In Depth

Diabetes and insulin access worldwide

Diabetes, both type 1 and type 2, is a health condition that has to be managed all over the globe. The rates of diabetes, as well as the treatment of it, vary from country to country. As it is Diabetes Awareness Month, we wanted to take the opportunity to look at the current state of diabetes and insulin access worldwide, and how this could change in the future.

Some quick-fire figures

It is hard to accurately estimate the worldwide prevalence of diabetes, as many cases are undiagnosed. For this reason, estimates from different sources can vary.

According to the International Diabetes Federation’s Diabetes Atlas (2017), 425 million adults across the world have diabetes and half of these cases remain undiagnosed. This includes cases of both type 1 and type 2 diabetes.

Together, China, India and the US account for over half of the world’s cases of diabetes. This is largely due to the large population of these countries, however it is worth noting that China and India also have some of the highest diabetes rates in the world, at around 10% each.

The Marshall Islands has the highest diabetes rate at 30.5%. In fact, all of the top ten countries with the highest rates of diabetes were all Pacific islands, including Tuvalu, Tokelau and Nauru.

In addition, over one million children and adolescents worldwide are estimated to have type 1 diabetes.

Public Health England (PHE) has estimated 3.8 million people in England to have diabetes, around 9% of the total population, with approximately 90% of these cases being type 2 diabetes.

Insulin access

People with type 1 diabetes rely upon insulin injections (or pumps) to control their blood glucose levels throughout the day, in order to prevent hyperglycaemia.

There are numerous treatments for type 2 diabetes, which used to be referred to as non-insulin-dependent diabetes mellitus (NIDDM). People that have been newly diagnosed with type 2 diabetes are usually prescribed metformin, a drug which improves insulin sensitivity and reduces the liver’s output of glucose. People with type 2 diabetes who do not achieve good blood sugar control with lifestyle and / or drug interventions may later be prescribed insulin to lower their blood glucose levels.

Despite insulin being an essential medication for many people, ease of access to it varies from country to country. Most Western countries have decent access to insulin while, according to the International Insulin Foundatio, things can be much more difficult in sub-Saharan Africa. For example, in 2000, a year’s supply of insulin would cost around 39% of a family’s income in Mali and would still be a significant burden on families in Mozambique and Zambia despite subsidised prices. There are also issues with cost of and access to syringes for insulin delivery and equipment for blood glucose testing.

In the US, insulin is much more accessible than in sub-Saharan African, however, it can carry a significant cost. Insulin must be paid for either through medical insurance or with personal funds. The average price of insulin in the US has nearly tripled between 2002-2013 and the UpWell Health survey found that 45% of people with diabetes have skipped care at some point due to costs and 43% have paid up to $1,000 a year out of their own pocket for treatment.

In comparison to many other countries, insulin access in the UK is very good. The NHS is largely funded by taxpayers and so most people contribute collectively to the cost of insulin. Glucose testing is also widely available on the NHS for people with type 1 diabetes, including increasing availability of continuous glucose monitoring systems such as the FreeStyle Libre. Blood glucose testing for people with type 2 diabetes, however, is usually self-funded.

Insulin prices are consistently on the rise and accusations of price-fixing have been made against companies that manufacture it. Despite large-scale criticism, two insulin manufacturers, Eli Lilly and Novo Nordisk, raised the prices of their insulin in 2017. There are campaigns such as #Insulin4all  calling for improvement of access to insulin and a decrease in its prices.

The prevalence of type 2 diabetes is on the rise worldwide, although most people with type 2 diabetes do not require insulin. For those who do, however, a recent study from The Lancet Diabetes & Endocrinology has highlighted that current rates of insulin access, particularly in Africa and Asia, cannot keep up with the increasing demand. Rates of type 1 diabetes, for which insulin is essential, are also on the rise.

The cost of diabetes

Sadly, according to the World Health Organization (WHO), 1.6 million deaths are directly attributed to diabetes each year.

On top of this, the complications of uncontrolled diabetes can cause significant discomfort and can reduce quality of life. Complications include neuropathy (nerve damage), nephropathy (kidney damage) and retinopathy (eye damage). Uncontrolled diabetes is also closely linked to heart disease and Alzheimer’s disease.

Aside from the human cost, diabetes is also a large financial burden on healthcare systems the world over. In England, type 2 diabetes costs the NHS around £8.8 billion per year, which is just under 9% of the NHS budget.

Jack Woodfield, Deputy Editor at Diabetes Digital Media, said “Of course it should be noted that there are several reasons for the cost of diabetes increasing which are more positive that one might think. Better diagnosis and treating of complications means that the life expectancies for people with either type 1 or type 2 are higher than ever before. More treatments also mean more tailored options are available for numerous comorbidities.

“The aim is of course to cure type 1 diabetes and prevent type 2, but don’t let the current costs and figures detract from the significant progress being made.”

Because type 2 diabetes is a preventable and potentially even reversible disease, there is hope for improving health and reducing insulin demand in the future. Indeed, results from our own Low Carb Program show that 60% of users with type 2 diabetes were able to reduce or eliminate use of insulin at one year. One in four users were also able to place their type 2 diabetes in remission. We have also developed the Type 1 Program, which is open for registering interest, for those with type 1 diabetes who wish to follow a low carb lifestyle.

What is the future?

There are some concerning stats regarding the state of diabetes worldwide, but it is not all doom and gloom.

Developments such as the rise of low carb and technology such as the Freestyle Libre and artificial pancreas show that progress is being made in bettering people’s diabetes control. People with type 2 diabetes are now able to put the condition into remissio, and this is significant, particularly as healthcare professionals had once assumed type 2 was a chronic, progressive disease.

The future of effective diabetes treatment and management could benefit from two things. Firstly, reducing the cost of insulin for those who are dependent on it, especially in more economically challenged areas of the globe, will make many lives easier. Secondly, preventing and potentially even reversing the type 2 diabetes epidemic through healthy lifestyle choices will have a huge impact on global health, saving lives and easing the burden on health services and people’s savings alike.

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