5.4.6. Control tools and policies

Long term complications, observed in both forms of the disease, can be reduced or even prevented if the appropriate near normoglycaemia is obtained through intensive treatment from the moment of diagnosis onwards.

For T2DM, primary intervention (prevention of obesity and overweight) as well as secondary intervention (early intensive treatment) can modify the progression of the disease. An early diagnosis and/or active detection of previously undiagnosed T2DM may contribute considerably to the reduction of complications, something even more important in the case of countries reporting a percentage as high as 50% of non-diagnosed patients (prior to complications), which translates into a diagnosis made when the first complications are already present.

According to Waugh et al (2007), the scope for screening undiagnosed diabetes has probably become somewhat stronger compared to the last review, because of the greater options for the reduction of CVD and of the rising prevalence of obesity and T2DM. A recent paper (Jessani et al. 2007) investigated patients with acute myocardial infarction (AMI), confirming the high frequency of previously undiagnosed diabetes mellitus and impaired glucose tolerance in patients with AMI. The importance of oral glucose tolerance testing for the diagnosis of this high-risk group should be better emphasised.

5.4.6.1. Surveillance

The development of reliable, reproducible and comparable indicators within the EU has become urgent in order to ensure close surveillance of the epidemiology of this disease and its complications, as well as the possible impact public health intervention programs may have on these issues,.

Close monitoring of diabetes mellitus and its complications in the EU requires carefully selected indicators, which should meet the usual requirements of relevance (i.e they should provide relevant information on the disease), validity (they should be realistic), comparability (they should be comparable or should allow future comparison between countries or regions); reproducibility and sensitivity (they should be sensitive to changes over time and place); and feasibility.

All projects undertaken in this field have to continuously face all these problems, and especially the one related to feasibility, which becomes increasingly difficult when taken at broader geographical level. The EU Program of Community Action on Public Health targeted the need for comparative information on the following aspects:

-          measuring health status trends/determinants throughout the Community;

-          facilitating planning, monitoring and evaluation of Community programs and action;

-          providing Member States with appropriate health information to compare and support their national health policies.

The European Commission, through this program, has favoured the progressive development of a surveillance system at continental level. In the field of diabetes, the “European Diabetes Indicator Project” (EUDIP) has provided the foundations to designate the candidate list of core and secondary indicators. The project aimed at “establishing the indicators for monitoring diabetes and its morbidity” at national level. The set of indicators released at the end of the project were considered as feasible for collection at national basis (de Beaufort 2003). The final report, published in December 2002, made it clear that the comparability of national indicators is far from straightforward. The subsequent “European Core Indicators in Diabetes” (EUCID) project was started in 2006 “to make the national facts of Diabetes Mellitus and its risk factors available throughout the European Union”. The project involved 19 Countries and ended in 2008. As shown in the previous section on data presentation, the project allowed to collect EUDIP indicators in 20 European countries, confirming the current limited availability of all indicators, but also forming the basis for knowledge sharing in Europe. The initiative will probably continue. The task of automating the production of EUCID indicators has now been passed to the EUBIROD project through the use of BIRO technology (see “Future developments”).

5.4.6.2. Primary prevention

For Type 1 diabetes, genetic susceptibility combined with one or many environmental factors will lead to the immune-mediated progressive failure of the beta cells. So far, no prevention is possible for this type of diabetes.

The burden of diabetes may be effectively reduced through appropriate lifestyle intervention. Risk factors are well known and must be taken very seriously by the entire population. Information campaigns are still among the most effective resources for national governments. Due to the great increase of obesity, the dither prevalence of type 2 diabetes is rising and has now become a public health issue. We can curtail the diabetes and obesity epidemic only when we take overweight and obesity seriously. The required public health measures include promotion of physical exercise and healthy lifestyles. See Chapter 5.13. on overweight and obesity for the preventive approaches to this important risk factor. For high blood pressure and high cholesterol, see Chapter 5.2.4. and for other risk factors see Chapter 10.

To prevent the occurrence of the disease, it is also very important to monitor other risk factors regularly in order to capture grey areas before entering a clear diabetes status.

 

5.4.6.3. Secondary prevention

Screening may be an important weapon in the secondary prevention of diabetes, but this poses the challenge of identifying high risk categories in order to reduce morbidity and mortality through the timely initiation of adequate treatments. The WHO 2003 report defines screening as the process used for identifying those individuals who are at a sufficiently high risk of a specific disorder in order to guarantee further investigations or direct actions. The definition of high risk state in the case of diabetes obesity should also include one or more of the above mentioned risk factors. This is one case in which screening on an annual basis should be guaranteed. Type 2 diabetes and cardiovascular disease share many risk factors, as for example high waist circumference, elevated blood pressure and hyperlipidaemia. When considering population-based screening, the screening of hyperglycaemia, alone is not enough as also the other factors should be included.

Regular management of diabetes, and in particular integrated management, is an effective tool for the reduction of diabetes complications. A fundamental guideline would be to respect targets for all process indicators reported in section 5.4.3, which indicate clearly the level of quality of care that must be ensured by health services in each country of the European Union. Benchmarking here is not really an issue compared to other areas: for most quality of care indicators the gold standard to achieve is 100%. Thus, the dissemination of average results through monitoring systems among clinicians and patients would be highly beneficial for the purpose.

 

5.4.6.4. National guidelines and control plans

In 2008, only 13 of the 27 EU Member States (IDF European Region 2008) had established national diabetes plans and/or guidelines. There has been very little development in the last years, with several countries taking steps to move forward in this direction. According to the IDF, among the 14 countries with no plan, six, namely Germany, Bulgaria, Estonia, Hungary, Latvia and Slovenia experience the highest prevalence rates in Europe, and will rank among the worst in predictions up to 2025.

There is currently no benchmark for assessing the level of implementation of national plans/guidelines in Member States. Existing national plans and guidelines differ significantly among Member States, especially for what concerns implementation. This causes inequalities in life expectancy, health status and access to high-quality health services for people living with diabetes across Europe. Clinical guidelines are established and normally published in all countries with the direct contribution of scientific associations.

One important aspect of control plans that applies particularly well to diabetes is patient empowerment. This process requires the combination of the theoretical knowledge of diabetes with the right attitude towards the disease. National governments should provide tools for citizens providing advise on:

·          how to accept diabetes;

·          how to deal with self-control and self-regulation;

·          what to eat and drink and how much;

·          how to exercise and how much;

·          how to quit smoking; and

·          how to deal with stressful situations.

·          Education and self-education are a separate part of treatment and care for people with diabetes and its goals should be duly considered by all EU countries. At the moment, these problems are dealt within the National Diabetes Plans, where existing, with substantial heterogeneity, frequently with greater attention where health promotion and prevention are particularly developed. Action from the European Union to provide a better standardisation of national diabetes plans would be highly beneficial.

 

5.4.6.5. EU initiatives against diabetes

The establishment of a diabetes strategy at EU-level would:

1.    create a framework for exchange and cooperation between Member States;

2.    help to increase the coherence of actions in different policy sectors;

3.    open a platform for involving stakeholders, including patient and civil society organisations, in finding common solutions.

Official steps in this direction have been undertaken by the EU through a number of documents:

·       the EU Health Council in 2004, under the Irish Presidency, stressed the importance of developing a coordinated European strategy for diabetes;

·       the Otocec Declaration (2004), signed by more than 80 representatives of 35 EU and national diabetes associations, recommended the EU to take immediate steps for the development of a EU Council Recommendation for diabetes prevention, diagnosis and control;

·       the Government of Austria made Type 2 diabetes a key health priority during its Presidency in 2006;

·       the European Parliament, in April 2006, urged the European Commission and the European Council to make care and prevention of diabetes a priority and develop a European wide strategy to tackle the disease;

·       the recommendations of the EU Conference on Prevention of Type 2 Diabetes, organized in Vienna in February 2006, were adopted by the formal Health Council in June 2006 as Diabetes EU policy;

·       the International Diabetes Federation – European Region (IDF Europe) and the Federation of European Nurses in Diabetes (FEND) presented the paper “Diabetes: EU Policy Recommendations” providing input on diabetes to the future work of the European Commission.

·       The Council of the European Union (2006) endorsed IDF recommendations, by releasing the Conclusions on the promotion of healthy lifestyles and prevention of type 2 diabetes at the Employment, Social Policy, Health and Consumer Affairs Council meeting held in Luxembourg, 1-2 June 2006 (see Table 5.4.1);

 

Table 5.4.1. EU Council Recommendations

To Member States:   ·          Collection, registration, monitoring and reporting at national level of comprehensive diabetes epidemiological and economic data as well as data on the underlying factors; ·          Development and implementation of framework plans, as appropriate, addressing diabetes and/or its determinants, of evidence-based disease prevention, screening ·          and management founded on best practices and comprising an evaluation system with measurable targets to track health outcomes and cost-effectiveness, taking into account Member States' organisation and delivery of their respective health services, ethical, legal, cultural and other relevant issues and available resources; ·          Development of evidence-based, sustainable and costeffective public awareness and primary prevention measures that are accessible and affordable to meet the needs of those most at risk of developing diabetes as well as the population as a whole; ·          Development of affordable and accessible secondary prevention measures based on national evidence-based guidelines and aimed at detecting and preventing the development of diabetes complications; ·          Adoption of a holistic, multi-sectoral, multidisciplinary management approach to people with diabetes including an emphasis on prevention, involving primary, secondary and community care, social services and education services; ·          Further development of comprehensive diabetes training for healthcare professionals.   To the European Commission:   ·          Identifying diabetes as a public health challenge in Europe and encouraging networking and the exchange of information between Member States with a view to promoting best practices, to enhancing the co-ordination of health promotion and prevention policies and programmes for the whole population and high-risk groups and to reducing inequalities and optimising healthcare resources; ·          Facilitating and supporting European diabetes research in basic and clinical science and ensuring the wide dissemination of the results of this research across Europe; ·          Examining and strengthening the comparability of diabetes epidemiological evidence by considering the establishment of standardised outputs for monitoring, surveillance and reporting of diabetes mortality, morbidity and risk factor data across Member States; ·          Reporting on Member States' actions in order to emphasise health determinants, promote healthy lifestyles, national diabetes plans and prevention measures, on the basis of information provided by Member States, assessing the extent to which the proposed measures are working effectively, and considering the need for further action; ·          Continuing the work on the development of a comprehensive approach to health determinants at European level, including a coherent and comprehensive nutrition and physical activity policy, and addressing the impact on public health of the promotion, marketing and presentation, in particular to children, of energy dense foods and sugar-sweetened drinks; ·          Building on the work of the EU Platform for Action on Diet, Physical activity and Health and encouraging the development and implementation of national diabetes prevention programmes and measures; ·          Taking the health determinants and risk factors of diabetes into account across EU policies. ·          to continue to cooperate with the relevant international and inter-governmental organisations, in particular the World Health Organisation and the OECD, to ensure effective coordination of activities.

 

5.4.6.6. International initiatives

 

The United Nations Resolution on Diabetes recognised the disease as a global health threat in December 2006 through the following statements (UN resolution A/Res/ 61/225):

·          All nations shall develop national policies for the prevention, diagnosis and treatment of diabetes in line with sustainable development of their healthcare systems

·          November 14^th, the current IDF World Diabetes Day, has been declared as a United Nations Day to be observed every year starting in 2007.