 Health Delivery

Complications are
responsible for most of
the diabetes-related direct
health costs in India.

education and negatively impacting

their long-term earning capability.

Excess costs
People with diabetes use more
health-care resources than those
who do not have the condition. © WHO/P Virot

This excess expenditure is related

to the high cost of treatment
for late-developing diabetes
complications, such as eye damage
(retinopathy) or kidney failure
(nephropathy), as well as indirect
costs resulting from lost work days
or unrealized economic opportunity.
The Cost of Diabetes in India (CODI)
study, sponsored by the Novo
Nordisk Education Foundation
and the pharmacoeconomics
department of Novo Nordisk, was
a large community-based survey
of diabetes costs, designed to
provide cost estimates of diabetes
care at the national level.3, 4
Factors influencing costs of care
Late vs early diagnosis
Diabetes is often diagnosed late
– perhaps too late: 50% of people
with diabetes even in developed
countries have complications at
diagnosis. Untreated or improperly
managed diabetes leads to serious and
often life-threatening complications.
Complications requiring multiple
therapies and prolonged hospitalization
are responsible for most of the
diabetes-related direct costs. Among
people with diabetes who are
Table 1: Total overall mean direct and indirect costs (57 INR = ~1 EUR)
hospitalized, the average annual direct
costs are more than double those
for people with diabetes who are not
hospitalized. Complications are also
responsible for indirect costs in terms
of productivity loss and absenteeism.
Education
Many socio-economic factors affect
the time of diagnosis and thus the
outcome of diabetes. Consequently
they also affect the costs. The level of
education appears to be important.
Whether this is related to greater

Table 1 gives the total overall mean

direct and indirect costs of diabetes
in India. Ambulatory care constitutes
65% of cost while the hospitalization
cost is 35%. Cost of medications
is 31% – of which specific diabetes
drug costs are only 17%. Ambulatory
care including monitoring and doctor
visits constitute 34% of costs.

19
September 2004 Volume 49 Issue 3
 Health Delivery
© dpa
understanding of the condition and
therefore greater commitment to
self-care, or whether it is a reflection
of a better socio-economic status and
therefore better access to medical
care (or both), is difficult to say.
Diagnosis can be delayed by 3-7 years
in the less-educated and uneducated
sections of the population. In the
CODI study, the age of diagnosis
was directly related to the level of
education: college-educated people
were on average diagnosed 7 years
before people with no literacy.
Despite a longer average duration
A person has impaired glucose
tolerance (IGT) when their blood
glucose (sugar) levels are higher
than normal, but below the level
of a person with diabetes. Most
people with IGT are at increased
risk of developing Type 2 diabetes.
September 2004 Volume 49 Issue 3
of diabetes, those with a college
education had a considerably lower
rate of diabetes complications
(45% complication-free) compared
with people with low or no
literacy (20% complication-free).
Unemployment
Type 2 diabetes produces few
symptoms and acutely is not life
threatening. Often, weakness and
tiredness are the only manifestations
of the condition. While it is common
for inactive unemployed people to
ignore these symptoms (consciously
or otherwise), those who are working
are more likely to notice the signs
as these influence the capacity to
work. In the CODI study, compared
to working people in urban areas,
people in lower-income groups were
diagnosed on average 4 years later
– as were people living in remote
rural areas. People who are aware
of diabetes before diagnosis or
those with a family member with
diabetes may be diagnosed earlier.
20
Complications
The factors that influence delay in
diagnosis also determine the rate
of complications. Place of residence
seems to play an indirect role: people
with diabetes living in the semi-
urban or rural areas have higher
rates of complications – despite less
duration of diabetes – than those
in urban settings. This would appear
to reflect delayed diagnosis and the
availability of less-than-optimum
or indeed the total lack of care.
A similar trend is noted with
regard to employment and socio-
economic status. Employed and
working people with diabetes have
fewer complications compared to
those not working or those in rural
areas engaged in agricultural labour.
Among people with similar diabetes
duration, larger proportions from
the higher socio-economic strata
are free of or have fewer diabetes
complications (54% complication-
free; 8% with three complications),
compared to the lower socio-
economic group (22% complication-
free; 26% with three complications).
As might be expected, education
appears to play a role in the
development of diabetes complications.
For people with a similar duration
of diabetes, 45% of those who
finished higher education had no
complications, compared to 20% for
the no-literacy group. While awareness
alone cannot overcome the socio-
economic barriers to health, within
the same socio-economic groups,
people who are aware of the problem
suffer fewer complications than
those who are not aware. Similar

findings have been reported from
the USA – see article by Lisa Chew
in this issue of Diabetes Voice.
While the average annual direct
cost for out-patient care for all
people with diabetes was 4724 INR
(82.7 EUR), the cost of care for
those without complications was
18% lower, but 48% higher for those
with three or more complications.
As with ambulatory care, the cost
of hospitalization increased with
the number of complications.
Conclusions
Uneducated, unemployed people with
diabetes who cannot afford or do not
have access to even minimum health-
care facilities – especially those living
in semi-urban or rural areas – are
likely to be diagnosed late. They are at
increased risk of developing diabetes-
related complications due to delays in
diagnosis and/or improper treatment.
( )
Those who need
expensive care for
diabetes-related
complications are
often the very people
who cannot afford it.
This has important socio-economic
significance: those who need more
advanced, more expensive care
for diabetes-related complications
are often the very people who
cannot afford such care. While
some of these people may be
able to afford routine care, when
burdened with debilitating and
often life-threatening complications
requiring expensive advanced
care, many of them are forced to
borrow money in order to pay for
treatment. Thus they enter the trap of
debt – with disastrous consequences
to the individual and society.
The presence and severity of
complications are the most
important determinants of
treatment, monitoring regimen
and the need for hospitalization.
Therefore these represent the most
important cost-related factor.
Adequate and appropriate
management can prevent, delay
or arrest the development of
complications both in Type 1 and
Type 2 diabetes. There is growing
evidence to suggest that this can be
achieved through improved diabetes
education and health awareness,
and the promotion of self-care.
Without effective preventative
intervention in the form of life-style
changes at society level, the diabetes
epidemic will continue to grow.
Secondary prevention can reduce
the burden of complications through
early diagnosis and proper care.
Clearly, those involved in diabetes
care delivery need to be aware of
the factors that drive health costs.
Effective treatment of diabetes is
not costly; however, in both human
and economic terms, not treating
the condition is extremely costly.
21
Health Delivery
ִ Anil Kapur, Stefan Björk,
Jyotsna Nair, Sanjeev Kelkar,
Ambady Ramachandran
Anil Kapur is Vice-chair of the World
Diabetes Foundation, Denmark.
Stefan Björk is Senior Advisor and Health
Economist at Novo Nordisk A/S, Denmark.
Jyotsna Nair is currently Research Director
AC Neilsen ORG Marg. New Delhi, India.
Sanjeev Kelkar is Medical Director
at the Novo Nordisk Education
Foundation, Bangalore, India.
Ambady Ramachandran is Director of
the Diabetes Research Centre and MV
Hospital for diabetes, Chennai, India.
References
1 Ramachandran A, Snehlata C, Kapur A, Vijay V,
Mohan V, Das AK, Rao PV, Yajnik CS, Prassana
Kumar KM and Nair J D. High prevalence of
diabetes and impaired glucose tolerance in India:
National Urban Diabetes Survey. Diabetologia
2001; 44: 1094-101.
2 Wild S, Roglic G, Green A, Sicree R, King H. Global
prevalence of diabetes. Estimates for the year
2000 and projections for 2030. Diabetes Care
2004; 27: 1047-53.
3 Kapur A. Cost of Diabetes in India – The CODI
Study Paper presented at the Novo Nordisk
Diabetes Update, Bangalore, February 2000.
4 Björk S, Kapur A, Kelkar S, Nair JD,
Ramachandran A. Aspects of diabetes in India: A
nationwide survey. Research and Clinical Forums
2003; 25(1): 5-34.
September 2004 Volume 49 Issue 3
 Health Delivery

Cost and availability of insulin

and other diabetes supplies:
IDF survey 2002-2003
ִ Ron Raab, Léopold Fezeu, Jean-Claude Mbanya

Insulin is a life-sustaining medication and as such has been the developed countries – of Europe
and North America, for example
designated an ‘essential drug’ by the World Health Organization
– the price is usually subsidized:
(WHO). Insulin therefore should be universally available to the yearly cost of insulin in these
everyone who requires it for survival. However, accessibility countries is usually below 0.5%
of the average annual income.
to the drug is often not secure. This results in life-threatening
complications for people who depend on insulin for survival. If people in the developed economies
were forced to pay the same amount
The authors of this article, in reporting on the results of the
for insulin relative to income as
International Diabetes Federation (IDF) survey, 2002-2003, people with diabetes in some low-
to middle-income countries, their
make a call for improvements to the pricing and availability
medication would cost around
of insulin and other essential diabetes supplies. 1000 USD for one month’s
supply (12000 USD per year)
>> – around 100 times more than
such people actually pay.
The cost of insulin to a person with with diabetes in the poorest
diabetes varies greatly between countries of the world, the inability Great uncertainty and despair
countries. This is a critical problem, to afford this essential medication exist among the many people
particularly in those low- and is a major cause of death. throughout the world who not
middle-income countries where only face difficulties affording insulin
the full, unsubsidized price of this In low- and middle-income countries, but also struggle to obtain other
medication is high, and must be animal-sourced insulin, which has essential diabetes supplies: the cost
paid by the user for many years or for decades saved lives, is being of blood glucose monitoring is a
decades. In many such countries, withdrawn. The result for people major problem in many economically
the annual cost of insulin for an in some areas of the world is an developing countries. In many cases,
individual exceeds 50% of the increase in the price of their life- equipment for self-monitoring is even
average annual income. For people sustaining medication. In contrast, in less accessible than insulin. The IDF

24
September 2004 Volume 49 Issue 3

The majority of people in
the world with diabetes live
in the low- to middle-income
countries.
survey 2002-2003 included information
on this issue for the first time.
In the developing economies, many
governments and public-health
planners remain largely unaware of
the current impact of diabetes in their
own countries and the projections for
future increases in the prevalence of
the condition. The number of people
with diabetes around the world
continues to escalate: diabetes is now
widely referred to as a pandemic. As
a result, the demand is increasing for
insulin, test strips and other diabetes
supplies. The majority of people in the
world with diabetes live in the low-
to middle-income countries. If their
diabetes supplies are not appropriately
made available, the burden of costly
diabetes complications will increase
significantly, impacting dramatically on
the economies of these countries.
( )
In many cases,
equipment for self-
monitoring is even less
accessible than insulin.
IDF survey 2002-2003
The survey questionnaire, which
expanded on the work of previous
IDF surveys, was sent to all IDF
Member Associations in over 140
countries around the world. Based
© dpa
on a professionally produced
epidemiological survey document,
the questionnaire was developed by
members of the IDF Task Force on
Insulin, Test Strips and Other Diabetes
Supplies. It will also provide the basis
for detailed comparative surveys in
the future. The survey is part of the
IDF Atlas project, which documents
world-wide diabetes data (available
through the IDF website, www.idf.org).
The survey was designed to assess the
magnitude and causes of the lack of
access to insulin and other diabetes
supplies under the following headings:
Y access to insulin
Y insulin strengths, types and origins
Y access to insulin syringes
and needles
Y access to blood and urine
glucose monitoring supplies.
The results assist the Task Force
and others to tackle the massive
25
Health Delivery
problem of the lack of accessibility and
availability of this essential drug and
monitoring supplies in many countries.
Results
Responses to the survey were
received from 81 countries in the
seven IDF regions, and these data
were then included in the statistical
analyses. The number of responses
by region was as follows:
Y Africa (AFR) – 10
Y Eastern Mediterranean and
Middle East (EMME) – 3
Y Europe (EUR) – 34
Y North America (NA) – 13
Y South and Central
America (SACA) – 10
Y South-East Asia (SEA) – 3
Y Western Pacific (WP) – 8.
In order to allow inter-regional
comparisons, some of the costs
given below are presented
after adjustment for GNP.
September 2004 Volume 49 Issue 3
 Health Delivery
Figure 1: Main reasons for unavailability of insulin in the different IDF regions
Insulin and insulin syringes
Availability and accessibility
Insulin and insulin syringes were
accessible to all people with diabetes
in only 60% of the countries that
responded to the survey. This
percentage varied from 11% in
Figure 2: Cost of different types of insulin in relation to the Gross National Product
(in USD)
September 2004 Volume 49 Issue 3
AFR to 100% in EMME; 33%
in SEA, 45% in NA and SACA,
63% in WP, and 85% in EUR.
According to the survey results,
the principal reasons for the
lack of access to insulin and
syringes were: unavailability
26
or cost (Figure 1), transportation
problems, and a low supply nationally.
Disparities existed between the
availability of different insulins in
terms of concentration. For example,
while only 100 units/ml insulin was
available in NA, in some countries
in AFR, EMME and WP both 40 and
100 units/ml insulins were available.
Some people with diabetes have
serious problems matching the
insulin strength with the appropriate
syringes in regions where two or more
concentrations of insulin were available.
Animal insulin was still in use in 12%
of the countries in EUR; and 100%
of the countries in NA and WP.
Cost of insulin and insulin syringes
The average price of a 10 ml vial of
human insulin varied from 4.5 USD in
EMME to 17.0 USD in SACA and NA;
a 10 ml vial cost 9.0 USD in SEA and
WP, and 15.0 USD in Africa and Europe.
Taxes were included in the price of
insulin in a number of the countries in
each region, except those in EMME.
Figure 2 shows the cost of human
insulin compared to animal insulin
within the different IDF regions
adjusted by the GNP of each country.
As expected, the highest costs for
all types of insulin were found in
AFR and EMME; and the lowest cost
in WP and EUR. In many countries
throughout the IDF regions, human
insulin was reported as more
expensive than animal insulin.
A pack of 100 insulin syringes was
around the same price in AFR and SEA
– two to ten times more expensive
 Health Delivery

than in the other IDF regions. In
42% of countries, some people
with diabetes were unable to
obtain insulin and insulin syringes
because they could not afford them.
This figure was 80% for Africa.
Other diabetes supplies
In 25% of the countries in AFR, NA,
SACA and WP, 25-50% of people
with diabetes were not monitoring
their blood glucose at all. In 90%
of the countries in Africa, and 70%
of those in SEA and SACA, self-
monitoring of blood glucose was
rarely carried out mainly due to
the high cost to the user of test
materials. In 50% of the countries
in Europe and SACA, the poor
level (or complete lack) of diabetes
education was reported as a road
block to effective self-monitoring.
Summary and conclusions
The response rate was variable
between the IDF regions – particularly
in some of the poorest regions – and
it was not possible to verify the
responses. The survey findings suggest
trends and major issues, rather than
rigorous epidemiological findings.
The major findings are that:
Y Most people in most economically
developing countries do not
appear able to access insulin
because they cannot afford it
Y Blood glucose test strips appear
to be even less accessible than
insulin for the same reason
Y Animal-sourced insulin is
considerably cheaper in those
countries where both human
and animal insulins are available
Y Urine testing strips – which
provide a viable testing method
In many countries throughout the
world, insulin and other essential
diabetes supplies are not subsidized
by government, insurance or other
arrangements. It is hoped that the
findings of this survey will provide
useful supporting information for those
working to improve the situation for
the majority of people with diabetes
in these countries with regard to
access to essential medical supplies.
ִ Ron Raab, Léopold Fezeu,
Jean-Claude Mbanya
Ron Raab is an IDF Vice-President and
a member of the IDF Task Force on
Insulin, Test Strips and Other Diabetes
Supplies. He is President of Insulin for Life
Australia (http://go.to/insulinforlife).

(
In the African and in the absence of affordable
Léopold Fezeu is Research Associate of
South-East Asian glucose testing – are significantly
the Health of Population in Transition
regions the price of more accessible because they
Research Group, Cameroon, and

)
a pack of 100 insulin
syringes was two to
ten times higher than
in the other regions.
The average prices of blood glucose
meters and glucose tests strips in
relation to GNP were lowest in
WP, NA and EUR. Taking these
regions as reference, the average
prices of blood glucose meters
and 50 blood glucose test strips
were respectively ten times and
15 times higher in AFR, four and
five times higher in SEA and EMME;
and two times higher in SACA.
Furthermore, the average price
of 100 urine test strips followed
approximately the same trends.
are more easily affordable.
a member of the Association des
The use of urine test strips
Epidémiologistes de Langue Française.
may be decreasing without a
commensurate increase in the
Jean-Claude Mbanya is an IDF Vice-
use of blood glucose testing strips
President and a member of the
Y Although according to the WHO
IDF Board of Management. He is
essential drugs guidelines there
Professor of Endocrinology at the
should be no taxes on insulin,
Faculty of Medicine and Biomedical
taxation remains a significant
Sciences in Yaoundé, Cameroon.
factor in the pricing of insulin
(and other diabetes supplies) in
a significant number of countries
The detailed survey results are published
Y In many countries, insulin in vial
in the IDF Diabetes Atlas Second Edition,
forms is significantly cheaper
available through www.idf.org.
than the same type of insulin
in pen-fill cartridge form. The
availability of insulin in vial
form should be maintained in
economically developing countries.

27
September 2004 Volume 49 Issue 3
 Health Delivery

How to procure insulin in times of emergency

ִ IDF Task Force on Insulin, Test Strips and Other Diabetes Supplies

As so often is the case, the wars, floods

and economic crises of recent decades have
impacted most dramatically and negatively
on the very people who are least able to
defend themselves. People with diabetes
in an area affected by military conflict
or natural disaster face added hardship
compared to people who do not suffer the
condition: acquiring the diabetes supplies
they need to survive turns into a daily
struggle. The Task Force on Insulin, Test
Strips and Other Diabetes Supplies of the
International Diabetes Federation (IDF)
was set up to facilitate the delivery to those
most in need of insulin and other diabetes
supplies in times of extreme hardship.
© dpa

>>
In 2002, the people of Goma, Democratic Republic of Congo suffered the consequences of a volcanic
eruption. The IDF Task Force on Insulin, Test Strips and Other Diabetes Supplies (at that time called the
Task Force on Insulin) worked with IDF–Africa and Insulin for Life to transport essential diabetes supplies to
around 400 people with diabetes in the area. The Task Force has on several occasions assisted IDF Member
Associations in procuring insulin and diabetes supplies for people with diabetes in disaster areas.

We collaborate with the manufacturers of insulin and diabetes supplies and other not-for-profit organizations –
as was the case in Goma – to distribute emergency supplies in situations of acute need. Guidelines have been
developed to guide Member Associations through the process for procuring these supplies should an
emergency situation arise in their area.

28
September 2004 Volume 49 Issue 3
 Health Delivery

Guidelines for the procurement of insulin and other diabetes supplies in case of emergency

S Contact the corresponding IDF Regional Office immediately

S Provide the Regional Office with the following:

U details of location(s) where acute shortages have occurred
U a description of the current situation
U estimate(s) of the number of people with diabetes affected
U details of any action already taken by the local association(s)
U required amounts (approximately) of insulin, and other diabetes supplies
U a description of methods to be used for the distribution of these supplies
U any other information that would help the procurement of emergency supplies

S Give clear details for the delivery of the diabetes supplies:

U name of contact person(s)
U name of organization
U delivery address – street name and number, name of village/town/city, postal code, country
U it is important to give a full postal address – not a Post Office box number
U e-mail, telephone and fax numbers of the contact person(s)

S Upon delivery of the supplies, please inform the Regional Office of:
U the supplies received (insulin, test strips, meters etc)
U the number of items received
U the sender (companies and/or organizations)

S Keep a record of all of the following information:

U name of the person who received the supplies
U place of delivery – street name and number, name of village/town/city, postal code, country
U the supplies received (insulin, test strips, meters etc)
U the number of items received
U the sender (companies and/or organizations)

The Regional Office will inform the Task Force on Insulin, Test Strips and Other Diabetes
Supplies of the request for assistance to obtain emergency supplies. The Task Force will then
contact the relevant companies and non-profit organizations to request aid. We will work
with the Regional Office and will inform Member Associations of the actions taken.

In case of any doubts or queries, please write to Jean-Claude Mbanya (jean-claude@idf.org)

or Delice Gan (delice@idf.org).

29
September 2004 Volume 49 Issue 3
 Health Delivery

The impact of low health literacy

on diabetes outcomes
ִ Lisa D Chew

According to the 1993 US National Adult Literacy Survey, far exceed many people’s reading
abilities. Compared to people
approximately 90 million people in the USA have deficiencies
with adequate levels of literacy,
in reading or computational skills that prevent them from those with low health literacy have
been shown to have significantly
fully participating in normal daily activities – such as reading
worse health outcomes; poorer
a bus schedule or entering background information on an knowledge about their health
application form. Although the Survey did not evaluate the conditions; lower use of preventative
services; higher rates of non-
ability to read and comprehend health-related materials, adherence to medication regimens;
results from this survey raised concern about whether people’s increased risk of hospitalization;
and lower health status.
reading abilities were adequate to function in a health-

( )
care environment. In this article – which makes particular Approximately a
third of the people
reference to the status of care in the USA – Lisa Chew reports
in the USA cannot
on the impact of poor health literacy on diabetes care, and read and understand
makes suggestions for improving communication between basic health-
related materials.
health providers and people with diabetes.
Health literacy and
>> diabetes outcomes
Diabetes is a leading cause of
Health literacy has been defined as care at one public hospital in the death and disability in the USA.
“the degree to which individuals USA, it was reported that up to Preventative care practices – such
have the capacity to obtain, process, 38% have low health literacy.2 as self-monitoring of blood sugar
and understand the basic health Low health literacy is especially (glucose), routine foot care, and
information and services needed to common among people who have eye examinations – can help to
make appropriate health decisions.”1 low educational attainment, older improve health status, prevent
Approximately a third of the people in people, and ethnic minorities. diabetes complications, and reduce
the USA cannot read and understand mortality among people with the
basic health-related materials and Despite the high prevalence of this condition. Although the majority of
therefore have low health literacy. disability, health-related materials people with diabetes in the USA
Among people with diabetes receiving are often written at levels that are followed closely by health-care

30
September 2004 Volume 49 Issue 3

People with diabetes with
low health literacy may not
develop the necessary skills
and knowledge to manage
their condition.
professionals, they are often asked to
perform complex self-management
activities, such as following a
complicated medication regimen and
monitoring their blood sugar levels.
Effective communication between
people with diabetes and health
professionals has been linked to
improvements in self-care and clinical
outcomes. However, low health
literacy may impair communication
between those with the condition
and their health-care providers.
Confusing communication can arise
from a combination of the terminology
often used by health-care providers,
insufficient comprehension of health
vocabulary among people with low
health literacy, their limited health
knowledge, and an impaired ability to
integrate new information. As a result,
people with diabetes with low health
literacy may feel overwhelmed by the
information about their illness and may
not develop the necessary skills and
knowledge to manage their condition.
Recent studies
Low health literacy has been
associated with poor diabetes
knowledge, poor glucose control,
and an elevated risk of diabetes
eye damage (retinopathy). In a study
of 408 adults with Type 2 diabetes,
those with low health literacy were
less likely to achieve optimal glucose
control and more likely to report
having retinopathy than a group of
more health-literate people.2
Moreover, studies have demonstrated
that among people with diabetes,
those with low health literacy scored
lower on diabetes knowledge tests.
For example, only 38% of people
with low health literacy knew the
signs and symptoms of low blood
sugar, compared to 73% of people
with adequate health literacy.3
Some similar results are reported from
India – see article by Anil Kapur and
colleagues in this issue of Diabetes Voice.
Another study attempted to look at
the communication problems faced by
31
Health Delivery
people with diabetes when interacting
with their health-care provider. People
with diabetes who had low health
literacy were more likely to report that
their physician did not clearly explain
the implications of their condition or
adequately describe the necessary
steps for the successful management of
their diabetes. This study implies that
people with low health literacy may
have limitations not only in reading
but also with oral communication.4
Identifying people with
low health literacy
It is difficulty to identify people
with low health literacy; often,
physical appearance offers no clues.
In addition, because of the shame
associated with low literacy, many
people with low health literacy
are often able to successfully hide
this limitation from others.
September 2004 Volume 49 Issue 3
 Health Delivery
Figure 1: Strategies for health-care providers to communicate clearly with people
with low health literacy.
Although health carers often attempt
to assess a person’s health literacy
by asking about the level of schooling
completed, the association between
educational attainment and health
literacy skills is poor. Therefore, it
is not possible to predict a person’s
health literacy level by asking
about their educational level.
In the USA, instruments to assess
health literacy such as the Rapid
Estimate of Adult Literacy in Medicine
(REALM) and the Short Test of
Functional Health Literacy in Adults
(STOFHLA) can be used to identify
people with low health literacy.
However, the literature does not
support the use of these instruments
unless health-care providers are
willing to tailor communication and
health education to the needs of
people with low health literacy who
are identified through testing.5
Recommendations and
future actions
So far, most of the solutions to the
problem of health literacy have
focussed on improving the readability
of written documents or replacing
September 2004 Volume 49 Issue 3
printed materials with other types of
health communication. Using visual
aids and computer-based multimedia
as alternatives to printed materials
may improve communication with
people with low health literacy.
(The value of health
literacy assessment
tools is limited unless
health-care providers
are willing to tailor
)
communication to
people identified with
low health literacy.
In addition, various sources offer
advice about how physicians and
other health-care providers can
communicate more clearly with
people with low health literacy
– such as ‘Lessons and Tips for
Addressing Health Literacy Issues
in a Medical Setting’, which is
available at the website of the
Harvard School of Public Health
(Figure 1).6
These efforts will lead to helpful
changes in the health-care
experience of people with low health
32
literacy. However, additional research
is needed to further understand the
impact of this disability on health
outcomes; identify optimal methods
for communicating with people who
have low health literacy; and develop
effective interventions to improve the
health and health care of people with
diabetes who have low health literacy.
ִ Lisa D Chew
Lisa Chew is a member of faculty in the
Health Services Research and Development
Center of Excellence at the VA Puget Sound
Health Care System, Seattle, USA and
in the Department of Medicine, Division
of General Internal Medicine at the
University of Washington, Seattle, USA.
References
1 Healthy People 2010: Understanding and
Improving Health. 2nd ed. Washington DC. US
Government Printing Office: US Department of
Health and Human Services; 2000. (Available
online at: www.healthypeople.gov/Publications)
2 Schillinger D, Grumbach K, Piette J, Wang F,
Osmond D, Daher C, Palacios J, Sullivan GD,
Bindman AB. Association of health literacy
with diabetes outcomes. JAMA 2002; 288:
475-82.
3 Williams MV, Baker DW, Parker RM, Nurss JR.
Relationship of functional health literacy to
patients‘ knowledge of their chronic disease.
A study of patients with hypertension and
diabetes. Arch Intern Med 1998; 158: 166-72.
4 Schillinger D, Bindman A, Wang F, Stewart A,
Piette J. Functional health literacy and the
quality of physician-patient communication
among diabetes patients. Patient Educ Couns
2004; 52: 315-23.
5 Davis TC, Michielutte R, Askov EN, Williams MV,
Weiss BD. Practical assessment of adult literacy
in health care. Health Educ Behav 1998; 25:
613-24.
6 Ebeling S. Lessons and Tips for Addressing
Health Literacy Issues in a Medical Setting.
Harvard School of Public Health: Health
Literacy Website. 2003. (Available online at:
www.hsph.harvard.edu/healthliteracy/insights.
html)
 Future Directions

New treatments for diabetes:

generating new insulin-producing cells
ִ Denise L Faustman

A new generation of treatments for Type 1 diabetes is likely to Y robust – provide a high fraction
of cells that give rise to beta-islet
come from within our own bodies. We know that a wide range
cells rather than other cell types
of cell types have the ability to regenerate. Although some of Y stable – remain a beta-cell of
these cells are found outside the pancreas, their regenerative the islet, not transforming into
a cancer cell or other cell type
capacity can be harnessed to replenish the insulin-producing Y durable – maintain the production
islet cells in the pancreas that are destroyed in diabetes. In this insulin over long periods
Y functional – induce normalization
article, Denise Faustman looks at the potential benefits and of blood sugar levels.
pitfalls of four biologically based therapies, all of which take
Stem cells from embryos
advantage of the body’s own capacity for healing and renewal.
Embryonic stem cells are taken
from fertilized human eggs at a very
>> early stage, 4-5 days after conception
when the embryo is made up of about
The media has focussed its spotlight insulin-producing beta cells in the 150 cells. At this stage – known as
on the potential for embryonic stem pancreas. Even if the immune attack the blastocyst stage – the embryo
cells to cure Type 1 diabetes (see cannot be altogether stopped in consists of a sphere of cells
News in Brief in this issue of Diabetes Type 1 diabetes, it is hoped these around a fluid-containing core with
Voice). Far from this spotlight and new therapies might also work in a cluster of cells at one end.
further along the research pipeline, the treatment of Type 2 diabetes.
there are also a number of other These cells have two key qualities:

promising biologically based therapies.
The new generation of therapies
fall into four general categories:
Y stem cells from embryos
Y stem cells from adult humans
Y growth factors
Y spontaneous regeneration.
Type 1 diabetes is caused by the
body’s immune system attacking the
( )
It is hoped the new
generation of therapies
might work in the
treatment of both Type 1
and Type 2 diabetes.
When considering the benefits of
these new therapies, it should be
remembered that to be effective,
any cellular therapy – whether
stem-cell or not – should be:
they can divide indefinitely and they
can change into a huge variety of
cell types, such as brain, blood, or
pancreatic cells. This is what occurs
in a woman’s uterus as a fetus
develops. In the diabetes field, it was
claimed in one study that embryonic
stem cells could be coaxed into
forming insulin-secreting beta-cells.
However, several other studies have
failed to confirm these findings.

34
September 2004 Volume 49 Issue 3

While the potential for embryonic
stem cells to form whole organisms
or multiple lineages cannot be
denied, the research is still only at
a very early stage. We have yet to
confirm that stable cell lines can be
produced. A fundamental problem
is the instability of embryonic stem
cells in culture. Because embryonic
stem cells have the capacity to
proliferate and to differentiate, they
also have the potential to turn into
highly undesirable cells. Research
has shown that embryonic stem
cells can become tumour cells.1
( )
Stem cells have the
potential to turn
into tumour cells.
If the embryonic stem cells are
able to avoid that outcome, they
must continue indefinitely to retain
their identity as beta-cells that
regulate the secretion of insulin.
Stem cells from adults
Research with adult stem cells is
more advanced. These cells are
inherently more stable than embryonic
stem cells, but they too present a
number of hurdles which must be
overcome if they are to be used as
effective treatments for diabetes.
The term ‘adult’ is somewhat
misleading. Adult stem cells come from
differentiated (adult) tissue found in a
person of any age – a child, adolescent,
or adult. While these cells cannot form
whole organisms or all types of tissues
and cells, they do have the potential to
mature into a number of different cell
types. For example, a blood-producing
(‘haematopoietic’) adult stem cell taken
from the blood or bone marrow can
become a red blood cell or several
types of white blood cells. Apart from
the pancreas, there are at least ten
known tissues in the human body
which contain adult stem cells, including
the lung, skin, intestine and inner ear.2
The application of adult stem-cell
research is underway in animal models
of Type 1 diabetes. At least seven
published studies over the past eight
years have produced different types
of adult islet stem cells – potentially
capable of producing insulin – in
animals or humans. Research is most
advanced with blood-forming
stem cells from bone marrow.
Blood-forming stem cells, in addition to
producing various blood cells, may form
small parts of adult organs including
the brain, heart, or gut. Moreover,
it is claimed that the bone marrow
contains other kinds of stem cells;
these cells may directly or indirectly
help in the generation of islet cells.
( )
The bone marrow
contains stem cells
which may directly or
indirectly benefit the
generation of islet cells.
The transformation of adult blood-
producing stem cells into insulin-
producing cells has drawbacks. The
blood-forming stem cells may not be
robust enough: an insufficient fraction
of harvested cells can be matured into
islet cells. It is claimed that blood-
forming stem cells can help to facilitate
islet-cell regeneration without directly
becoming islet cells. However, it might
be impossible to harvest enough of
35
Future Directions
these specific bone-marrow stem cells
to produce sufficient insulin to change
the course of diabetes and continue
producing insulin over many years.
Spleen cells as the source
of adult stem cells
Until recently, the spleen was
considered an unlikely source of
adult stem cells. The spleen was
thought to hold only a reservoir
of a particular kind of white blood
cell, the lymphocyte. Now however,
several laboratories – including my
own – that are working with animal
models of Type 1 diabetes and
studying normal islet development
in mice have found a possible role
for spleen cells in the formation of
islet cells (reported in News in Brief
in previous issues of Diabetes Voice).
Furthermore, after being injected into
the blood stream, stem cells of the
spleen are able to find their way to the
pancreas. We demonstrated that these
newly formed islet cells are durable and
functional and they continue to secrete
insulin throughout adulthood.3 Thus
they appear to fulfil two of the criteria
listed above: durability and functionality.
Whether this new population of adult
stem cells exists in humans remains
unknown. And whether these new adult
stem cells play a role in the normal
cell renewal of islets in the pancreas
or only play a role in islet regeneration
during or after disease is also unknown.
The research is in the early stages.
No one recommends that spleen cell
transplants are ready for clinical trials.
The key problem is the prevention
of the body’s immune attack on
September 2004 Volume 49 Issue 3
 Future Directions
islet cells. But if this major obstacle
can be surmounted, the use of
adult stem cells from the spleen to
regenerate islets and produce insulin
will become a realistic option.
Growth factors
Research in both animals and humans
now supports an entirely different
approach to islet cell regeneration,
namely the purification of natural
growth factors and the use of these
to stimulate the regeneration of islet
cells. This line of research proposes
the use of growth factors as drugs to
cajole stem cells residing within the
diseased pancreas or elsewhere in the
body to mature into insulin-secreting
islet cells. At least five different growth
factors are candidates for promoting
islet cell regeneration. The use of one
of these (Exendin-4 – see article by
El-Ouaghlidi and Nauck in the
June 2004 issue of Diabetes
Voice) has progressed to human
clinical trials – and many more
are being identified in research.
Growth factors avoid transplantation
of tissues and only affect growth
and maturation of cells. However,
over time, they might cause
tumours or exhaust the supply
of stem cells within the pancreas.
This represents a risk particularly
in Type 1 diabetes, where the
autoimmune attack appears
to be stimulated by a new
supply of islet targets.
Spontaneous regeneration
Let us imagine a therapy that can
regenerate islets within the body
without the use of drugs or transplants.
There is growing evidence that in
September 2004 Volume 49 Issue 3
Type 1 diabetes, islet cells are
continually replenished – even in
adult life – both from populations
of adult stem cells (in the pancreas
or perhaps the spleen), and by cell
division of existing beta-cells.4
In animal models researchers have
shown that, when the underlying
autoimmune disease is eliminated,
there is a very brisk renewal of
islets in the pancreas – and these
actively produce and secrete
insulin. This only occurs with tight
control of blood sugar levels.5
( )
Imagine a therapy that
can regenerate islets
without the use of
drugs and transplants.
In diabetes tight blood sugar control
is central to the prevention of
complications; the new finding suggests
another benefit of tight control may
be to set the stage for regeneration.
Indeed, research involving people
with longstanding diabetes shows the
remaining islet cells in the pancreas
trying to regenerate; they form but
then are killed by the immune system.
However, while the encouragement
of spontaneous regeneration has
many advantages, the natural time
course for regeneration may be too
long or not robust enough to restore
blood sugar to normal levels.
Conclusions
Stem-cell therapies and other
biologically based treatments hold
tremendous potential for curing
Type 1 diabetes, provided that the
underlying immune assault can be kept
at bay. The field of cellular therapies is
thriving, thanks to years of progress
36
with embryonic stem cells and a wide
variety of adult stem cells. A major
landmark has been achieved with adult
stem cells harvested from the spleen,
an organ not previously known to
contain stem cells for making islets. The
use of growth factors and enhancement
of spontaneous regeneration also
hold immense promise for the new
generation of treatments for diabetes.
ִ Denise L Faustmann
Denise L Faustman is an Associate
Professor of Medicine at Harvard Medical
School and Director of the Immunobiology
Laboratories at Massachusetts General
Hospital, Charlestown, USA.
References
1 Draper JS, Smith K, Gokhale P, et al. Recurrent
gain of chromosomes 17q and 12 in cultured
human embryonic stem cells. Nat Biotechnol
2004; 22: 53-4.
2 Anderson DJ, Gage FH and Weissman IL. Can
stem cells cross lineage boundaries? Nat Med
2001; 7: 393-5.
3 Kodama S, Kuhtreiber W, Fujimura S, Dale EA
and Faustman DL. Islet regeneration during the
reversal of autoimmune diabetes in NOD mice.
Science 2003; 302: 1223-1227.
4 Dor Y, Brown J, Martinez OI and Melton DA.
Adult pancreatic beta-cells are formed by
self-duplication rather than stem-cell
differentiation. Nature 2004; 429: 41-6.
5 Ryu S, Kodama S, Ryu K, Schoenfeld DA
and Faustman DL. Reversal of established
autoimmune diabetes by restoration of
endogenous beta cell function. J Clin Invest
2001; 108: 63-72.
 Diabetes in Society

The nutrition transition and

the global shift towards obesity
ִ Barry M Popkin

Populations worldwide are becoming more corpulent. The levels animal fats in countries in the lowest
75% of per capita income distribution
of overweight and obesity in many low- to middle-income – all of which have annual incomes
countries such as Mexico, Egypt, and South Africa rival that of below 5800 USD per person. While
the change in the prices, supply, and
the country used as the benchmark for this problem, the USA.
consumption of edible vegetable fat
Moreover, the rates of increase in obesity in these countries affects rich and poor countries equally,
are double to quadruple those in the USA. In this article, Barry the net impact is relatively much
greater on low-income countries.
Popkin reports on the impact of important shifts in nutritional
patterns and the trend towards inactivity.

>> ( The westernization

of diets begins with
major increases in the

Dietary shifts
The diet of poor people in rural or
urban settings in Asia during the 1960s
continues to be associated with the
increased consumption of animal fats.
However, the nutrition transition in Caloric sweetener
)
domestic production
and imports of vegetable
oils and oil seeds.

was simple and rather monotonous:
rice with a small amount of vegetables,
beans or fish. Today, their eating
is transformed. It is common for
people in these settings to regularly
consume complex meals at any
number of away-from-home food
outlets – western or indigenous. The
overall composition of diets in the
developing world is shifting rapidly,
particularly with respect to fat, caloric
sweeteners, and animal-source foods.
Edible oil
It is commonly held that the
westernization of the global diet
developing countries typically begins
with major increases in the domestic
production and imports of oil seeds
and vegetable oils; rather than meat
and milk. Principal vegetable oils
include soybean, sunflower, rapeseed,
palm, and groundnut oil. With the
exception of groundnut oil, the global
availability of each approximately
tripled between 1961 and 1990.
This dramatic dietary change resulted
principally from a major increase in
the consumption of vegetable fats. In
1990, these fats accounted for a greater
proportion of dietary energy than did
Sugar (sucrose) is the world’s
predominant sweetener. For this article,
however, due to the wide range of non-
sugar products in use today, the term
‘caloric sweetener’ is used in place of
‘added sugar’. High-fructose corn syrup
is a prime example: this sweetener is
used in all non-artificially sweetened
mass-produced soft drinks in the USA.
The overall trend shows a large
increase in caloric sweeteners
consumed throughout the world.
On average, each person consumed
306 kcal per day in 2000 – about
30% more than in 1962; caloric

38
September 2004 Volume 49 Issue 3

sweeteners also accounted for a
larger share of both the total energy
and total carbohydrates consumed.
Animal-source foods
The revolution in animal-source foods
refers to the increase in demand and
production of meat, fish, and milk.
Most of this increased demand is
occurring in low-income countries.
Developing countries will produce
63% of the meat and 50% of the milk
produced in 2020. Transformation
of the grain market to supply animal
feed is a global food activity. This
also leads to: the degradation of
natural resources; rapid increases
in imports of animal-feed grain; the
rapid concentration of production and
consumption; significant social changes.
( Transformation of
the grain markets
for animal feed leads
)
to the degradation
of natural resources,
and significant
social changes.
Critical reductions in
physical activity
Around the world there have been
drastic shifts in physical activity from
people using simple equipment to
work the land, to people working
at computers in an office. Indeed,
there are several changes in physical
activity which are linked and occurring
together. One is a shift from high-
energy-expenditure activities such
as farming, mining, and forestry,
toward the service sector and
sedentary activities such as sitting
in front of a computer terminal.
Reduced energy expenditure within
© dpa
an occupation constitutes a further
change, linked to altered modes
of transportation and patterns of
low activity during leisure hours.
While the proportion of adults
participating in vigorous physical
activity has decreased, in rural areas
there has been a shift for some adults
toward increased physical activity
linked to multiple employment and
more intensive effort. For example
there has been a shift toward the
involvement of a larger proportion
of rural women in more energy-
intensive work. However, there are
also instances where light effort is
increasing. In contrast, there is a small
decrease in the proportion of rural
men engaged in light-effort work.
In China, 14% of households acquired
a motorized vehicle between 1989
and 1997; this doubled the proportion
of overweight in men with these
vehicles. Television ownership has risen
39
Diabetes in Society
We have seen large increases in
caloric sweeteners consumed
throughout the world.
dramatically in China, leading to greater
inactivity during leisure time. Today,
more than 97% of Chinese households
own at least one television set.
Resultant changes in obesity
The interaction of dietary shifts
with changes in physical activity has
significant consequences for obesity,
diabetes, and mortality – the burden
of which lies most heavily on the poor.
In a series of studies, we have shown
that in countries with a national annual
per capita income of 2500 USD or
higher, there is a greater likelihood of
increased rates of overweight among
the poor, lower-educated households
compared to the higher social
classes. This remarkable worldwide
development has transformed obesity
into a major problem of poverty.
September 2004 Volume 49 Issue 3
 Diabetes in Society
Figure 1: Obesity trends among adults in selected developing countries
(annual percentage point increase in prevalence). GNP is given in USD.
Figure 1 shows the speed with which
overweight and obesity have emerged
as a major public health problem in
a number of low- to middle-income
countries. The annual increase in the
prevalence of overweight and obesity
is about 0.25-0.50% of all adults in the
USA and Western European countries;
however, the rates of change are two to
five times greater in Asia, North Africa,
and Latin America than in the USA.
What can be done?
The recent debates about the World
Health Organization’s strategy on diet,
physical activity and health represent
the early rounds of a struggle for
the world to identify these as major
problems and to take action. Solutions
in the system of food production,
distribution and consumption, and
in the physical environment are
important factors for consideration.
September 2004 Volume 49 Issue 3
It is critical that effective investments
and social regulations are found which
will enhance the components of
lifestyle, reduce obesity and diabetes,
and provide for a healthier population.
In particular, it is important to focus
on changes that affect poor people,
who are least able to incur the costs
of the resultant health burden.
The food industry in general has yet
to see that its co-operation is critical
to improving global health – through
the identification of effective society-
level measures to increase the relative
intake levels of fruit, vegetables and
high-fibre products, replacing the
intake of caloric sweeteners and fat.
Similar potential exists in the
physical environment in order to
enhance physical activity. There
is a growing body of knowledge
40
that points to the role of a spread
of environmental factors, ranging
from the pedestrian-friendly urban
planning and the availability of safe
routes for walking or cycling, to the
organization and layout of buildings.
( )
The food industry has
yet to see that its
co-operation is
critical to improving
global health.
Increased opportunities for physical
activity (public facilities such as parks
and recreation centres); and enhanced
transport options (cycle paths, public
transport, road connectivity) will
increase levels of physical activity and
decrease the prevalence of overweight.
Conversely, the constraints to physical
activity provoked by the results of
poorly considered urban and social
planning – such as street crime
and air pollution – will continue to
reduce physical activity and increase
the prevalence of overweight.
ִ Barry M Popkin
Barry M Popkin is Professor of Nutrition
at the University of North Carolina,
Chapel Hill, NC, USA, where he heads the
Division of Nutrition Epidemiology in
the School of Public Health. He serves on
several scientific advisory organizations
and is Chair of the Nutrition Transition
Committee for the International
Union for the Nutritional Sciences.
 IDF Publications Order Form
Please find below a list of IDF publications. Once completed, you can return it by fax at +32-2-5385114
or by e-mail to merry@idf.org. These publications can also be ordered via our online bookshop at
www.idf.org/bookshop. All prices are in EUR and are exclusive of postage and packaging. Shipping costs
will be calculated based on weight and destination. The total cost will be communicated to you upon
receipt of your order. Thank you.

>>
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Diabetes Atlas second edition (2003, 360 pp) EN 90.00

Diabetes Atlas second edition Executive Summary (2003, 56 pp)
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Diabetes and Obesity: Time to Act (2004, 60 pp) EN, FR, ES * 35.00
Diabetes and Kidney Disease: Time to Act (2003, 65 pp) EN, FR, ES * 35.00
Cost-effective Approaches to Diabetes Care and Prevention (2003, 36 pp) EN 15.00
Global Strategic Plan to Raise Awareness of Diabetes (2003, 20 pp) EN free
Diabetes Voice (Special Issues):
Putting People at the Centre of Care (2004, 44 pp) EN, FR, ES * 12.00
Prevention (2003, 56 pp) EN, FR, ES * 12.00
The Kidney Issue (2003, 44 pp) EN, FR, ES * 12.00
International Standards for Diabetes Education (2003, 24 pp) EN free
Guide for Guidelines (2003, 35 pp) EN free
International Curriculum for Diabetes Health Professional Education
(2002, 112 pp) EN free
Diabetes and Cardiovascular Disease: Time to Act (2001, 90 pp) EN, FR, ES * 25.00
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 Diabetes in Society

Reviving the St Vincent

Declaration
ִ Michael Hall, Itamar Raz, Lex Herrebrugh

On the occasion of the signing of the St Vincent Declaration in data, a pre-requisite for measuring
progress, proved problematic,
St Vincent, Italy in October 1989, representatives of diabetes
as did the existence of diverse
organizations and government health departments from approaches to drawing up plans for
national diabetes programmes.
European countries agreed unanimously on key health objectives
for people with diabetes. Five-year targets were incorporated In order to revive the momentum
within the framework of the Declaration, which effectively that drove the St Vincent Declaration,
the Board has taken some concrete
recognized that diabetes outcomes were measurable; European steps, including the appointment of
nations were thus challenged to improve standards of care. a St Vincent Declaration manager
funded by grants from the Dutch
In this article, representatives of the European Region of the
Diabetes Association and Novo
International Diabetes Federation (IDF-Europe) report on Nordisk. The first objective of the
manager (supported by the Board of
achievements in European diabetes care as a result of the
IDF-Europe) was to formerly assess
St Vincent Declaration, and look forward to legislative measures the situation among IDF-Europe’s
to ensure its implementation at European level. Member Associations regarding the
development and implementation
>> of national diabetes programmes.

In 2003 the Board of IDF-Europe
concluded that the consensus
behind the successful signing of the
St Vincent Declaration had not
been lost. However, a number of
the objectives agreed upon in 1989
were either never reached or were
by-passed as new initiatives were
undertaken; most of the latter,
while they were not included in the
original text, were implied by the
Declaration. This was the case of
the call for the implementation of
national diabetes programmes.
Furthermore, the Board recognized the
difficulties experienced by European
states in executing a number of the
recommendations of the Declaration.
In particular determining baseline
( )
European states
experienced difficulties
in executing a number
of the recommendations
of the St Vincent
Declaration.
In order to do this, a short
questionnaire was sent to all
IDF-Europe Member Associations in
December 2003. By the end of April

42
September 2004 Volume 49 Issue 3
 Diabetes in Society

2004, the European office had received have a voice in these working groups. topics such as prevention of diabetes,
33 responses from 31 different A wide variety of topics are awareness, access to medication, and
countries. We provide a brief round- covered in the existing European psychological aspects of having diabetes
up of the survey findings below. national diabetes programmes. could be addressed more systematically.

The IDF-Europe survey
Of the 33 respondents, 17 reported
that their country has a national
diabetes programme. The first of
the national diabetes programmes
was initiated in 1989; all the other
programmes began around the
mid-1990s or later. In all but one
of those countries without a
diabetes programme, work is under
way to establish a national plan
for diabetes action – through the
initiative of a diabetes association
and/or the pharmaceutical industry
or under the supervision of the
government. In a number of
countries, existing programmes have
been cancelled due to the lack of
resources or political instability.
The principal areas covered are:
Y diabetes care and services
Y diabetes complications
Y early detection
Y diabetes education
Y information systems.
Other topics are: raising awareness,
prevention, medication, psychological
and behavioural issues, research, and
evaluation of the programme. It is clear
from the results of the survey that
There was a consensus among
respondents on the key problems
relating to the preparation,
agreement and implementation of
a national diabetes programme:
Y a weak national health-
care structure
Y the lack of co-operation
between the various
stakeholders in diabetes care
Y the lack of empowerment
of people with diabetes

( National diabetes
associations are
represented in

)
inclusive working
groups to prepare and
implement national
diabetes programmes.

In most countries (17), inclusive

working groups have been established
or are in the process of being set up
to prepare and implement a diabetes
programme. Many of these groups
appear to be government-centred.
Concern was expressed that people
with diabetes may be excluded or
kept at a distance by medical and
political ‘experts’. Fortunately, in
many cases, the national diabetes
association(s) are represented and
© mauritius

43
September 2004 Volume 49 Issue 3
 Diabetes in Society
Y the excessive time between
implementing a plan and
achieving its final results
Y reductions in the health-care
resources devoted to diabetes care.
Respondents indicated further
difficulties in the implementation
of a country-wide diabetes
programme. These included:
Y the excessive focus given to the
health-care professionals compared
to the people with diabetes
Y time restraints, especially
during consultations
Y a lack of defined targets
Y overall shortage of
physicians and nurses
Y a lack of training for
nurse educators
Y the under-use of diabetes
associations – despite there
being an important source of
knowledge and influence.
The Member Associations were
asked to suggest ways in which
IDF-Europe could play an increased
role in promoting the implementation
of national diabetes programmes.
A common request was for IDF-
Europe to act as a clearing house for
the diffusion of published material,
including: a framework for such a
programme; comparative data on the
national programmes of individual
countries; and information and
training material for health carers.
It was felt that IDF-Europe should
continue to work to enhance public
awareness of the condition, and to
lobby the European Union (EU) at
parliamentary level for increased
prioritization and resources for
September 2004 Volume 49 Issue 3
diabetes. The need was also expressed European states in tackling
for IDF-Europe to offer support to more effectively the barriers
encourage and facilitate Member to achieving best practice.
Associations themselves in lobbying
the EU and their own governments. The recent statement by the EU Health
Council (in May 2004) recognizing the
Suggestions were made regarding importance of prioritizing attention to
the provision by IDF-Europe of diabetes will hopefully lead to a request
some financial support and the by the next Health Council (due at
staging of European symposia on the end of 2004) to the European
quality assurance in diabetes care. Commission for the formulation of
such a strategy. The status of this
( )
It is time to use our
knowledge of diabetes to
move from programme
recommendations
to best practice.
strategy would be advisory rather
than legislative; its existence would
enhance the ability of EU states
to achieve the recommendations
of the St Vincent Declaration.
Some conclusions
The St Vincent Declaration helped
initiate a consistent approach to the
management of diabetes. Although ִ Michael Hall, Itamar Raz,
the targets agreed in 1989 have since Lex Herrebrugh
been proved over-optimistic, these Michael Hall is a member of the Board of
served as challenges to governments IDF-Europe.
and professionals throughout Europe.
Itamar Raz is a member of the Board
The Declaration empowered of IDF-Europe and country representative
people with diabetes and diabetes for Israel.
organizations in the Region to
question health services and demand Lex Herrebrugh is Regional Manager,
better care. We believe that in too IDF-Europe.
many European countries, plans
continue to be discussed; it is
time to use the knowledge at our
disposal on the management of The text of the St Vincent Declaration
diabetes to move from programme and its objectives can be obtained from
recommendations to best practice. the European pages of the IDF website at
www.idf-europe.org.
The Board of IDF-Europe is in
agreement that the development
of a European strategy for diabetes
– including recommendations on
diabetes prevention, diagnosis and
management – would support
44
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 Diabetes in Society

Diabetes-related websites:
are they readable?
ִ Sanja Kušec

The Internet has become a useful tool that is relatively easy have been developed, and the sources
that have been used to provide
to operate. With little effort, huge amounts of information
supporting background information.
can be found about specific health conditions or health in Information should be safe and easy
general. Views and concerns about health can be shared to use, which means that it should be
presented in a language that is clear
with literally millions of other people; spreading health and appropriate for the intended users.
information to people around the world is a simple process.
HONcode of Conduct
Clearly however, there is a need to evaluate this information The Health On the Net (HON)
in order to ensure and improve its quality. There is also a Foundation makes recommendations
for presenting information on the
need to empower readers to assess the reliability of such
Internet.1 These guidelines are based
information. Sanja Kušec reports on guidelines designed to on ethical standards. In an effort
support Internet users in determining the reliability and to enhance the quality of health
information on the Internet, the
quality of the health information on the Internet. HON Foundation introduced the
HONcode of Conduct in 1996.

>>
Millions of people use the Internet to
find health information – almost half
the people in the USA and around
Quality of information
Whereas searching for and finding
health information is a simple process,
( )The quality of the
health information
available on the Internet
is questionable.

a third of Europeans – and this
proportion grows every day. Anyone
can publish information on the Internet,
regardless of their background, medical
qualifications, or intentions; however,
the reliability and quality of the health
information currently available on the
Worldwide Web is questionable.
defining and assessing the quality of this
information is more difficult. To meet
minimum requirements for quality,
information should at least be accurate
and up to date; and presented in such
a way that it is easy to understand.
Websites should also describe clearly
the methods by which health messages
The mission of HON is to guide
non-medical people and medical
practitioners to “useful and
reliable online medical and health
information.” The HONcode is a
self-regulatory, voluntary certification
system. The objective of the Code
is to hold website developers

46
September 2004 Volume 49 Issue 3

to basic ethical standards in the
presentation of information, and to
help make sure that readers always
know the source and the purpose
of the data they are reading.
The HONcode seal is seen on
websites that, according to the
criteria of the Foundation, respect
a number of ethical principles. The
HONcode seal is intended primarily
for health website publishers. It is
carried on subscribing websites and
serves as evidence that the principles
mentioned above are respected – thus
supporting Internet users in a search
for sources of reliable information.
Literacy and reading ability
Low literacy is a problem in the
wealthy developed countries such as
those in Western Europe as well as in
the low- to middle-income countries
of the developing world: almost a
quarter of the adult population in
the USA and Canada are functionally
illiterate (a reading age below that
of a ten-year-old child). An additional
25% of the population has poor
reading and comprehension skills; for
information to be widely understood
in the UK, texts should also be
written for a reading age of ten years.
While Type 2 diabetes is increasingly
present in young people from a
variety of social backgrounds, this
condition is also widely suffered by
those from mature groups or socio-
economically disadvantaged groups,
whose health literacy is often poor.
Moreover, while the reading ability
of any population varies widely, it is
generally below the level suggested
by the years of schooling completed.
© mauritius
In order to make health education
materials accessible to as many
people as possible, it is important to
grade these to be comprehensible
to people at the lower end of
the scale of reading abilities.
( )
Almost a quarter of the
adult population in the
USA and Canada have a
reading age below that
of a ten-year-old child.
Readability of health information
The term ‘readability’ refers to the
difficulty of a text – the level of reading
skills necessary to be able to read and
comprehend the text without difficulty.
The application of one of a number
of formulas is a standard method
for testing the readability of written
materials. There are over 40 different
readability formulas. These estimate the
minimum reading-age level required to
read but not necessarily fully understand
47
Diabetes in Society
a piece of text. Among the most
frequently used readability formulas are:
Y Flesch Reading Ease (FRE)
Y Flesch-Kincaid Grade Level Index
Y Simple Measure of Gobbledegook
(SMOG)
Y Gunning Fog Test.
Most of these evaluation tools calculate
the sentence length and the number of
syllables in a text, and some even take
into account the number of characters.
First created to evaluate English
language texts, they were later modified
for use with a wide range of other
languages including German, Spanish,
Chinese, Russian, and Vietnamese.
Readability of diabetes-
related websites
The word ‘diabetes’ is frequently
searched by Internet users. The
Internet search results of ‘diabetes’
show many websites displaying the
HONcode logo, which therefore
September 2004 Volume 49 Issue 3
 Diabetes in Society
© mauritius
can be recognized by non-medical
people as good-quality reliable
health websites. However, the
reliability of the websites is often
insufficient to guarantee that
important diabetes information
has been correctly received by
people with the condition.
We tried to explore the readability
of diabetes-related websites
displaying the HONcode seal.2
Ninety-nine of those websites
– written in English, and developed
by different organizations around
the world – were analyzed using the
Flesch Reading Ease (FRE) and Flesch-
Kincaid algorithms for readability.
September 2004 Volume 49 Issue 3
The FRE scores range from 0 included on diabetes websites. Both
(most difficult to read) to 100 readability and understanding can
(easiest to read). An ideal score of be improved by increased attention
60-70 is referred to as ‘standard’. to the linguistic aspects of health
Overall, the analyzed diabetes- information. Using simple vocabulary,
related websites were not easy to and avoiding medical jargon and
understand. On average, they had long complex sentences could
an FRE score of 41.7 – classifying only benefit all those concerned.
them as ‘difficult’, requiring for
comprehension around 11 years
of schooling. However, it was even
more significant that more than 70%
of the websites offered diabetes
information that is appropriate for
academic or scientific journals.
(
The reliability of a
website is often not
enough to guarantee
that important
)
diabetes information
has been correctly ִ Sanja Kušek
received by people Sanja Kušec is a translator, teacher
with the condition. and researcher in the field of health
communication. She works at the
This left only 13% of the websites Department of Educational Technology
that could be categorized placed in of the Andrija Stampar School of Public
the ‘standard’ range of difficulty for Health, University of Zagreb, Croatia.
an average person with diabetes. It Her primary field of interest is the
seems that most of the information language aspect of health information.
we viewed was either written
for physicians or extracted from
References
scientific writings, and then posted 1 Health On the Net Foundation. Available at:
on the Internet without taking into www.hon.ch/HONcode. Access verified:
10 August, 2004
account the profile of the readers.
2 Kusec S, Brborovic O, Schillinger D. Diabetes
websites accredited by the Health On the Net
Conclusion
Foundation Code of Conduct: readable or not?
Those who publish diabetes Stud Health Technol Inform 2003; 95: 655-60.
information on websites should be
aware of the reading ability of their
potential readers. Their materials
should be adapted accordingly. For
greater transparency, the reading
level of a text – and the method
used to determine this – could be
48
 Media and Events

Karachi, 2004: Diabetes in Asia

ִ Fatema Jawad

The rising prevalence of diabetes in Asia demands effective with diabetes should live or die. This
is a totally unacceptable situation.”
strategies to combat and relieve the burden to health posed by
this condition – now described as an epidemic. To this end, for Major achievements in the field of
the past 5 years the Diabetes in Asia conferences have brought insulin supply include the decision by
one of the principal pharmaceutical
together experts in diabetes-related fields, such as nutrition, companies to provide insulin to
nursing, education and endocrinology. These meetings serve to the 49 poorest countries at a cost
20% below that of the average
elevate the awareness of diabetes in Asia, promote preventative market price. A further reason for
measures, and improve diabetes care. The fifth Diabetes in Asia hope is offered by the IDF child
sponsorship programme, Life for a
conference was held in Karachi, Pakistan this year. Supported
Child with Diabetes. The objectives
by the International Diabetes Federation (IDF) and World and activities of this international
Health Organization (WHO), the conference provided a forum initiative were presented at the
conference: these are the delivery
for lectures, discussions and workshops which contributed to the of insulin, syringes, and diabetes
development of diabetes guidelines and the Karachi and Colombo management tools to underprivileged
children in low-income countries.
Declarations. Fatema Jawad reports.

>>
(
International economics,
accidents of geography,
and colonial history
The fifth Diabetes in Asia conference
was hosted in April 2004 by the
Diabetic Association of Pakistan
and WHO Collaborating Centre,
Karachi. The meeting brought
Insulin
The importance of the unrestricted
global availability of insulin – a life-
preserving medication that remains
beyond the reach of people with
)
determine whether a
person with diabetes
should live or die.

together delegates from Asian
countries such as Bangladesh,
India, and Sri Lanka, as well as
participants from countries
around the world, including
Switzerland, Tanzania, Iran, and
Australia. A round-up of the
discussions in Karachi is presented
here on a topic-by-topic basis.
diabetes in many developing
countries – was emphasized in
Karachi. In one session, the Chair
of the IDF Task Force on Insulin,
Test Strips and Other Diabetes
Supplies commented, “Even today the
accidents of geography and colonial
history, together with international
economics, determine which person
Guidelines
The combined childhood population
of the South-East Asia Region and the
Eastern Mediterranean and Middle
East Region is 618 million; around
150 000 of these young people have
Type 1 diabetes. The difficulties
faced by a child living with diabetes
are exacerbated by the social and
economic conditions in developing

49
September 2004 Volume 49 Issue 3
 Media and Events
countries. For these young people,
diabetes ketoacidosis remains the
main cause of death. This is more
frequent in countries with limited
diabetes awareness, medical expertise
and resources for health delivery;
however, it is easily preventable.
Evidence-based guidelines designed
to improve care for people with
Type 1 diabetes are now being
formally prepared in UK and
Australia and will be released this
year. Evidence-based guidelines for
Type 1 diabetes in children and
adolescents were presented and
discussed at the conference in Karachi.
Evidence-based care
A significant body of evidence exists to
prove that Type 2 diabetes is at least
in part preventable. Discussions took
place in Karachi on the major challenge
facing the diabetes community and
the health authorities of the world: to
translate this evidence into practice.
September 2004 Volume 49 Issue 3
Obstacles exist at an individual level
(people developing the condition and
health-care professionals), and at the
organizational level (the structures
put in place to facilitate care). People
with Type 2 diabetes continue to
consider it a mild condition and hence
are unwilling to change their life style;
family physicians often underestimate
the importance of impaired glucose
tolerance (IGT – see page 20 for
an explanation of the term IGT)
and lack confidence in diabetes
management; meanwhile, these primary
carers lack the necessary time and
training to communicate effectively
with the people in their care. It was
concluded that these obstacles should
be overcome through education,
empowerment and incentives.
Women
Many of the topics of regional
importance discussed at the Diabetes
in Asia conference also have a global
significance. The reasons for maternal
50
weight gain after childbirth – provoking
negative long-term diabetes-related
consequences – in urban Nepal were
explored. The principal contributing
factors were reported as excess food
intake and a lack of physical exercise
– often due to the limitations of
widely held cultural beliefs. Suggested
solutions to these barriers to health
included the promotion of health
education and awareness – coinciding
with the reported needs of women
in wealthy and poor countries alike.
Metabolic syndrome
The significance of the metabolic
syndrome to current and future
diabetes care was discussed at length.
This condition puts people at high
risk of dying from a heart attack. The
metabolic syndrome is a cluster of at
least three of a number of risk factors:
abdominal fat; high blood sugar; high
blood fat; low HDL (‘good’) cholesterol;
high blood pressure; raised urinary
albumin (protein) excretion rate.

Ketoacidosis is caused by a lack
of insulin in the blood. It requires
emergency treatment. Ketoacidosis
may occur through illness (when
insulin needs are high) or lack
of insulin injections. The body
starts using excessive amounts of
stored fat for energy, and acids
(ketones) build up in the blood. The
symptoms include nausea, vomiting,
and excess urination. This can lead
to loss of body fluids, stomach
pains, and hyperventilation. If the
person is not given replacement
fluids, insulin, and salts right
away, ketoacidosis can lead
to coma and even death.
The metabolic syndrome – which has
been called the disease of the new
millennium – has an enormous impact
on the person with the condition, their
family and the national economy.
( ) The metabolic
syndrome has been
called the disease of
the new millennium.
Asians with diabetes in Europe
Delegates from Norway focussed
on the high prevalence of diabetes
in migrant populations originating
from the Indian subcontinent. The
consumption of a high-calorie high-
fat diet and a lack of physical activity
among these groups were identified
as the key factors influencing these
disturbing figures. Problems of
integration into European societies
were reported as contributing to
the increased levels of diabetes in
first-generation immigrants, who
moved from their countries of
origin three decades ago; high
levels of obesity and illiteracy,
and linguistic difficulties are
common in the senior members
of these communities.
Compared to that of native
Norwegians, the prevalence of
diabetes in pregnant women of
Pakistani and Indian origin was also
significantly higher – 55% compared
with just 7%. With the support of
the second- and third-generation
Norwegians of Asian origin and the
co-operation of the Norwegian
health carers, the communication
gap and cultural differences
which form barriers to effective
diabetes care will be reduced.
Stress
Stress is increasingly recognized
as a common risk factor
for developing diabetes and
cardiovascular disease. Discussions
were held on the origins of stress
in intra-uterine life provoked by
under- and over-nutrition, psycho-
social problems faced by the
mother, and infections. It was
suggested that the under- and over-
nutrition of the fetus cause the
release of mediators which produce
a state of insulin insensitivity,
blood-fat abnormalities, vascular
changes, and an increased tendency
toward thrombosis (a combination
of which are common in the
metabolic syndrome). If this theory
is proven, the logical response
will be primary prevention
implemented through a healthy
pre- and post-natal environment.
51
Media and Events
Rising prevalence
WHO estimates for the prevalence of
diabetes in Asia were presented at the
conference: in 2000 this was 2.8% for
all age groups; it is projected to rise to
4.4% in 2030. These figures correspond
to an increase from 171 million to
366 million people with diabetes
worldwide, which includes an
increase of 150% in developing
countries. Massive rural-urban
migration continues to provoke
negative life-style changes in people
in low- to middle-income countries.
India, the Republic of China, Indonesia,
Japan, Pakistan and Bangladesh are
among the ten countries in the world
with the highest numbers of people
with diabetes. In Japan it is projected
that the diabetes population will
increase by 30%; while in Bangladesh
and Pakistan it will increase more
than three-fold. Globally, diabetes is
responsible for 3 million attributable
deaths per year; over one million in
Asia. Thus in Asia diabetes contributes
to 6-10% of total mortality; the
condition is more prevalent in the
35-64-year age group. Mortality is
reported to be more in females than
males. These figures are likely to be
a significant underestimate; sadly,
more realistic figures are needed.
The next Diabetes in Asia conference
will be held in Egypt in 2006.
ִ Fatema Jawad
Fatema Jawad is a Consultant
Diabetologist and Research Fellow.
She is Editor of Diabetes Digest,
bulletin of the Diabetic Association
of Pakistan, Karachi, Pakistan.
September 2004 Volume 49 Issue 3
 Calendar

November 2004 6-8 APRIL July 2005

3-6 NOVEMBER
ISPAD 2004
30th Annual Meeting of the
International Society for Pediatric
and Adolescent Diabetes
Republic of Singapore
Raffles City Convention Centre
T: +65-62972822
F: +65-62927577/62962670
ispad2004@mpgroupasia.com
14-18 NOVEMBER
NAASO 2004 Annual Scientific Meeting
Las Vegas, USA
www.naaso.org/annualmeeting04
Diabetes UK Annual Professional
Conference 2005
10-14 JULY
Glasgow, UK Diabetes and the Mediterranean Diet.
conferences@diabetesuk.org.uk/ Organized in collaboration with the American
www.endocrinology.org.uk/apc/apc2005/ Diabetes Association, Università Campus Bio-
index.html Medico di Roma, Università di Tor Vergata
and the Istituto Nazional della Nutrizione
13-16 APRIL Orvieto, Italy
1st International Congress on Prediabetes T: +39-06-22541 357
and the Metabolic Syndrome r.duesi@unicampus.it
Berlin, Germany www.diabetes.org/for-health-professionals-
T: +41-22-9080488 and-scientists/meetings/meetings.jsp
F: +41-22-7322850
prediabetes@kenes.com September 2005
www.kenes.com/prediabetes
3-7 SEPTEMBER
June 2005 7th European Congress of Endocrinology

18-20 NOVEMBER Goeteborg, Sweden

2nd Annual World Congress on the
1-4 JUNE T: +46-31-7086000
Insulin Resistance Syndrome
14th European Congress of Obesity F: +46-31-7086025
Las Vegas, USA Athens, Greece ece2005@gbg.congrex.se
T: +1-818-342-1889 www.eco2005.gr/index.html www.ece2005.com
F: +1-818-342-1538
metabolicinst@pacbell.net or 10-14 JUNE 10-15 SEPTEMBER
insulinresistance@pacbell.net 65th Annual Scientific Sessions of the ADA 41st Annual Meeting of the European
www.insulinresistance.us San Diego, USA Association for the Study of Diabetes (EASD)
ADA Athens, Greece
February 2005 1660 Duke Street T: +30-2107-297565
Alexandria VA 22314, USA F: +30-2107-7239472
T: +1-800-2323472 secretariat@easd2005athens.gr
11-13 FEBRUARY
F: +1-703-5491715 www.easd2005athens.gr
4th World Congress on Prevention of
meetings@diabetes.org
Diabetes and its Complications
Chennai, India
www.diabetes.org/meetings/default.asp November 2005
T: +91-44-25954913-15
F: +91-44-25954919 26-30 JUNE 30 NOVEMBER – 3 DECEMBER
3rd World Congress of Nephrology 2nd International Congress on Self-
ramachandran@vsnl.com
www.mvdiabetes.com/wcpd.htm Singapore Management Education for Diabetes
T: +65-6379 5261 and Other Chronic Diseases
F: +65-6 475 2077 / 6 475 6436 Rome, Italy
April 2005 admin@wcn2005.org T: +41-22-9080488
www.wcn2005.org/home.htm F: +41-22-732 2850
4-7 APRIL
tpe2005@kenes.com
24th Joint Meeting of the British
www.kenes.com/tpe2005
Endocrine Societies
Harrogate, UK
T: +44-(0)1454-642212
F: +44-(0)1454-642222
info@endocrinology.org
www.endocrinology.org./SFE/confs.htm

52
September 2004 Volume 49 Issue 3
 International Diabetes Federation

Executive Board Regions Executive Office

President Africa Luc Hendrickx, Executive Director
Pierre Lefèbvre, Belgium Chair: Kaushik Ramaiya Safo Najmabadi, Executive Assistant
Regional Manager: Nishita Ojha Alain Baute, e-Project Manager
President-Elect
Phone: +255-22-2114994 Anne Coupé, Project Co-ordinator
Martin Silink, Australia
Fax: +255-22-2113459 Delice Gan, Special Project Manager
Vice-Presidents nishita@idf.org Yohana Ibekwe, Accounts Co-ordinator
Clive Cockram, People‘s Republic of China www.idf-africa.org Tim Nolan, Editor Diabetes Voice
Nigishi Hotta, Japan Lorenzo Piemonte, Public Relations Assistant
Eastern Mediterranean
Massimo Massi-Benedetti, Italy Anne Pierson, Public Relations Manager
and Middle East
Jean-Claude Mbanya, Cameroon Marcel Pirlet, Finance Manager
Chair: Morsi Arab
Margaret McGill, Australia Catherine Regniers, Managing Editor Diabetes Voice
Regional Manager: Lolwa Hassan Al Obaidli
Valentina Ocheretenko, Ukraine Philip Riley, Communications Manager
Phone: +974-4474678
Ron Raab, Australia Merry Rivas Gonzalez, Communications Assistant
Fax: +974-4876065
Linda Siminerio, USA Victoria Rugg, Project Editor
lalobaidli@maktoob.com
Eberhard Standl, Germany Sonia Scott, Congress Assistant
www.idf-emme.org
Denis Taschuk, Canada Maguy Sicuro, Congress Manager
Brian Wentzell, Canada Europe
Rhys Williams, UK Chair: Wim Wientjens
Regional Manager: Lex Herrebrugh
Corporate Partners
Regional Chairs Long Term Contributors
Phone: +32-2-5371889/6392094
Morsi Arab Eli Lilly and Company
Fax: +32-2-5371981
Egypt, Eastern Mediterranean and Middle East Novo Nordisk A/S
lex@idf-europe.org
Susana Feria de Campanella www.idf-europe.org Roche
Uruguay, South and Central America Servier
North America
Debbie Jones Chair: Debbie Jones Lawrence Circle
Bermuda, North America Regional Manager: Linda Cann Eli Lilly and Company
Phone: +1-703-5491500 Novo Nordisk A/S
Sung-Koo Kang Fax: +1-703-5491715
Republic of Korea,Western Pacific Mayes Circle
lcann@diabetes.org
AstraZeneca
Kaushik Ramaiya www.idf-na.org
Merck and Co.
Tanzania, Africa South and Central America Novartis Pharma AG
Wim Wientjens Chair: Susana Feria de Campanella Roche
The Netherlands, Europe Regional Manager:Vasco Campanella Lemes
Platinum Corporate Partners
Phone: +598-2-9016214
Mahen Wijesuriya AstraZeneca
Fax: +598-2-9083979
Sri Lanka, South-East Asia Bayer Corporation
susanafe@adinet.com.uy
Becton Dickinson
Delegate Country Representatives www.saca-idf.org
Eli Lilly and Company
Kwamena Attome Beecham South-East Asia LifeScan
Ghana, Africa Chair: Mahen Wijesuriya Novartis Pharma AG
Warren Lee Regional Manager: Farzana Hameed Novo Nordisk A/S
Republic of Singapore, Western Pacific Phone: +94-11-2872951 Pfizer UK
Fax: +94-11-2872952 Sanofi-Aventis
Zobida Ragbirsingh dasl@sltnet.lk Servier
Trinidad and Tobago, North America www.idf-sea.org
Corporate Partners
Ursule Ramdanee Western Pacific Roche
Mauritius, South-East Asia Chair: Sung-Koo Kang GlaxoSmithKline
Regional Manager: Esther Ng Merck and Co.
Itamar Raz
Phone: +65-64587172 Owen Mumford
Israel, Europe
Fax: +65-65531801
A Samad Shera idf_wpr@diabetes.org.sg
Pakistan, Eastern Mediterranean and Middle East www.idf-wp.org
Manolo Vera
Cuba, South and Central America

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expressed in articles by contributors do not necessarily represent the views of the IDF.

Can a small-changes approach help address the obesity epidemic?
A report of the Joint Task Force of the American Society for Nutrition,
Institute of Food Technologists, and International Food Information
Council1,2
James O Hill
ABSTRACT
The continued rise in obesity rates in most countries suggests that
current programs and initiatives designed to combat obesity have
not been successful in reversing the obesity epidemic. Obesity rates
are increasing because of a gradual weight gain in most populations.
There has been little long-term success in treating established obesity
through lifestyle change, perhaps because of the large permanent
changes in diet and physical activity required to keep weight off.
An alternative strategy to address the obesity epidemic involves
not focusing on weight loss but promoting small changes in diet
and physical activity to initially prevent further weight gain. With
the use of this strategy, obesity rates could first be stabilized in most
populations and then, over time, decrease gradually. Supporting data
show that small reductions in conscious energy intake and increases
in physical activity can reduce excessive weight gain. The opportu-
nity exists to use the small-changes approach to bring different stake-
holders together to create a national initiative to address the global
epidemic of obesity. The Joint Task Force of the American Society
for Nutrition, Institute of Food Technologists, and International Food
Information Council believe that a small-changes framework, aimed
at helping people make conscious small changes in lifestyle behav-
iors, in combination with efforts by the private sector to gradually
‘‘ratchet down’’ some of the environmental factors that have contrib-
uted to excessive energy intake and the declining rates of physical
activity, can be successful in reducing obesity rates. Such an initiative
would benefit from the support of educational and social marketing
campaigns developed with governmental input and support. Am
J Clin Nutr 2009;89:477–84.
INTRODUCTION
Obesity is already recognized as one of the most serious public
health issues in the world (1, 2) and will likely get worse because
obesity rates are continuing to increase in most countries (3, 4).
Moreover, increases in weight appear to affect all populations. A
comparison of the US body mass index (BMI; in kg/m2) distribu-
tion in 1976–1980 with that in 2005–2006 (Figure 1), indicates that
the latter distribution is shifted to the right, which indicates that
body weight and BMI are increasing in the entire population (5).
Am J Clin Nutr 2009;89:477–84. Printed in USA. Ó 2009 American Society for Nutrition
Special Task Force Report
Downloaded from https://academic.oup.com/ajcn/article/89/2/477/4596677 by guest on 30 August 2022
There is little disagreement about the urgent need to address the
global epidemic of obesity. However, despite heightened aware-
ness of the problem and many suggestions on how obesity can be
reduced (1, 6–8), there has been no real long-term success in
tackling this public health problem. This lack of long-term success
is due in part to the difficulty many people have in maintaining
healthy dietary and physical activity patterns in an environment
that discourages physical activity and encourages excessive energy
consumption (9–11). In fairness, it is possible that some existing
initiatives have had some success over longer periods of time.
On an individual level, treating established obesity through
lifestyle modification has proven to be extremely difficult (12),
and those few who do succeed have had to make dramatic
changes in their diet and physical activity patterns (13). Most
people who achieve weight loss through lifestyle modification
regain most of the weight lost over time (12, 14).
On a population level, efforts have been directed toward either
producing weight loss or preventing those who are not obese from
becoming obese. Even though population efforts aim for smaller
behavioral changes, there is little indication that these efforts
have produced any sustainable changes. Given the complexity of
the situation and the many factors promoting weight gain in the
population, many consider the situation to be hopeless and predict
that most of the population will eventually become obese (15).
In 2003, Hill et al (11) published an article in Science sug-
gesting a paradigm shift in prioritizing strategies to reverse the
global epidemic of obesity. These authors suggested that efforts
should be focused first on promoting small lifestyle changes and
not on producing weight loss or preventing obesity but on elim-
inating or reducing the gradual excessive weight gain that is
occurring in people of all ages. Over time, such efforts can lead
to observable reductions in obesity rates. Although previous
1
From the Center for Human Nutrition, Denver, CO.
2
Reprints not available. Address correspondence to JO Hill, 4455 East
12th Avenue, University of Colorado, Denver, Denver, CO 80220. E-mail:
james.hill@cudenver.org.
Received June 2, 2008. Accepted for publication November 15, 2008.
First published online December 16, 2008; doi: 10.3945/ajcn.2008.26566.
477
478
FIGURE 1. Distribution of BMI for 1976–1980 and for 2005–2006 from
the National Health and Nutrition Examination Survey (NHANES). The latter
distribution is shifted to the right, which indicates an increase in BMI across
the population. The data are available at http://www.cdc.gov/nchs/nhanes.htm.
efforts at promoting small behavioral changes have been made,
this article is the first to suggest that a comprehensive approach
involving small changes in both diet and physical activity can be
effective at addressing the global epidemic of obesity.
RATIONALE FOR CONSIDERING A SMALL-CHANGES
APPROACH TO ADDRESSING OBESITY
A task force consisting of members of the American Society for
Nutrition, the Institute of Food Technologists, and the In-
ternational Food Information Council was established to consider
whether a small-changes approach could be useful in addressing
obesity. This 17-member task force met in person and by tele-
phone to review data and to evaluate the small-changes approach.
There are several reasons why a small-changes approach might
be an effective way to address the obesity epidemic.
1) Small changes are more feasible to achieve and maintain than
are large changes. Hill et al (11) argued that given human bi-
ology and the external food and physical activity environment in
the United States, it is difficult to sustain the large behavioral
changes required to achieve reductions in body weight by those
who were already overweight or obese. The authors argued that
small lifestyle changes, such as 2000 more steps of walking
(which would burn ’100 kcal) and simple food substitutions,
such as a diet soda for a regular soda [saving ’150 kcal per 12-oz
(340.2 g) serving] would be more sustainable than efforts to
achieve the larger changes in diet and physical activity required
for permanent weight-loss maintenance. This is not to say that
small lifestyle changes will have a greater impact on body
weight than will smaller ones but rather that small sustainable
changes are better than larger ones that cannot be sustained.
2) Even small changes can have an important impact on body
weight regulation. Small changes in diet and/or in physical
activity, which might still fall short of optimal diet and phys-
ical activity recommendations, might be sufficient to stop the
gradual weight gain of individuals and populations. Hill et al
(11) made this argument based on their analysis showing that
most of the US adult population gradually gains weight over
time because of, on average, a very slight average daily dis-
crepancy between energy intake and energy expenditure.
This ‘‘energy gap’’ could be eliminated with very small daily
behavioral changes resulting in increases in energy expendi-
ture and decreases in energy intake of ’100 kcal/d. The
energy gap was estimated from the average weight gain in
US adults, which was determined, using longitudinal and
cross-sectional weight data, to be ’0.4–0.9 kg/y. This gain
would result from an average accumulation of body energy
HILL
of ’15 kcal/d. The authors assumed that excess energy in-
take is stored with 50% efficiency (a very conservative as-
sumption), so that the average energy gap in the population is
30 kcal/d. The average accumulation of excess energy at the
90th percentile for weight gain was 50 kcal, producing an energy
gap of 100 kcal/d.
3) Achieving small lifestyle changes could lead to increased self-
efficacy and could stimulate people to make additional small
changes. Thus, the small-changes approach could be the start
of a process that could ultimately lead to larger changes.
4) The small-changes approach can be applied to reduce environ-
mental forces that promote increases in energy intake and de-
creases in physical activity. The environmental situation thought
to promote obesity did not develop overnight and will not be
reversed immediately. A small-changes approach could be used
to lessen, over time, the environmental pressures toward obesity.
Downloaded from https://academic.oup.com/ajcn/article/89/2/477/4596677 by guest on 30 August 2022
5) The small-changes approach could be a unifying platform to
allow the public and private sectors to work together to ad-
dress obesity. This platform would not focus on blame to
existing forces, but rather would provide credit for making
positive changes, regardless of the starting point. For example,
a food company would not be evaluated on the ‘‘healthiness’’
of their current products but rather would be given credit for
positive changes in their product offerings.
Since the publication of the Science article, the small-changes
approach has been widely embraced. For example, the US De-
partment of Health and Human Services launched a small-changes
initiative that included television and radio commercials and
a website (www.smallstep.gov; accessed 13 October 2008).
The small changes message was promoted by the US Surgeon
General (www.surgeongeneral.gov/priorities/prevention; accessed 1
December 2008). A nonprofit initiative, America On the Move
(www.americaonthemove.org; accessed 13 October 2008), was
formed to promote the small-changes approach to modifying
diet and physical activity. Through its Partner with My Pyramid
Corporate Challenge, the US Department of Agriculture enlisted
81 companies to make product, packaging, and promotion changes
to help consumers make small changes consistent with the Di-
etary Guidelines (www.MyPyramid.gov; accessed 2 December
2008). Groups such as the American Diabetes Association, the
American Heart Association, and the American Cancer Society
recommend the small-changes approach, as do many other public
health organizations.
The food industry has embraced the small-changes approach by
addressing portion size. Offering snacks in 100-kcal packages has
become extremely popular and is based on research showing
slightly higher energy intakes when food is presented in large rather
than small portions, although the impact of packaging snacks in
smaller portions on energy intake of the population is yet unclear.
In short, the small-changes strategy is increasingly being em-
braced by many of those interested in addressing the obesity
epidemic. The purpose of this article is to evaluate the scientific
evidence supporting the feasibility and effectiveness of this strat-
egy for addressing the global epidemic of obesity. An additional
intent is to consider how this approach could be used in modifying
environmental determinants of energy intake and physical activity.
In this review, we consider the following specific questions:
1) Can the energy gap help in developing strategies to address
obesity?
2) Is there evidence to suggest that a small-changes approach can
be effective at reducing or stabilizing obesity rates?
 SMALL-CHANGES APPROACH AND OBESITY
3) Has the small-changes approach been used successfully to
reduce or prevent excessive weight gain?
4) Can the small-changes approach be used to change environ-
mental determinants of obesity?
5) Can the small-changes approach serve as the foundation for
a national campaign to address obesity?
CAN THE ENERGY GAP HELP IN DEVELOPING
STRATEGIES TO ADDRESS OBESITY?
Hill et al (11) defined the energy gap for preventing weight
gain as the average difference between energy intake and energy
expenditure of the population or of an individual that leads to
weight gain over time. This energy gap is the level of energy
intake above energy expenditure that is causing weight gain. For
example, an extra 15 kcal/d will not lead to continued weight
gain over time, whereas an extra 15 kcal/d above energy ex-
penditure will. This energy gap is small (median: ’15 kcal/d)
and is in contrast with the energy gap that is created by cumu-
lative weight gain leading to obesity. The energy gap provides
an estimate of the degree of behavioral change that would be
required to achieve a specific weight outcome. For example, the
energy gap required for an obese individual to return to a healthy
BMI would be large (16). This is because there is a cumulative
increase in body weight as obesity progresses, which leads to in-
creased energy costs. The energy gap for preventing weight gain is
small because it estimates the degree of behavioral change re-
quired to not gain any additional weight, regardless of whether the
person is lean, overweight, or obese.
The energy gap for weight loss can also be estimated. Energy
requirements are higher in the obese, but decline with weight loss
because of declines in resting energy expenditure and reductions
in the energy cost of physical activity (17). The energy gap
required to produce and maintain weight loss would be signifi-
cantly larger than the energy gap required to prevent weight
gain. We used data obtained in a whole-room calorimeter (JO
Hill, HR Wyatt, unpublished observations, June 2007) to esti-
mate that the energy gap to maintain a 9–14-kg weight loss in
obese subjects would be ’175–250 kcal/d and that the energy
gap to maintain an 18–27-kg weight loss would be 325–480
kcal/d (Figure 2). This large energy gap created by weight loss
illustrates why large behavioral changes are required to achieve
and maintain reductions in body weight in obese individuals. It
FIGURE 2. Estimates of the energy gap for weight losses of 10% and 20%.
A reduction in body weight of ’10% in obese individuals would create an
energy gap of 170–250 kcal/d. A reduction in body weight of ’20% in obese
individuals would create an energy gap of 325–480 kcal/d. The energy gap
represents the reduction in energy requirements that occurs with weight loss.
479
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FIGURE 3. Energy gap for preventing weight gain in adults and in children
and adolescents. The energy gap is the amount of energy that would prevent
additional weight gain. Estimates of energy gaps in different populations are
shown in Table 1.
is important to emphasize that these values are applicable to the
obese population and should not be extrapolated to whole
populations because there may be some metabolic adaptations to
established obesity.
Alternatively, regardless of someone’s current weight or BMI,
further weight gain can be prevented by small decreases in energy
intake and/or increases in physical activity. This concept is il-
lustrated in Figure 3 for adults and children.
The fact that there is a small energy gap underlying global
increases in body weight and obesity is supported by several other
investigators in other populations. The studies in which the
energy gap was estimated or could be estimated from the data
collected are listed in Table 1. In addition to Hill et al (11),
Brown et al (18) determined the energy gap in middle-aged
Australian women and reported that the average weight gain was
’0.5 kg/y over 5 y and resulted in the daily accumulation of
energy of ’10 kcal/d. More recently, Zhai et al (19) estimated
the energy gap in the Chinese population to be 45 kcal/d. Wang
et al (20) estimated the energy gap to be 110–165 kcal/d among
children by investigating the difference between the actual and
optimal trajectory of weight gain. In a longitudinal study that
compared growth in children of 2 lean parents with growth in
children of 2 obese parents, Goran et al (21) found that the
average excess accumulation of body energy between groups
was ’25 kcal/d, or ’50 kcal/d, based on the assumptions of Hill
et al concerning energy storage.
Several other studies did not calculate the energy gap but
reported rates of weight gain over time in populations that would
be consistent with a small energy gap. For example, Tataranni
et al (22) examined the Pima Indians, a largely obese population
in southwestern Arizona. An average weight gain comparable
with an accumulation of body energy of 30–40 kcal/d was
found. Sheehan et al (23) found that Americans gain weight at
a steady rate until ’60 y of age. From 1971 to 1992, the average
weight gain of those aged ,60 y ranged from 0.25 to 0.54 kg/y.
Ebrahimi-Mameghani et al (24) followed a Scottish population
for a total of 9 y and found that only 20% of the population re-
mained at a stable weight. Approximately 42.2% of the population
gained .5 kg, and 17.6% of the population gained .10 kg
480
TABLE 1
Energy gap in different populations
Population Energy accumulation
US adults (9) 15 kcal/d; 59 kcal/d for 90th percentile
US children (20) — 110–165 kcal/d
US children (21) 25 kcal/d
Australian women (18) 10.5 kcal/d
Chinese adults (19) 22.5 kcal/d
Adult Pima Indians (22) 30.6 kcal/d
Scottish adults (24) 11.5 kcal/d in 42.2% of population;
23 kcal/d in 17.6% of population
Swedish adults (25) 4.1 kcal/d for men; 6.2 kcal/d for women
Chilean women aged 16.8 kcal/d
40–53 y (26)
during the 9-y study period. Berg et al (25) examined a pop-
ulation of men and women in Sweden and found a mean body
weight increase of 3.3 kg for women and 5 kg for men over the
17-y study period. A study in Chilean women aged 40–53 y
found an average weight gain of 3.8 kg over 5 y (26).
Several studies have shown that some groups are gaining weight
at a much higher rate than the general population. In these pop-
ulations, the energy gap is .100 kcal/d. Levitsky et al (27) fol-
lowed a sample of students during their first semester in college.
The results showed a mean weight gain of almost 2 kg in the first
12 wk of college, which constituted an energy gap of 367 kcal/d.
A study conducted by Butte et al (28), which followed a large
cohort of Hispanic children (4–19 y of age) for 1 y, found that the
mean weight gain was significantly higher in overweight children
(7.5 kg/y) than in nonoverweight children (4.4 kg/y). The energy
gap was ’130 kcal/d more for overweight Hispanic children than
for nonoverweight Hispanic children.
In summary, the available data suggest that many populations
are gradually gaining weight, which is being fueled by a relatively
small difference between energy intake and energy expenditure.
Put simply, on average, most people are consuming only slightly
more calories than they are expending and, consequently, are
gradually gaining weight at an average of 0.5–1 kg/y.
IS THERE EVIDENCE TO SUGGEST THAT A
SMALL-CHANGES APPROACH CAN BE EFFECTIVE AT
REDUCING OR STABILIZING OBESITY RATES?
Effects of large compared with small changes on increases
in physical activity
Several government bodies and scientific organizations have
issued guidelines for physical activity. Many of these guidelines (29,
30) recommend 30 min/d of moderate-intensity physical activity
most days. Some guidelines recommend 60 min/d of moderate-
intensity physical activity to prevent weight gain and 60–90 min/d
of physical activity to maintain weight loss and prevent weight re-
gain (31, 32). Meeting these recommendations requires large changes
for most people. Brownson et al (32) reviewed population data on
physical activity trends among US adults. In 2000, only ’26% of
this population met even the 30-min/d physical activity level
recommendation. Moreover, this number has not changed over the
past decade. It is clear that guidelines that set large behavioral
goals for physical activity have not been successful.
HILL
Energy gap
30 kcal/d; 100 kcal/d for 90th percentile
50 kcal/d
21 kcal/d
45 kcal/d
61.2 kcal/d
23 kcal/d for 42.2% of population;
46 kcal/d for 17% of population
8.2 kcal/d for men; 12.4 kcal/d for women
33.6 kcal/d
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Alternatively, Hill et al (11) estimated that an extra 2000
steps/d would be sufficient to increase energy expenditure by
’100 kcal/d and that this simple change could stop weight gain
in most adults. These authors further suggested that pedometers
could be used as tools to allow people to set and monitor physical
activity in steps/d. Before 2003, several studies had been published
that used pedometers to measure physical activity, but a Medline
search found that only 4 of these studies used an increase in the
number of steps per day as a physical activity intervention. Since
2003, .30 studies that used an increase in the number of steps per
day as a physical activity intervention have been conducted. A re-
view by Ogilvie et al (33) provides the details and outcomes of
these interventions. Bravita et al (34) reviewed 26 studies (n ¼ 2767
subjects) in which pedometers were used as tools to increase
physical activity. Pedometers work because they provide physical
activity goals that are simple and measurable. The average increase
in steps per day was 2491, which represented a 26.9% increase in
physical activity over baseline. Most people can obtain this type of
increase by walking for ’20–25 min. Such an increase would be
effective for most people to achieve the recommended physical
activity level of 30 min/d. Moreover, this increase of 2491 steps/d,
or ’20 min/d of walking, was associated with a slight decline in
BMI (0.38). The main point is that 20 min of walking is a small
behavioral change that was achieved and was sufficient to prevent
weight gain.
Other small-changes approaches to increasing physical activity
have been shown to be effective. Dolan et al (35) evaluated the
impact of prompts to take the stairs instead of the escalator. These
researchers reviewed 8 studies and found that the mean (6 SD)
increase in stair usage was 2.8% 6 2.4%. It was projected that
a 2.8% increase in stair usage could result in the prevention of
a weight gain of 300 g/person per year in new stair users. The
authors concluded that this strategy could have a slight impact on
reducing the national prevalence of obesity. However, it should be
noted that if the impact of the environment worsens, additional
changes might be required to avoid weight gain.
Another small-changes approach is the Take 10! Program,
which is aimed at integrating increased energy expenditure into
academic curricula. Caloric expenditure with this intervention
ranges from 25 to 37 kcal/10-min session (36). Participating in 5–
10 Take 10! sessions per week would burn an additional 150–
300 kcal during this period. This small change could have a big
impact on energy balance and weight maintenance in the school-
aged population.
 SMALL-CHANGES APPROACH AND OBESITY
Effects of large compared with small changes on
improvements in diet
Efforts to achieve large changes in the diets of Americans have
not been widely successful. The More Matters program (formerly
known as the 5-a-Day program) has promoted the consumption of
5 servings of fruit and vegetables/d since 1991, with only modest
success. The percentage of Americans who know that they should
eat 5 servings of fruit and vegetables/d has increased from ’8%
to ’20%, but the consumption of fruit and vegetables changed
little from 1994 to 2005 (37).
Americans were told to make big reductions in dietary fat
intake in 1980 and in the early 1990s (38, 39). Although much
was made of the resulting decline in the percentage of calories
from fat eaten, the total fat consumed (in g/d) declined very
slightly in the mid-1980s but actually began increasing in the
late 1980s (40). The percentage of calories consumed from fat
declined because of an increase in total energy intake (40).
Additionally, efforts to promote big reductions in dietary car-
bohydrate during the late 1990s and early 2000s were not sus-
tainable, as evidenced by a decline in several formerly very
popular low-carbohydrate diets.
Some big changes in diet have been successful. One such
change has been an increase in the consumption of reduced-fat
milk; however, this change has occurred over 35 y (41). Another
successful big dietary change has been recent efforts to elimi-
nate most synthetic trans fatty acids from the US diet. This
change may be working largely because it does not require
major behavioral changes on the part of the consumer. The
changes are being done by the food manufacturers and by res-
taurants, which have reduced their use of partially hydrogenated
fats. Consumers who seek to eliminate trans fatty acids can do it
with little or no sacrifice of taste or convenience.
The small-changes approach as a single strategy to reducing
energy intake in populations has not been directly tested. However,
a great deal of research suggests that small changes in specific
components of the diet could produce small but important
changes in energy intake without the need for conscious energy
restriction. For example, Donahoo et al (42) found that energy
intake will decrease by ’20 kcal/d with each 1% decrease in the
percentage of fat in the diet. Perhaps small changes in dietary fat
would be more sustainable than larger ones. Similarly, small
reductions in portion size can produce reductions in energy in-
take without stimulating hunger (43–46). Consumption of sugar-
sweetened beverages in the United States has increased from an
average of 222 to 458 kcal/d over the past 25 y (47). Reducing
the consumption of caloric beverages has been found to decrease
total energy intake (48), so there may be merit in recommending
small reductions in the consumption of these products. Studies
have also shown that fiber supplementation can reduce energy
intake by 15–20% (49).
Reducing the energy density of certain foods is a strategy that
can be achieved with reductions in fat or sugar intake (provided
these macronutrients are replaced by ingredients with fewer calo-
ries, such as protein or carbohydrate in the case of fat) or with
increases in fiber, water, or air. The advantage of this approach is
that calorie intake can be reduced without a decrease in serving size.
Prentice and Jebb (50) reviewed the published data on energy
density and energy intake and concluded that the evidence is clear
that energy intake increases directly with increases in energy
481
density. Rolls et al (51) consistently found that reducing energy
density produces small reductions in energy intake in short-term
experiments. They estimated that a reduction of 0.1 kcal/g in the
energy density of the diet produces reductions in energy intake
of 110 kcal/d in men and of 82 kcal/d in women. The strategy
of reducing energy density seems to reduce energy intake in
children as well. Leahy et al (52) found that reducing the energy
density of an entrée served to children reduced energy intake
from that entrée by 25% and total intake from the meal by 18%.
HAS THE SMALL-CHANGES APPROACH BEEN USED
SUCCESSFULLY TO REDUCE OR PREVENT EXCESSIVE
WEIGHT GAIN?
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A substantial amount of research suggests the feasibility of
changing energy intake and total physical activity through a
small-changes approach. Another important question is whether
the small-changes approach can be shown to be effective at
reducing excessive weight gain, as suggested by Hill et al (11).
The most direct evidence for the ability of the small-changes
approach to reduce or prevent excessive weight gain comes from
Rodearmel et al (53, 54), who used a family-based small-changes
intervention in families with at least one child who was over-
weight or at risk of overweight. These researchers tested the
efficacy of the America On the Move initiative, which advocates
an increase in walking by 2000 steps/d and reducing energy
intake by 100 kcal/d. In one study (53), the intervention families
were asked to make 2 small changes: 1) to consume cereal for
breakfast and 2) to increase physical activity by 2000 steps/d
over baseline. After 14 wk, the increase in BMI-for-age in the
target children was significantly less in the intervention group
than in the control group. Mothers in the intervention group also
experienced a favorable change in BMI.
In a second study conducted by Rodearmel et al (54), the
intervention consisted of 1) reducing energy intake by ’100
kcal/d by replacing sugar or sugar-containing beverages with
noncaloric sweeteners or products containing noncaloric sweet-
eners, and 2) increasing walking by 2000 steps/d over baseline.
After 6 mo, significantly more children in the intervention group
than in the control group maintained or decreased their BMI-for-age
(Figure 4).
FIGURE 4. Percentage of target children in the America On the Move
(AOM) and Self-Monitoring (SM) groups who maintained/reduced or
increased their percentage BMI-for-age over 6 mo (54). Significantly more
AOM children than SM children maintained or reduced their percentage
BMI-for-age (P , 0.05). Significantly fewer AOM children than SM
children increased their percentage BMI-for-age (P , 0.05).
482
Several studies that used pedometers to increase physical
activity showed reductions in weight. Chan et al (55) used
pedometers in a 12-wk work-site intervention in 106 sedentary
workers and achieved slight decreases in both BMI and waist
circumference. Toole et al (56) conducted a self-reported pe-
dometer-walking program in which participants increased their
walking by 2000 steps/d and experienced a decrease in BMI.
Clarke et al (57) used pedometers to measures increases in
physical activity in low-income mothers. They found that the
use of pedometers was associated with increased physical ac-
tivity and with reductions in body weight, percentage body fat,
and waist circumference.
Fewer studies have been conducted to evaluate the impact of
a small-changes approach to reducing energy intake alone on
obesity rates. James et al (58) reported initial success in a school-
based intervention aimed at reducing the consumption of car-
bonated soft drinks by children. The percentage of overweight
children increased by 7.6% in the control group and decreased
by 0.2% in the intervention group. The difference in energy
intake due to the intervention was ’35–40 kcal/d. However, the
impact of the intervention was not sustained over 3 y (59). This
illustrates the potential of a relatively modest decrease in energy
intake to affect anthropometric variables but also emphasizes the
difficulty of sustaining even small behavioral changes.
The available data strongly suggest that excessive weight gain
in most of the population is due to a slight degree of positive
energy balance and that small lifestyle changes can reduce the
energy gap. The small-changes approach has been shown to be
effective at increasing total physical activity, decreasing total
energy intake, and preventing or reducing excessive weight gain.
Given the lack of success with other approaches to lifestyle
changes, the small-changes approach deserves serious attention.
The small-changes approach might, at a minimum, help prevent
things from getting worse until larger societal changes can be
made. It remains to be established whether small lifestyle
changes are easier to sustain than are larger ones. Although this
hypothesis seems reasonable, achieving and sustaining the be-
havioral change necessary to accomplish this goal, even though
only small changes are sought, will take concerted and coordinated
efforts across all sectors of society. In effect, the obesity epidemic
will only be halted through fundamental lifestyle changes in the
way individuals work, play, learn, and socialize.
CAN THE SMALL-CHANGES APPROACH BE USED
TO CHANGE ENVIRONMENTAL DETERMINANTS
OF OBESITY?
Most experts agree that the obesity epidemic is being driven by
many interacting determinants, including changes that have oc-
curred in the physical environment. However, these environmental
changes have not occurred all at once, nor was their cumulative
effect felt all at once. These environmental changes have been
small and unidirectional and have acted like a ratchet—always
movinginonedirection,promotingweightgain.This‘‘ratchet’’effect
occurred both at a population level and on an individual level.
It is a reasonable hypothesis that stopping the obesity epidemic
can be approached by reversing the ratchet effect with small,
unidirectional changes that would operate to discourage excess
weight gain. These changes do not have to be massive, but they
need to be in the right direction and they need to be maintained. In
effect, this strategy would engage all stakeholders (eg, the policy
HILL
environment and the commercial environment) to foster a healthy
ratchet effect that is always moving in the right direction. This kind
of approach has not been tried because there is the tendency to look
at the problem as a whole and to consider that no one small change
of any kind can cure the problem in its entirety. However, the
available data suggest that a small-changes approach may be the
fuel needed to move our nation to a new ‘‘tipping point,’’ where
the conditions change just enough for the population as a whole to
embrace even more change than is currently deemed possible.
Adopting the healthy ratchet approach can also be a means to
bring together different stakeholder groups that are often difficult
to engage because they are so far apart in their immediate goals.
Across private and public sectors, virtually every stakeholder is
motivated to do something to help prevent obesity. The end goal of
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the small-changes approach, moving society in a positive direction
healthwise, is something that all stakeholders can embrace in a
coordinated fashion. Likewise, small changes easily become insti-
tutionalized by policy as they are adopted, which would help solve
one of the most vexing problems of public health interventions,
namely sustainability. In order for something to be sustainable, it
has to become ‘‘business as usual,’’ moving beyond a ‘‘program’’ or
an ‘‘initiative’’ that has only temporary support. It is important to
support an approach that makes it hard to slip back into old habits.
This strategy has appeal because it does not require stakeholders to
abandon their current business or interest wholesale, but empowers
them to contribute something positive to the solution.
The ideal way to sustain positive change is to have it become
a key driver of the American way of life. If the desired behaviors
are in high demand because people are motivated and rewarded,
they will have a greater chance of being adopted long term. In
a crude sense, to make an impact in today’s culture, there needs to
be a compelling business model. There has to be a clear benefits
exchange between the provider and the consumer, and it has to fit
within the current economic and social values structure. For
example, a business model for food already exists. An entire
industry supplies food to the market, and the particular types of
food vary according to consumer demand. So, if one wants to
change some elements of the food supply, it is feasible to estimate
the demand, the economics, supply chain requirements, etc. In
contrast, the business model for physical activity either does not
exist or is grossly underdeveloped. Fitness clubs and sports in-
dustries sell goods and services that support physical activity, but
they are small industries compared with the food industry.
Physical activity is not a requirement for survival, so there is no
strong biological drive for it. There is no requirement for physical
activity as a driver of the economy. No data as yet provide
compelling evidence that physical activity improves productivity,
reduces health care costs, or improves some other aspect of our
lives that is tied to the current economic values system. It is
reasonable to hypothesize that it will be difficult to increase physical
activity levels on a population level unless there is compelling
evidence for making physical activity ‘‘worth’’ something to
society as a whole, beyond just enhancing individual health.
CAN THE SMALL-CHANGES APPROACH SERVE AS
THE FOUNDATION FOR A NATIONAL CAMPAIGN TO
ADDRESS OBESITY?
Society is poised on the brink of a tremendous opportunity for
food science and nutrition to unite and take the lead in a national
 SMALL-CHANGES APPROACH AND OBESITY
campaign to address obesity. The historic record clearly demon-
strates remarkable advances in the application of nutrition and food
science research to benefit health (60). Given the gravity of the
obesity epidemic and the ensuing public health consequences,
there is a pressing need to implement the small-changes approach.
As presented, a small-changes initiative aimed at affecting the
food supply could result in a landmark discovery in nutrition and
food science that dramatically benefits public health and could
lead to a national initiative to address obesity around the world.
This task force believes that a small-changes framework aimed
at helping people make conscious small changes in lifestyle
behaviors in combination with efforts by the private sector to
gradually ‘‘ratchet down’’ some of the environmental factors
that have contributed to excessive energy intake and to the de-
clining rates in physical activity could be successful in reducing
obesity rates. This initiative could be supported by educational
and social marketing campaigns driven by or influenced by the
many government agencies addressing this problem.
The manuscript was reviewed by all members of the Joint Task Force: Susan
Borra (International Food Information Council); Roger Clemens (ET Horn
Company); Fergus Clydesdale (University of Massachusetts, Amherst); John
Courtney (American Society for Nutrition); Sarah Davis (Institute of Food
Technologists); John Erdman (University of Illinois, Urbana-Champaign);
Mary Christ-Erwin, Porter-Novelli, and Shelley Goldberg (International Food
Information Council); James Hill (University of Colorado, Denver); Lori
Hoolihan (Dairy Council of California); Guy Johnson (McCormick Science
Institute); Penny Kris-Etherton (Pennsylvania State University); Gil Leveille
(Wrigley Science Institute); Daryl Lund (Emeritus, University of Wisconsin,
Madison); Indra Mehrotra (General Mills Bell Institute of Health and Nutri-
tion); Keith Singletary (University of Illinois, Urbana-Champaign); and Con-
nie Weaver (Purdue University).
The author’s responsibility was as follows: JOH: wrote and reviewed the
manuscript. JOH has served on advisory boards for PepsiCo, General Mills,
the Wrigley Science Institute, and the McCormick Science Institute.
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 Jurnal Gizi Indonesia (The Indonesian Journal of Nutrition)
Jurnal Gizi Indonesia Vol. 10, No. 2, June 2022 (88-94)
Submitted: 10 February 2021, Accepted: 16 January 2022
Online https://ejournal.undip.ac.id/index.php/jgi

Anthropometric Measurements and Inflammatory Marker in Obese

Women
Kartika Rizky Aulia1, Meita Hendrianingtyas2*, Edward Kurnia Setiawan Limijadi2, Dodik Pramono3.

ABSTRACT

Background: Obesity is one of global epidemic health problems and its prevalence is higher among women. Obesity can
cause low grade chronic inflammation mechanism in adipose tissue, which is characterized by the increase of
proinflammatory cytokines and adipokines. Neutrophil lymphocyte ratio (NLR) is a simple inflammatory marker which
can be reliable in evaluating the inflammatory status occurring in obese women. Waist to height ratio (WHtR) and waist
to hip ratio (WHR) are anthropometric measurements, have been reported to be associated with obesity and risk of
metabolic syndrome.
Objective: This study aimed to determine the correlation of WHtR and WHR with NLR in population of obese women.
Materials and Methods: This was a cross sectional study enrolling 80 obese women with Body mass index (BMI) > 27
aged 30 - 50 years in National Diponegoro Hospital Semarang, Indonesia. WHtR was determined by dividing waist
circumference by height and WHR was determined by dividing waist circumference by hip circumference. NLR was
examined manually from automatic hematology analyzer by dividing absolute neutrophil count (ANC) and absolute
lymphocyte count (ALC). Spearman correlation test was performed, p<0.05 was considered as statistically significant.
Results: There was significant weak positive correlation between WHtR and NLR in obese women (p = 0,046; r = 0,224).
There was no significant correlation between WHR and NLR in obese women (p = 0,961; r = 0,006).
Conclusion: The present study showed that WHtR is one of better anthropometric measurement because it is associate
with NLR as a simple marker of inflammation in obese women.

Keywords: WHtR; WHR; NLR; Obesity

BACKGROUND
Obesity is one of the global health problem whose prevalence continues to increase every year. World
Health Organization (WHO) in 2016 stated that 1.9 billion adults with 18 years of age or over are overweight
and more than 650 million are obese. Based on WHO, approximately 13 % of world adult population were
obese that more cases found in woman (15%) than man (11%)1. Results of Basic Health Research (Riskesdas)
2007-2018 in Indonesia also shows an increasing trend of obesity, namely 10.5% (2007), 14.8% (2013) and
21.8% (2018) 2 and in Central Java, Indonesia prevalence obesity cases in woman (27,53 %) are higher than
in man (13.09 %)3.
Obesity is defined as s abnormal or excessive fat accumulation that presents a risk to health. Obesity
increase the risk of chronic diseases including type 2 diabetes mellitus (Type 2 DM) and cardiovascular disease
4
. There are two types of obesity based on where fat accumulate in body namely android obesity and gynoid
obesity. Abdominal, central, or android obesity characterized by fat distributed around the waist or Gynoid
obesity that fat accumulate in the lower part of the body 5. Risk factor of obesity are multifactorial including
genetic, lifestyle, and environmental factors 6. Women are more at risk for obesity than men because they have
more sedentary lifestyle like physical inactivity, consumption food that high simple sugar, high calories and
fat that are risk factor of obesity 7. Body Mass Index (BMI) is anthropometric measurements which is more
often used as a parameter of obesity. WHO criteria for obesity are if BMI is ≥ 30 kg/m2, while this study refers
to the classification of obesity for Asia Pacific population which is having BMI ≥ 27 kg/m2 8. Waist
Circumference (WC), Waist to Hip Ratio (WHR), Waist to Height Ratio (WHtR) are another anthropometric
measurements that also can be used to predict obesity. Kwang Pil Ko et al stated that WHR is a better method
1
Faculty of Medicine, Diponegoro University
Jl. Prof. Soedharto SH, Tembalang, Semarang, Central Java 50275, Indonesia
2
Department of Clinical Pathology, Faculty of Medicine, Diponegoro University
Jl. Prof. Soedharto SH, Tembalang, Semarang, Central Java 50275, Indonesia
*
Correspondence : E-mail: meitanote2015@gmail.com, Phone +628122543265
3
Department of Public Health Science, Faculty of Medicine, Diponegoro University
Jl. Prof. Soedharto SH, Tembalang, Semarang, Central Java 50275, Indonesia

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 Kartika Rizky Aulia, Meita Hendrianingtyas, Edward Kurnia Setiawan Limijadi, Dodik Pramono

of predicting metabolic syndrome in obesity than WC, WHtR, and BMI 9. A meta-analysis study by Labarrere
et al in more than 300,000 multi-ethnic people, shown that measuring obesity with WHtR can better explain
its association with cardiometabolic risk from inflammation than using BMI and WC 10.
Obesity has a negative impact on tissues and body systems related to inflammatory mechanisms. Low
grade inflammation due to obesity has been demonstrated in several studies using various markers of
inflammation. Obesity measured using BMI parameters was shown to be positively associated with increased
CRP levels, leukocyte count, IL-6, tumor necrosis factor alpha (TNF-α), and neutrophil lymphocyte ratio
(NLR) 11. Neutrophil lymphocyte ratio is effective, simple, inexpensive parameter of inflammation and widely
examined in various laboratory 9. During the inflammatory process, neutrophil count can be increased up to
five times the normal number, while the lymphocyte count tends to be constant due to continuous recycling by
lymphoid tissue, lymph and blood. This difference in the distribution of cells during inflammation is the basis
for the use of NLR. Neutrophil lymphocyte ratio is considered more stable as a marker of inflammation than
the absolute leukocyte count which can change according to physiological and pathological conditions 12. No
further study on the correlation between WHtR and WHR and the NLR value in Indonesian obese women.
This encourages researchers to determine the correlation between WHtR and WHR and NLR values in obese
women.

MATERIALS AND METHODS

This cross-sectional study was conducted in July - September 2020 at the Diponegoro National Hospital
Semarang, Central Java, Indonesia.

Subject of Study
Minimum subject for this study was 46 people that was calculate with formula below:
2
𝑍𝛼 + 𝑍𝛽
𝑛=( ) +3
1+𝑟
0,5 ln
1−𝑟
Altough minimum subject for this study was 46 people, total subject in this study was eighty obese women
with criteria aged 30-50 years, body mass index (BMI) ≥ 25 kg/m2, healthy and having normal vital sign, and
have regular menstrual cycles for 6 months before join the study. Subjects which have history of DM, subjects
with cardiovascular disease, hematological abnormality, or pregnant at the time this study was conducted, were
excluded from this study. Screening for subject in this study that meeting all criteria using short interview and
simple screening form.
a. Antropometric Measurements
1. Body Mass Index (BMI)
Body mass index (BMI) in this study were calculated using weight data that obtained by using
a digital scale and height data using microtoa with formula:

𝑊𝑒𝑖𝑔ℎ𝑡 (𝑘𝑔)
Body Mass Index : 𝐻𝑒𝑖𝑔ℎ𝑡 (𝑚𝑒𝑡𝑒𝑟) 𝑥 𝐻𝑒𝑖𝑔ℎ𝑡 (𝑚𝑒𝑡𝑒𝑟)

2. Waist to Hip Ratio (WHR) and Waist to Height Ratio (WHtR)

Waist circumference was measured with inelastic band at the midpoint between the last rib
and the anterior superior iliac crest at the end of respiratory movement of expiration in standing
position. Hip circumference was measured over thin clothing at the point of the maximum
circumference of the buttocks. Both circumferences were measured to the nearest 0.1 cm.
b. Blood Analysis
Blood was collected by venipuncture and tested using automatic hematology analyzer (Sysmex
XN L Series XS 500, Sysmex Asia Pacific Pte Ltd.) for absolute neutrophil count (ANC) and absolute
lymphocyte count (ALC). The NLR value was calculated manually from ANC divided by ALC.
Statistical analysis in this study was performed in this study by SPSS 16.0, Correlation Test using
Pearson if data from this study normally distributed and Spearman correlation test if data not distributed
normally with p<0.05 was considered as statistically significant. This study was obtaining an ethical clearance
from the Health Research Ethics Commission of the Faculty of Medicine, Diponegoro University / RSUP Dr.
Kariadi Semarang No. 32/EC/KPEK/FK-UNDIP/III/2020. Study subjects were providing written informed

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 Anthropometric measurements and inflammatory marker in obese women

consent.

RESULTS
Subjects Characteristics Data
Total respondent in this study was 81 respondents, only 80 respondents that met the inclusion criteria.
The mean age of respondent in this study was 36.61 ± 5.20 years with mean body mass index (BMI) were
31.97 ± 4.49 kg/m2 and have regular menstrual cycles. Mean Waist Circumference respondent in this study
were 93.86 ± 9.15 cm with WHtR and WHR score were 0.85 ± 0.06 and 0.61 ± 0.06. Respondent mean
leukocytes count, neutrophil, and lymphocyte in this study were 7.08 ± 1.48 (103/µL), 61.15 ± 5.95 (%), 30.32
± 5.58 (%). Average Neutrophil Leucocyte Ratio respondent in this study were 2.13 ± 0.63. The baseline
characteristics of the subjects is presented in table 1.

Table 1. Data on the Characteristic of Research Subjects

Parameter Mean ± SD Min – Max
Age (years) 36.61 ± 5.20 30 – 50
Body weight (kg) 76.83 ± 12.03 60.4 – 126.6
Height (cm) 154.93 ± 4.99 145.0 – 169.5
BMI (kg/m )2
31.97 ± 4.49 27.00 – 52.00
WC (cm) 93.86 ± 9.15 80.00 – 120.00
WHR 0.85 ± 0.06 0.71 – 1.00
WHtR 0.61 ± 0.06 0.52 – 0.77
Leucocyte (103/µL) 7.08 ± 1.48 4.50 – 12.00
Neutrophil (%) 61.15 ± 5.95 47.00 – 77.00
Lymphocyte (%) 30.32 ± 5.58 19.00 – 45.00
NLR 2.13 ± 0.63 1.04 – 4.05
BMI : Body mass index, WC : Waist circumference, WHR: Waist to hip ratio, WHtR : Waist to height ratio

The Spearman correlation analysis test between WHtR and NLR showed p = 0.046; r = 0.224, this
indicates that there is a significant correlation between WHtR and NLR in obese women. The Spearman
correlation analysis test between WHR and NLR showed p = 0.961; r = 0.006, this indicates that there is no
significant correlation between WHR and NLR in obese women. The results of the correlation test are shown
in Table 2.

Table 2. Spearman Correlation Test Result of WHtR, WHR, and NLR in Obese Women
Variable NLR
r p
WHtR 0.224 0.046*
WHR 0.006 0.961
*
= p value <0.05 is significant

DISCUSSION
Obesity
In this study we determined several anthropometric measurements include Body Mass Index (BMI),
Waist to Hip Ratio (WHR) and Waist to Height Ratio (WHtR). Body mass index (BMI) is common
anthropometric measurements as parameter of obesity. People with BMI score ≥ 25 kg/m2 categorized as obese
people. All respondents in this study have met the criteria of obesity from BMI score. Lowest BMI score in
this study was 27 kg/m2 and highest BMI score was 52 kg/m2. Obesity is characterized by the accumulation of
body fat and unfortunately, body mass index (BMI) cannot be used to determine body fat composition.
Someone who has ≥ 25 kg/m2 not necessarily having high body fat percentage because body weight also consist
of muscle mass.
Waist Circumference (WC), Waist to Hip Ratio (WHR) and Waist to Height Ratio (WHtR) can be
used as a better indicator to determine obesity. Waist circumference (WC) is better indicator that can predict
fat deposit in abdominal area. Lowest waist circumference respondent in this study is 80 cm that has been

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 Kartika Rizky Aulia, Meita Hendrianingtyas, Edward Kurnia Setiawan Limijadi, Dodik Pramono

categorized as obese for adult Asian people ( ≥ 80 cm) 13. The WHtR distribution in this study ranged from
0.52 to 0.77. The criteria for central obesity were enforced if the WHtR was ≥ 0.5 so that all study subjects
met the criteria for central obesity 14. The WHR distribution of study subjects ranged from 0.71 to 1.00. The
cut off points of WHR according to WHO is ≥ 0.85 in women to categorized people having central obesity 15.
There are 42 (52.50%) study subjects who fall into the criteria for central obesity and 38 (47.50%) study
subjects who do not meet the criteria for central obesity. According to the previous study by Hastuti et al, 2017
in Indonesia, it is stated that obesity is central if the WHR is ≥ 0.77 in women 16. Based on these criteria, there
are 74 (92.50%) research subjects who fall into the criteria for central obesity.

Inflammatory Parameters
This study using Neutrophil Leukocyte Ratio (NLR) to predict inflammatory state in obese
respondents. Obese condition can lead to systemic inflammation in body that can increase Neutrophil
Lymphocyte Ratio (NLR). An increase in NLR is determined by an increase of neutrophils and or reduction
in lymphocytes. An increase in circulating neutrophils is thus suggestive of an acute or chronic inflammatory
response. Chronic inflammation stimulating the release of immunoregulatory granulocytic myeloid-derived
suppressor cells from the bone marrow, which can increase up to 10% of peripheral leucocyte and suppress
lymphocyte counts and function17. The increase in NLR in the obese female population can be caused by
increased neutrophils. An increase in the number of neutrophils in obesity is an acute inflammatory response
to a chronic inflammatory state 18. Neutrophils describe a nonspecific immune system condition that initiates
the body's response to inflammation 19. High levels of circulating neutrophils are associated with depressed
activity of other immune cells such as T-lymphocytes and natural killer cells. Based on the results of several
previous studies, obesity causes a chronic inflammatory condition associated with increased secretion of
adipokines and cytokines proinflammatory of adipose tissue 20.
Currently there is no definite NLR intersection point value. Various studies use NLR intervals (ditile
or quartile) or use a receiver operator curve (ROC) to classify NLR values. According to study by Patrice
Forget et.al., (2017) it was concluded that the threshold value of NLR in a non-geriatric adult population with
good health was 0.78 - 3.5 21. Based on these criteria, there were 4 (5.00%) research subjects who had a value
NLR above normal. Possibility factor that cause not all respondents having high NLR value is subjects in this
study were not grouped based on their degree of obesity. Dixon et al. revealed that a significant increase in the
number of neutrophils occurred in severely obese patients (BMI >40 kg/m2) due to the mechanism of
neutrophil activation by leptin through TNF-α 22. Atmaca et al. through his study reported that there was no
significant increase in the number of leukocytes in mild obesity (BMI <35 kg/m2), besides that it was proved
that inflammation which is characterized by an increase in the number of neutrophils and lymphocytes is
parallel with the severity of obesity18.

Correlations of WHtR and NLR in Obese Women

Increased abdominal adiposity has been reported in previous study as major risk factor of metabolic
syndrome. Main pathway to describe the correlation between metabolic syndrome and VAT is insulin
resistance (IR). Excessive VAT decreasing insulin sensitivity that lead to systemic inflammation beside
inflammation also occur in obesity condition 23. Increased secretion of inflammatory mediators from visceral
fat in obese individuals reflects the ongoing chronic inflammation within the adipose tissue of the individual
24
. NLR is one of the inflammation indicator that simple and easy to do with measuring ratio between neutrophil
and leucocyte. Spearman test in this study show that there are no significant correlation between Waist to Hip
Ratio (WHR) with NLR in obese woman (p = 0.961 and r = 0.006) meanwhile, there was a significant weak
positive correlation between WHtR and NLR in obese women (p = 0.046 and r = 0.224). The results of this
study are in accordance with several previous studies. Study conducted by Rodriguez et al. in 2020 stated that
WHtR had a significant positive correlation with NLR in the abdominal obesity population (p<0.001; r2 =
0.011) 25. According to Rodriguez, both obese men and women with chronic inflammatory conditions
characterized by increased NLR had higher WHtR values. Serbanescu et al. in 2015 through his study also
stated that WHtR had a significant positive correlation with NLR in obesity (p <0.001; r = 0.203) 26. WHtR is
better indicator to identify central obesity that have higher risk to lead systemic inflammation. According to
the Bener study in 2013, WC and WHtR are anthropometric parameters that have a better correlation with
central obesity than WHR and BMI and can be used as predictors of cardiovascular and metabolic disease 27.

Correlations of WHR and NLR in Obese Women

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 Anthropometric measurements and inflammatory marker in obese women

There was no significant correlation between WHR and NLR in obese women (p = 0.563 and r = -
0.74). The results of this study differ from several previous studies. Study conducted by Carranza et al. in 2020
states that there is a significant positive correlation between WHR and NLR in a population of obese women
at premenopausal age (p <0.05 and r = 0.374) 28. Differences in study conducted by Carranza et al. with this
study is the subject inclusion criteria. The inclusion criteria in the Carranza study were obese premenopausal
women (42 - 55 years) with vasomotor symptoms indicating decreased estrogen. Whereas in this study the
subjects were obese women of productive age who still experienced regular menstruation.
The results of this study are consistent with the study of Dev et al. in 2012 which revealed that WHR
was not significantly associated with several markers of inflammation, especially CRP in obese non-comorbid
female subjects. According to Dev, WHR is not as good as WC in explaining the correlation between increased
markers of inflammation 29.
No correlation between WHR and NLR can be caused by several factors. One of the factors that
influence the results is the varied physical activity of the research subjects. According to study by Rias et al.
in 2020 shows that moderate and excessive physical activity significantly reduces NLR in a population of
women with type 2 diabetes mellitus with and without obesity 30.
Another factor that can cause an insignificant correlation is that the subjects in this study were not
grouped based on the degree of obesity. Dixon et al. revealed that a significant increase in the number of
neutrophils occurred in severely obese patients (BMI >40 kg/m2) due to the mechanism of neutrophil activation
by leptin through TNF-α22. Atmaca et al. through his study reported that there was no significant increase in
the number of leukocytes in mild obesity (BMI <35 kg/m2), besides that it was proved that inflammation which
is characterized by an increase in the number of neutrophils and lymphocytes is parallel with the severity of
obesity18.
The age factor also influenced the subject's NLR. According to study by Jian Li et al. in 2015, NLR
was positively correlated with age in the healthy adult female population (p<0.001, r = 0.119) 31. Jian Li's study
showed that the NLR in the 40-49 years age group was higher than the 30-39 years age group. This is because
the number of granulocytes shows an increasing trend with age and the number of lymphocytes shows a
decreasing trend with age.
The limitation of this study is that only one type of inflammatory marker was used and the subjects
were not classified based on the severity of obesity.

CONCLUSIONS
WHtR is one of better anthropometric measurement because it is association with NLR as a simple
marker of inflammation.

ACKNOWLEDGEMENT
This study was supported by research grant from Faculty of Medicine, Diponegoro University 2020.

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