Issue: April 2017 - Advancing the urgency for action
Section: The global campaign
The Berlin Declaration: strengthening early action for diabetes prevention and care
Globally, one in 11 adults currently has diabetes (415 million people), costing health systems 12 percent of their total expenditure. By 2040, the global number of people living with diabetes is expected to rise by 227 million or 10.4 percent of the population, increasing health system costs by $129 billion.1 The effects of diabetes are well known. The condition, both directly and indirectly, is responsible for a major proportion of diabetes-related morbidity and mortality. Type 2 diabetes is one of the leading causes of cardiovascular disease, blindness, kidney failure, and lower limb amputation in many countries.2
World leaders, politicians and policy leaders can no longer afford to ignore the evidence. Our world is facing a health crisis so pervasive that it has become responsible for devastating national healthcare systems, economies, and personal lives from communities in the Northern Territories of Australia to the manic streets of Mumbai as well as the wealthy avenues of Manhattan and across the globe in cities and villages in sub-Saharan Africa where diabetes is significantly on the rise. No country or state is immune from the public health disaster of diabetes. Almost half of the total diabetes population are not aware they have it and nearly 75 percent of all people with diagnosed and undiagnosed diabetes live in low- and middle-income countries.
It is also well established that the implementation of effective policies and strategies are required immediately to stem the tide of the diabetes catastrophe.
The Berlin Declaration
In December 2016, best practice policy recommendations across four pillars for diabetes prevention, early detection, early control and early access were presented at the Global Diabetes Policy Forum in Berlin, Germany. The Forum, organised and funded by AstraZeneca in collaboration with the International Diabetes Federation (IDF), Primary Care Diabetes Europe (PCDE) and the World Heart Federation (WHF) and supported by German Diabetes Aid (GDA) followed the work begun under the banner of ‘Early Action in Diabetes’ at the first Global Diabetes Policy Summit held in November 2015. Participants in the 2016 Forum included leading clinical experts in diabetes, as well as patient group representatives, policy makers, and political leaders from 11 countries. Their task was to debate and identify key diabetes issues for early actionable targets and consolidate these findings into a single document calling it the Berlin Declaration. (link) The Declaration was ratified by experts from 38 countries and launched to stimulate meaningful policies at the national level and drive action for local platforms.
Four Pillars of Action
The four pillars of the Early Action initiative are based upon firm evidence and were established to drive tangible, local action to implement policies that focus on:
- Early detection,
- Early control
- Early access to the right interventions.3
The Berlin Declaration highlights the urgency to make early action for diabetes prevention and care a political priority. Written by experts from multiple nations, professions and disciplines, the Declaration has a relevance which extends far beyond clinical diabetology. It serves as an international catalyst for change that seeks to truly transform people’s lives.
Levels of Prevention
This taxonomic structure covers the entire spectrum of proactive approach to diabetes from primary, through secondary, to tertiary prevention. Primary prevention includes actions designed to prevent progression of risk factors (such as unhealthy eating habits and physical inactivity). Secondary prevention encompasses the actions listed in early detection and control (early diagnosis and management). Tertiary prevention is concordant with early control (which also includes timely care of complications of diabetes).4 Early access to the right interventions conveys the need to ensure translation of thoughts and words into action and results.
The Berlin Declaration envisages a national diabetes control plan for each country, which should focus on prevention of diabetes in both adults and children. The national screening program should also include systemic and proactive assessment of high risk individuals; foster alignment between relevant healthcare specialties; allow for collection of data; and plan for capacity building. Early control can be promoted by creating national guidelines on management of type 2 diabetes, establishing monitoring systems, and offering financial incentives to healthcare professionals for optimal care.
The national diabetes plan should also identify clear cut recommendations, strategies, goals, and timelines for achieving the same. A national formulary of drugs should be put in place, and a ten-year plan prepared for ensuring better access to diabetes healthcare. Such plans should cover policies promoting preventive measures such as taxation of sugar-sweetened beverages, restricted advertisement of unhealthy foods, modification of urban environments and better access to healthy consumer foods and markets in order to encourage healthy living.
The importance of these strategies cannot be overemphasized. Yet, it is challenging to implement them on the ground. The reasons for failure to meet targets fall under two factors: first, poor sensitization about the adverse effects of uncontrolled diabetes, and second, other priorities which prevent adequate focus on diabetes prevention and care.
Both these issues need to be addressed by all stakeholders defined as the five Ps (patient, physician, public (community), policymaker/politician and payer (insurance).5 Concerted and sustained efforts should be made to inform, influence and empower these stakeholders to the unwanted effects of uncontrolled diabetes and the evidence-proven improvement in outcomes that are possible with metabolic control. Apart from the health impact, the economic burden of diabetes and its complications should be mentioned. While no attempt should be made to denigrate the significance of other health and non-health related priorities, the role of diabetes in these conditions can be highlighted. Thus, diabetes can be positioned as a complementary rather than conflicting priority with tuberculosis, HIV, hepatitis, pregnancy, road traffic accidents, mental illness, and cancers.6
The South Asian physician occupies a significant place of pride and respect in his or her community. The primary care physician is community-based, community-oriented, community-responsive and community-relevant. As a result, any health related message coming from a healthcare professional is heard, accepted and often implemented by the community. Physicians should ensure that they all speak the same language in a manner their community can understand to promote prevention, early detection, early control and early access. Planning should involve religious, cultural and government leaders in diabetes related activities. Campaigns to create diabetes friendly physical and social environments can be spearheaded and supported, as can movements for healthy cooking and eating.
The Berlin Declaration is meant to help us challenge the current status quo in diabetes prevention and care and improve efforts towards better management of diabetes. By working together and learning from each other, we will become more efficient and effective in our progress. The Berlin Declaration will improve the current state of diabetes to a significant degree enhancing the lives of individuals and improving diabetes prevention and care around the world.
Physicians form the backbone of the healthcare system and provide care to the vast majority of people with diabetes. The Berlin Declaration should be adopted by every country worldwide where diabetes efforts will be prioritized ensuring prevention, early detection, early control, and early access to the right interventions. This will achieve a global victory over diabetes and its complications.
About the authors
Sanjay Kalra is Vice President of South Asian Federation of Endocrine Societies (SAFES) and an endocrinologist at Bharti Hospital, Karnal in Haryana, India.
Ashok Kumar Das is Professor & Head Medicine PIMS, Pondicherry, India and Patron for the Research Society for Study of Diabetes in India.
1. International Diabetes Federation, IDF Diabetes Atlas, Seventh Edition, 2015.
2. Complications of diabetes. http://www.idf.org/complications-diabetes Accessed on 19 December 2016.
3. The Berlin Declaration. October 2016.
4. Kalra S, Sreedevi A, Unnikrishnan AG. Quaternary prevention and diabetes. J Pak Med Assoc 2014; 64:1324-6.
5. Kalra S, Unnikrishnan A G, Das A K. Improving adherence to insulin: Hope with degludec. J Soc Health Diabetes 2014; 2: 1-2.
6. Sharma R, Kumar KH, Kalra S. The ominous octet of “S” in noncommunicable disease. J Soc Health Diabetes 2017; 5: 12-15.