In Depth

Is type 2 diabetes as big a crisis as we’re led to believe?

There’s no denying that the high rates of type 2 diabetes is a problem. We see the headlines all the time: “diabetes out of control,” “type 2 diabetes ‘a ticking time bomb'”. It’s a compelling narrative. But maybe the reason we find it so scary isn’t because so many people have it – it’s because so many people have it compared to just a few decades ago.

And yes, unhealthy diets play a large part in that. The ever-decreasing price of processed food, the ever-increasing price of fresh fruit and vegetables, the abundance of sugars and other refined carbohydrates: these are all part of a serious problem. But if type 2 diabetes rates had been twice as high 30 years ago as they are today, we’d be calling today’s figures a success. The real problem, what we’re really afraid of, is that our lifestyles are going down a slippery slope. It’s that idea, rather than the numbers themselves, that make it a “ticking time bomb.”

Is it all as bad as it sounds? Not according to Nick Wareham, of the MRC Epidemiology Unit at the University of Cambridge. In an editorial published in PLOS Medicine called “Progress in Medicine: Experts Take Stock,” he was asked “Diabetes is at epidemic levels. How can its progress be halted?” In answering, he explained that there might be more to the worrying statistics than it seems.

There might be more to the worrying statistics than it seems.

For one, we’re all living longer[1], and type 2 diabetes is strongly connected to age.[2] As we get older, our blood glucose levels naturally rise, so insulin resistance inevitably becomes more likely. With a much older populatio, and a much larger proportion of the population over a certain age than there used to be, a small increase in rates of type 2 diabetes is to be expected. In fact, so distinct is age-related type 2 diabetes as a condition that a study recently called for it to be renamed “type 4 diabetes.” Not only would this be more scientifically accurate – the metabolic process of type 2 diabetes is largely different when it’s related to age – it would allow us to see what proportion of type 2 diabetes statistics is being beefed up by our increased life expectancy.

“[T]he prevalence of diabetes has increased markedly across all continents. Part of that increase is undoubtedly due to an increase in the incidence of diabetes, but much is attributable to the ageing of populations (since type 2 diabetes is such an age-dependent disease),” said Wareham.

type 2 diabetes elderly blood testing

Increased life expectancies are partly to blame for today’s high rates of type 2 diabetes. Blood sugars naturally rise as we get older.

Moreover, improved treatment options mean that people with type 2 diabetes are living longer, which also inevitably bumps up the statistic.[3] Decades ago, people with type 2 diabetes would have died of their condition more quickly, so there simply wouldn’t have been as many people with type 2 diabetes around.

Another reason for the worrying type 2 diabetes statistics might also be that we’re now much better at diagnosing it. Glycemic thresholds for type 2 diabetes are periodically revised and often lowered. Some people believe that’s so more people can be given glucose-lowering medications, others feel it’s a necessary step to encourage people to make serious lifestyle changes.[4] Whatever the reaso, the rates of diabetes will automatically increase if you move the threshold.

Another reason for the worrying type 2 diabetes statistics might also be that we’re now much better at diagnosing it. Glycemic thresholds for type 2 diabetes are periodically revised and often lowered.

It’s also likely that the reported type 2 diabetes rates from decades ago are actually far too low, and it’s simply the case that more people were living with undetected type 2 diabetes back then. It’s possible that high rates of type 2 diabetes are both worrying and oddly positive; it suggests that we’re getting better at finding the people who have it and making useful changes to diagnostic criteria in order to improve health outcomes.

Beyond that, Wareham says a number of interesting things about how diabetes should be treated. He argues that it’s better to target people at low to moderate risk of type 2 diabetes, because in these people it can be easily prevented. By focusing on high-risk people, you’re constantly fighting an uphill battle, meanwhile millions of moderate-risk people are becoming high-risk people.

It’s better to target people at low to moderate risk of type 2 diabetes, because in these people it can be easily prevented. By focusing on high-risk people, you’re constantly fighting an uphill battle, meanwhile millions of moderate-risk people are becoming high-risk people.

“Although such intervention programs are effective for those individuals who participate in them, the impact of these high-risk prevention approaches on the epidemic of diabetes is relatively small. Much greater public health benefit can be achieved by population approaches that seek to promote small changes in behaviour in large groups of people at low to moderate risk. Although such changes make little impact on individual-level risk, when they are amassed across large populations, this strategy makes the greatest impact on the epidemic of diabetes. There is no single intervention that can effect such population-level changes; instead, a wide range of different approaches are needed.”

Wareham also identifies type 2 diabetes as a societal problem:

“Perhaps the biggest initial step is for governments to recognise and accept that diabetes is a clinical manifestation of a societal problem that requires societal solutions.”

When people talk about diabetes as a social problem, it means that it is caused, at least indirectly, by the structure of society; to solve diabetes, we need a society that is more equal. For example, it is well-established that people from working class and less affluent tend to consume more processed food and, on the whole, eat less healthy diets. They also have higher rates of type 2 diabetes. The reasons behind that are complex and numerous. If we are to get anywhere in solving diabetes, Wareham argues, we need to stop pretending that this aspect of diabetes does not exist.

Although type 2 diabetes is clearly a hugely significant health problem, don’t let the numbers scare you too much. The story behind them is a little more complex, and a little less bleak.

 

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