There is an urgent need for governments to face the challenge of translating the evidence on preventive initiatives into affordable and feasible programmes in order to curb the diabetes epidemic. At the same time, investments must be made in diabetes care and management, including diabetes education, to enable the millions of people with diabetes to lead full and productive lives.
A substantial proportion of type 2 diabetes is preventable, while the prevention of type 1 diabetes remains a critical area for research. This section looks at some of the evidence that confirms that there are effective measures to prevent or delay the onset of type 2 diabetes. Such measures include supporting changes in behaviour to reduce overweight and increase physical activity, and the use of certain glucose lowering drugs. This section raises the challenge of how to translate the evidence from well-resourced research studies into initiatives that are affordable and feasible, whether in richer or poorer parts of the world. It is clear that what is needed are not only initiatives to identify people at high risk of developing type 2 diabetes, for whom appropriate preventive measures can be provided, but also measures that will lower the risk across the entire population. Population-wide measures will need to include approaches to increasing physical activity and promoting healthier diets. Such measures require actions outside the health sector. For example, measures may include policy initiatives in areas such as transport, urban planning, food pricing, food advertising and education. In short, a sector-wide approach is needed.
The challenges of diabetes for the individual and society, with a particular emphasis on type 2 diabetes, are also examined. For those who have diabetes many of the complications can be prevented or delayed with access to the right support and healthcare. Good control of blood glucose, lipids and blood pressure, high quality foot care and retinal screening are examples of measures that are known to be effective. Even in low-resource settings there is much that can be done to improve the lives of people with diabetes.
Providing good diabetes care for a population requires coordination across three levels of organization. At the micro level, and at the centre of all care, are the people with diabetes, their families and their immediate carers. At the meso level is the community and healthcare organizations within which care is delivered. At the macro level are the supporting policy and financing frameworks. The World Health Organization’s Innovative Care for Chronic Conditions Framework provides guidance on the relationships between, and the contents of, these three levels. This framework can be used to help repair the fragmentation of health services across the range of needs that people with diabetes have, and to provide links to broader population interventions, such as those for the prevention of diabetes.
The person with diabetes is the key member of the diabetes management team, as on a day to day basis they make most decisions that affect their care. This section also looks at the urgent need to invest in diabetes education, the cornerstone of self-care management, in all healthcare systems. Investment must be made not only to ensure specialized diabetes education is accessible to healthcare personnel and people with diabetes but also to ensure both groups are trained in how to implement change.
There is excellent evidence that type 2 diabetes can be prevented, or at least its onset delayed, in individuals at high risk. Most of the evidence is from studies that have included people with IGT. Behavioural modification and pharmacological interventions have both been shown to be effective, and to reduce the onset of new diabetes by up to 60% or more. Overall the evidence suggests that lifestyle counselling to support behavioural change, such as losing weight (for those overweight), increasing physical activity, and eating a healthy diet is more effective than pharmacological interventions 1 . For example, for around every six people at high risk treated with lifestyle counselling one new case of diabetes will be prevented over five years, whereas to prevent one new case with an oral diabetes drug, around 11 people will need to be treated. There is evidence that the lower risk of diabetes from lifestyle counselling persists long after its discontinuation, with results from a study in China showing that the benefits were still apparent 20 years later.
Translating findings from prevention trials into the community
The challenge now is to translate the findings from the well resourced research studies into diabetes prevention initiatives that are affordable and feasible in both low- and high-income countries. The challenge includes finding the most efficient and cost-effective ways to identify people at high risk of developing diabetes, and then providing an effective intervention that is feasible and affordable within the local setting. While there are examples of such initiatives they have tended to be small and poorly evaluated. It is also clear that an initiative developed for one population or group may not be appropriate for another population or group. Thus, community initiatives aimed at the prevention of type 2 diabetes in individuals at high risk need to be developed and evaluated for the specific settings in which they will be used.
National efforts to prevent diabetes
It is acknowledged that while it is important to identify individuals at high risk of developing diabetes for preventive efforts, this will have a limited impact on the rate of diabetes at a national level. What are also needed are measures that reduce the risk across the whole population. Evidence suggests that relatively small improvements in nutrition, reductions in obesity and increases in physical activity if applied across a whole population can have a large impact on the rates of diabetes, and other chronic diseases that share the same risk factors (such as cardiovascular disease and many cancers). Much more attention needs to be given as to how to achieve such population-wide changes. The DEHKO project in Finland 2 provides an example of a comprehensive approach to diabetes prevention and management, which aims to improve nutrition and physical activity across the population, identify and provide individualized support to those at high risk of diabetes and assist with the early detection and management of those who actually have diabetes (see Box 4.2).
Cost effectiveness of prevention
Economic evaluations of approaches to identifying and providing preventive measures to people at high risk of diabetes generally suggest that these are cost effective. However, most evaluations contain many uncertainties and there is a need for further work to examine the cost effectiveness of interventions in everyday practice. There is an even greater challenge in assessing the cost effectiveness of population-wide measures.
The background paper, The Prevention of Type 2 Diabetes, on which this summary is based is available in the Downloads  section.
Box 4.1 National Diabetes Prevention Plans 3
Government initiatives should include:
—Supporting national associations and non-government organizations
—Promoting the economic case for prevention
• Community support
—Providing education in schools on nutrition and physical activity
—Promoting opportunities for physical activity through urban design (e.g. to encourage cycling and walking)
—Supporting sports facilities for the general population
• Fiscal and legislative
—Examining food pricing, labelling and advertising
—Enforcing environmental and infrastructure regulation (e.g. urban planning and transportation policy to enhance physical activity)
• Engagement of private sector
—Promoting health in the workplace
—Ensuring healthy food policies in food industry
• Media communication
—Improving level of knowledge and motivation of the population (press, TV and radio)
The Development Programme for the Prevention and Care of Diabetes in Finland (DEHKO 2000–2010) 2 was the first national diabetes programme to implement strategies for the prevention of type 2 diabetes on a population-wide scale. It is now in its final phase after nearly a decade of activity, but there are further plans for the future. DEHKO is a programme that is widely watched for the comprehensiveness in which it has worked towards reducing the incidence of type 2 diabetes in a population and, at the same time, raising the quality of diabetes care.
The FIN-D2D Project (2003–2008) within DEHKO and the follow-up project to D2D are specifically tasked with the implementation of the prevention programme for type 2 diabetes. The FIN-D2D Project has also developed new models for prevention to be disseminated to all primary healthcare centres and occupational healthcare units in Finland. The effectiveness and the cost-effectiveness of these new prevention and care practices are being evaluated. The project is now working towards making the prevention of diabetes and cardiovascular disease part of healthcare routine. More information on DEHKO, which is coordinated by the Finnish Diabetes Association, is available at www.diabetes.fi .
A project to reduce the burden of type 2 diabetes by education and lifestyle interventions in people at high risk is currently underway in Latin America. The LATIN_PLAN project will implement an intervention programme at primary healthcare level in Argentina, Brazil, Colombia, Ecuador, Peru, Uruguay and Venezuela.
The project is based on current evidence and best practice in the prevention of type 2 diabetes, especially those found in the European diabetes prevention projects (DE-PLAN and IMAGE projects). It also will develop and implement a curriculum for training diabetes prevention managers in Latin America, who will provide a basis for long-term activities at population level, and guarantee sustainability and continuity at the community level. The project is coordinated by the Research Unit of the Hospital Universitario La Paz in Madrid, Spain. More information is available from firstname.lastname@example.org .
1: Gillies CL, Abrams KR, Lambert PC, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ 2007; 334 (7588): 299.
2: Finnish Diabetes Association. Development Programme for the Prevention and Care of Diabetes in Finland DEHKO 2000-2010. 2009. http://www.diabetes.fi/sivu.php?artikkeli_id=831 
3: Alberti KG, Zimmet P, Shaw J. International Diabetes Federation: a consensus on Type 2 diabetes prevention. Diabet Med 2007; 24 (5): 451-463.
The ultimate goal of diabetes therapy is to prevent diabetes complications, such as kidney and heart diseases, in order to improve quality of life and life expectancy. There is excellent evidence that the development of complications can be significantly reduced and their progress and impact limited once they have developed 1 .
On a day to day basis most decisions that affect the risk of complications are made by people with diabetes themselves, not by health professionals. Therefore, structured diabetes education to empower people with diabetes, and their carers, to manage their condition is crucial (see Diabetes Education ). Lifestyle measures such as eating healthily, maintaining a normal weight, regular physical activity, and not smoking are central to diabetes management, and could lead to improvements in blood glucose, lipids and blood pressure and a reduced risk of complications. In addition, medication often has an important role to play, particularly for the control of blood glucose, lipids and blood pressure.
The IDF Global Guideline for Type 2 Diabetes 1 provides an evidence-based framework for setting targets for glucose, blood pressure and lipids, and titrating treatment in order to achieve them. Oral glucose lowering medication is prescribed when lifestyle measures are insufficient to achieve blood glucose control. For most people metformin, which increases sensitivity to insulin, is the drug of first choice followed by a sulfonylurea, which stimulates insulin release. These drugs have been used in the management of diabetes for decades. If these drugs fail to control blood glucose then other options include thiazolidinediones (increase sensitivity to insulin) and alpha glucosidase inhibitors (decrease rate of glucose absorption from the gut). Newer options include the so-called GLP-1 (glucagon-like peptide) mimetics and DPP-4 (dipeptidyl peptidase 4) inhibitors, both of which increase insulin release. At this time experience with these newer agents is limited but they may have a more prominent role in the future.
Overtime the insulin-producing cells within the pancreas of people with type 2 diabetes deteriorate and eventually in most people insulin is needed as other measures are not sufficient to control blood glucose. Insulin analogues may offer some advantages, particularly with respect to hypoglycaemia and weight gain. The introduction of insulin requires close cooperation between the person with diabetes and health carers.
Diabetes care does not need to be expensive to be highly effective. In work carried out for the World Bank and World Health Organization 2 interventions for diabetes were classified into three levels based on an assessment of their feasibility and cost effectiveness in developing country settings. Interventions in the first level were found to be highly cost effective or even cost saving, and included moderate blood glucose and blood pressure control and foot care. Recognizing that most people with diabetes live in developing countries, the IDF Global Guideline provides guidance appropriate to three different levels of resource availability.
Type 2 diabetes has a long asymptomatic phase, which frequently goes undetected but during which diabetes complications are developing, and can be present in half or more people with diabetes at diagnosis. Thus, early detection and treatment could help reduce the burden of diabetes complications, and evidence suggests that earlier intensive treatment is indeed effective. However, issues such as who to screen, and what to do with those found to be at high risk of developing diabetes are unresolved. The solutions to these issues will differ between countries, dependent on factors that include the prevalence of undiagnosed diabetes, and the available healthcare resources.
The background paper, Challenges of Type 2 Diabetes, on which this summary is based is available in the Downloads  section.
Box 4.3 Areas of individual diabetes care requiring regular review
1: International Diabetes Federation. Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation; 2005. http://www.idf.org/node/1285?unode=B7462CCB-3A4C-472C-80E4-710074D74AD3 
2: Narayan KV, Kanaya PZA, Williams D, et al. Diabetes: The Pandemic and Potential Solutions. In Jamison D, Breman J, Measham A, et al, editors. Disease control priorities in developing countries. Second Edition. World Bank/Oxford University Press; 2006. p591-604.
Architect-trained Zahida Khan was diagnosed with type 2 diabetes as an adult, and has continued to live a full and active life, free of complications, through careful management of the disease.
Although guidelines for best practice in diabetes care are readily available, including the IDF Global Guideline on Type 2 Diabetes, and there are several frameworks to guide their implementation, it remains a challenge in all countries to bridge the gap between actual and optimal care.
One important part of any solution is education. Diabetes-specific education is required for healthcare personnel and people with diabetes; and in addition training is needed to help them integrate new knowledge and transform old practices. The latter is essential if clinical outcomes for people with diabetes are to be improved. It has been shown that without a purposeful, planned method of changing clinical or personal behaviour, very little happens. Investment must be made not only to ensure specialized diabetes education is accessible to healthcare personnel and people with diabetes but also to ensure both groups are trained in how to implement change 1 2 .
Ministries of Health and health administrators need to recognize and give support to the special healthcare needs of people with diabetes 1 and this includes designing health systems that facilitate best practice 2 . Providing good diabetes care for a population requires the coordination of the health systems across three levels. At the centre of all care is the person with diabetes, their family and their immediate carers. At the middle level is the community and healthcare organizations within which care is delivered. Effective functioning across the providers needed to care for people with diabetes requires supporting policy and financial frameworks. The World Health Organisation’s Innovative Care for Chronic Conditions Framework 3 provides guidance on the relationships between, and the contents of, these three levels. This framework was designed to be helpful within different resource settings, rich to poor, and has been developed with suggested methods of quality improvement to incrementally strengthen health systems for diabetes and other chronic diseases (see Beyond Access to Insulin ).
Modern improvement processes have had positive results in many countries, including Canada, USA, United Kingdom, Ghana, Malawi, South Africa, Russia and Peru. A critical factor in their success is that they develop and implement solutions specific to the realities of their settings 2 . Reorganization of current resources or addition of new resources may be required to fill overt gaps in care, such as interdisciplinary teams specially trained to provide diabetes self-management education and follow-up or access to essential medicines packaged with education to support their use. The advancement of diabetes care relies not only on increased knowledge and behaviour change but also on using proven methods to advance health systems to support best practice 4 .
"Diabetes self-management education (DSME) and ongoing self-management support are critical components of effective diabetes care, and significant contributors to metabolic and psychological outcomes." 5 In many areas of the world people with diabetes cannot access this essential treatment. Interactive DSME is essential for people with diabetes to understand their condition, protect themselves from harm and make lifestyle changes to optimize their health. To design an accessible programme, funding needs to be provided for healthcare personnel with specialized training in DSME. Programmes must be locally affordable, offered in areas accessible to the target population, delivered at appropriate literacy levels and be culturally relevant. Diabetes self-management education and diabetes self-management support must be available and accessible for people with diabetes if optimal outcomes are to be achieved 5 .
People with diabetes have the right to understand their disease, make informed choices and receive care based on best practice. They must be part of the team that manages their condition.This can only be achieved if interdisciplinary teams and people with diabetes have the information and tools to make changes based on best practice and recognized improvement strategies are used to support meaningful system change.
A survey was carried out by the IDF Consultative Section on Diabetes Education in 2008 to gain a deeper appreciation for diabetes education practices worldwide and to provide a preliminary look at diabetes education in specific areas. The purpose of the survey was to capture responses from providers regarding practice setting, descriptions of diabetes teams, resources for diabetes education, community services and barriers to diabetes education.
The survey questionnaire was based on the structural and process standards for diabetes health education defined in the IDF’s International Consensus Standards for Diabetes Education 6 , which provide a benchmark against which the quality of DSME programmes can be evaluated.
The surveys were completed by healthcare professionals selected to participate in train-the-trainer sessions. The survey respondents represented healthcare institutions in the IDF African, European, Middle East and North African, North America and Caribbean, and South and Central American Regions.
The survey results provide preliminary data on the status of diabetes education in the different regions. Forty-five out of 55 participants responded, giving a response rate of 82%. Respondents represented 26 countries in the five regions.
The results indicated that diabetes education was integrated into national diabetes programmes in two-thirds of the countries which had such a programme. The results also showed that diabetes education was practised in a variety of settings by many different healthcare providers. When asked about the most significant barriers to diabetes education, lack of resources in terms of the number of diabetes educators from the systems perspective was most often cited (see Figure 4.1). Another important barrier was that people with diabetes did not have time or support from employers to pursue diabetes education. The results also confirm that despite the presence of national diabetes programmes, people with diabetes may not have access to adequate education and care.
These data are limited by the sample chosen to participate and should not be considered statistically representative. However, the respondents do provide insight into their perception of diabetes education in their country. Despite the limitations of the survey, the results demonstrate a clear need for increased numbers of diabetes educators and support for diabetes self-management education for people with diabetes.
1: World Health Organization. Innovative Care for Chronic Conditions: Building Blocks for Action. Global Report. Geneva: World Health Organization; 2002. http://www.who.int/diabetesactiononline/about/icccreport/en/ 
2: Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282 (15): 1458-1465.
3: Jordan EJE, Pruitt SD, Bengoa R, et al. Improving the quality of health care for chronic conditions. Quality and Safety in Health Care 2004; 13 (4): 299-305.
4: World Health Organization. 2008-2013 Action Plan for the Global Strategy for the prevention and control of non-communicable disease. Geneva: World Health Organization; 2008. www.who.int/nmh/Actionplan-PC-NCD-2008.pdf 
5: Berwick DM. Lessons from developing nations on improving health care. BMJ 2004; 328 (7448): 1124-1129.
IDF Consultative Section on Diabetes Education International Consensus Standards for Diabetes Education 2003
IDF Consultative Section on Diabetes Education International Consensus Standards for Diabetes Education 2003