The Pan American Health Organization and World Diabetes Day
Several landmarks related to diabetes are being marked this year. This is the eightieth anniversary of the discovery of insulin by Frederick Banting and Charles Best. This year is also the fifth anniversary of the Declaration of the Americas on Diabetes (DOTA), which the Pan American Health Organization (PAHO), the International Diabetes Federation (IDF), and other partners established to promote better health for people affected by diabetes in the Region of the Americas. November of this year is particularly notable. World Diabetes Day is celebrated on 14 November, which was Frederick Banting's birthday. As one part of commemorating these various events, PAHO is proud to dedicate this special issue of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health to the subject of diabetes in the Americas.
Diabetes is reaching epidemic proportions around the world. It is estimated that the number of people with diabetes in the Region of the Americas will increase by 83% over the next 25 years (1). In the Region approximately one-third of the people with diabetes are undiagnosed (2), and half of the people newly diagnosed with diabetes are already affected by chronic complications at the time of their diagnosis (3). People with diabetes are 13 times more likely to have lower-limb amputations than are those without diabetes (4). More than 20% of people with type 2 diabetes are affected by diabetic retinopathy, and about 5% of them are legally blind (5, 6).
In Latin America and the Caribbean (LAC) there is limited information on the quality of diabetes care. However, the available information suggests that diabetes care in the LAC countries is suboptimal. For example, information from Argentina, Brazil, Chile, Colombia, Paraguay, Trinidad and Tobago, Uruguay, and the U.S. Virgin Islands (Tortola) indicated that between 37% and 71% of patients under care were classified as having poor glycemic control (7, 8). Access to health education and preventive care for people with diabetes in Latin America and the Caribbean is limited. For instance, people with diabetes who had had an eye exam documented during the preceding year varied from 2% in Tortola and in Trinidad and Tobago to 6% in Jamaica (8, 9). Similarly, foot-care rates varied from 4% in Tortola to 19% in Barbados (8).
Globally, the impact of diabetes on mortality is a problem of unknown magnitude. As an underlying cause of death, diabetes is related to about 40 000 deaths per year in Latin America and the Caribbean (10). However, it is well known that diabetes is not well represented in mortality statistics coming from death certificates. The Global Burden of Disease estimated that the number of deaths related to diabetes in Latin America and the Caribbean was more than 300 000 in 1995 (11), while recent estimates from the World Health Organization placed this number at more than 400 000 per year3. It was recently reported that diabetes was related to 13% of all deaths in Dominica (12).
Coming from the Finish Diabetes Prevention Study and the United States Diabetes Prevention Program, there is new evidence on the preventability of type 2 diabetes through lifestyle modifications (13, 14). There is no denying that we need to work harder to find new ways to implement public health strategies that are based on current knowledge. There is also unquestionable evidence that diabetes control can improve survival and prevent microvascular complications such as retinopathy, nephropathy, and neuropathy, in both type 1 diabetes and type 2 diabetes (15, 16). Although in Latin America there is limited experience with community-based diabetes interventions, reports have been consistent in showing the advantages of education efforts and of programs to improve the quality of care. For example, a multinational diabetes intervention program called PENID-LA demonstrated improved glycemic control as well as savings of 34% in the cost of medication following a diabetes education program (17).
PAHO and its associates are working to improve diabetes prevention and control in the Americas. One of the best examples of this are the efforts that PAHO, IDF, and other partners have made to implement the Declaration of the Americas on Diabetes (DOTA). Over the past 5 years, this coalition's achievements have included:
implementing workshops to enhance and support the development of multidisciplinary partnerships at the country level as well as to strengthen the development of national diabetes programs
establishing a regional program aimed at delivering standardized diabetes education in Latin America
supporting the pilot implementation of the "Qualidiab" quality-of-care information system in Argentina, Brazil, Chile, Colombia, Paraguay, and Uruguay, through the fssunding of DOTA industry partners
implementing a pilot evaluation on quality of care in the Caribbean, for Dominica, Jamaica, and Saint Lucia
using contacts at the country level throughout the Americas to enhance communications and expand awareness of diabetes at the local level
creating a framework to facilitate training for national and local organizations to enable them to develop self-sufficiency in organizational functioning and fund-raising
In another initiative, PAHO is working with the Centers for Disease Control of the United States on the U.S.-Mexico Border Diabetes Prevention and Control Project, to address the problem of diabetes in states on both sides of the border.
PAHO and its partners are committed to finding better public health measures to identify people at risk and to prevent type 2 diabetes. At the same time, secondary prevention needs to be improved through better access to quality care so as to reduce the enormous toll that diabetes takes on the people of the Americas. We are confident that through its collaborative efforts that PAHO will help improve the situation of diabetes in this Region.
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2. Barceló A, Daroca M, Rivera R, Duarte E, Zapata A, Vorha M. Diabetes in Bolivia. Rev Panam Salud Publica 2001:10(5):318-323.
3. Damiano M, Rebollo S, Castro P, Gheggi M, Sereday M. Diabetes tipo 2: Complicaciones crónicas al diagnóstico. Revista de la Asociación Latinoamericana de Diabetes 1998;2:93.
4. Stambovsky Spichler ER, Spichler D, Lessa I, Costa e Forti A, Franco LJ, LaPorte RE. Capture-recapture method to lower extremity amputation rates in Rio de Janeiro. Panam Salud Publica 2001:10(5):334-340.
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7. Gagliardino JJ, Echegoyen G. A model educational program for people with type 2 diabetes. A cooperative Latin American implementation study (PENID-LA). Diabetes Care 2001;24:1001-1007.
8. Gulliford MC, Alert CV, Mahabir D, Aryanayam-Baksh SM, Fraser HS, Picou DI. Diabetes care in middle-income countries. A Caribbean case study. Diabet Med 1996; 13(6):574-581.
9. Wilks RJ, Sargeant LA, Gulliford MC, Reid ME, Forrester TE. Management of diabetes mellitus in three settings in Jamaica. Rev Panam Salud Publica 2001;9(2):65-72.
10. Pan American Health Organization. Health statistics from the Americas, 1998 edition. Washington, D.C.: PAHO; 1999. (PAHO Publication SP 567).
11. Murray CJL, Lopez AD. The global burden of disease in 1990: final results and their sensitivity to alternative epidemiological perspective, discount rates, age-weights and disability weights. In: Murray CJL, Lopez AD, eds. Global burden of disease. Cambridge, Massachusetts, United States of America: World Health Organization, Harvard School of Public Health, and World Bank; 1996. pp. 247-294.
12. Simeon DT. Diabetes related morbidity and mortality in Dominica and Grenada 1996- 1998. Bridgetown, Barbados: PAHO/WHO Office of Caribbean Program Coordination; 2001.
13. Tuomilehto J, Lindstrom J, Erikson J, Valle TT, Hamalainen H, Ilanne-Parikka P, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344(18):1343-1350.
14. United States, Department of Health and Human Services. Diet and exercise dramatically delay type 2 diabetes. Diabetes medication metformin also effective [news release]. 8 August 2001. Available from: http://www.hhs.gov/news/press/2001pres/20010808a.html
15. The Diabetes Control and Complication Trial Research Group. The effect of intensive diabetes treatment of diabetes on the development and progression of long-term complication in insulin-dependent diabetes mellitus. New Engl J Med 1993; 329(14): 77-86.
16. United Kingdom Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53.
17. Gagliardino JJ, Echegoyen G. A model educational program for people with type 2 diabetes: a cooperative Latin American implementation study (PENID-LA). Diabetes Care 2001;24:1001-1007.
1 Pan American Health Organization, Program on Non-Communicable Diseases, Washington D.C., United States of America.
2 Declaration of the Americas on Diabetes, Alexandria, Virginia, United States of America.
3 King H, Roglic G, Lozano R, Boshi-Pinto C. Global burden of diabetes: estimates of mortality for the year 2000 [unpublished document]. 2001.