5.4.4. Data discussion
Information shown in the presentation section indicates an objective difficulty
in collecting and analysing data at EU level. There are very large
discrepancies between reports, all though with a unique common message:
diabetes is an increasingly threatening disease that is growing at an alarming
rate. The EUCID core indicators are definitely the best way to start collecting
data for an analysis of the current health status and represent a fundamental
framework for the future collection of complete data.
It has been demonstrated that the most important risk factor for prevention,
i.e. body mass index, increases with age. About 50% of the general population
in most countries are now overweight. The body mass index is measured by weight
and height and calculated by weight in kilogram divided by the square of the
height in meters. The outcome categories are: below 20 underweight, 20-25 ideal
weight, 25-30 overweight, and the most important, obesity, being defined as a
BMI equal or above 30. According to EUCID, obesity in Europe ranges between 12%
(Netherlands) and 25% (UK), with a median value of 14%. The problem increases
with age, with a peak between 65 and 74 yrs, where all countries approach at
least a figure of 20%. Overweight and obesity, combined, add up to almost 50%
in the countries with figures available for EUCID. However, data are based upon
BMI; on the other hand, there is another approach that is gaining credibility
from scientific evidence, i.e. the measuring of one’s waist circumference.
However, this characteristic is still not measured routinely in clinical practice,
thus we cannot provide consistent data. The emergency dictated by this figure
should be rather obvious for European Governments: we know from scientific
literature that the current social trends also push for worsened conditions,
particularly for disadvantaged strata. It is time to act strongly on this front
with proper prevention strategies.
Incidence of T1DM seems to be less of a problem overall, but it is
highly variable across Europe, flagging attention towards particular
geographical areas and high risk strata. Regardless of the type of diabetes,
the data may become more alarming, as we know from scientific evidence that the
rise of diabetes is increasingly affecting the younger generation with an
impact on lifestyle behaviours.
The emergency is constantly underlined by prevalence results. Evidence
shows that prevalence is rapidly increasing. However, the figures currently
available are too variable between sources, and are often unstable across the
years, thus all estimates must be taken with extreme caution. The three fold
difference found between EUCID (median=3%) and IDF (median=8.7%) data is
difficult to explain. A joint effort to enhance the quality of data, with the
adoption of standardised criteria is absolutely necessary. Prevalence forecasts
for 2025 must be really taken only as one among the many possible scenarios.
Among core outcomes, blindness is one of the most difficult to capture,
as it can be not only difficult to directly link this problem to diabetes (in
the absence of validated registers), but also prone to differential selection,
as blind patients are harder to reach and visit their physician on a less
regular basis. Complete data in this area will remain extremely difficult to
obtain in the short term.
The situation is certainly different for what concerns dialysis, for
which patients are unfortunately urged to make regular visits at clinical
centres. Cross-country variations here are not easy to interpret (Scotland more than 30 times the dialysis/transplant incidence of Cyprus), so it is possible that
some countries are using tracking systems that probably lead to incomplete and
inconsistent estimates. The variation in the prevalence of dialysis/transplant
among countries is even more striking, the range being 3-632, something that
may arise the same sort of considerations as those above.
Secondary outcomes, including renal failure, amputations, stroke,
myocardial infarction, reflect and perhaps amplify the same problems of high
variations found in dialysis. Mortality rates are extremely important, but this
data also is more biases related possibly due to the use different coding
practices. The average figure obtained by EUCID should serve to inform policy
makers that, on average, a town of Europe with 100 000 inhabitants would loose
30 citizens per year due to diabetes.
As far as secondary indicators are concerned, it is worth reminding that
impaired glucose tolerance has a prevalence at least as high as that of
diabetes. 10% of these subjects will develop diabetes in one year. Clinical
management can be followed up through a long list of process indicators,
showing that, despite the large variations in data between countries, which may
be the result of reporting problems, there is still room for improvement for
many procedures in most countries. Notably, fundus inspection is performed in
57% of countries submitting data, with information on retinopathy and laser
treatment scarcely available, flagging a gap that requires a fast filling.
Moreover, between 25-60% of the patients are poorly controlled for a range of
important clinical measurements. An average of 20% smokers among diabetics is
realistic and extremely alarming.
Overall, process and outcome indicators in diabetes seem to highlight
that health systems in Europe are not optimally organized to deliver the
results expected for a proper management of the disease. Although more complete
and consistent data are necessary to confirm this picture, this issue must be
addressed with urgency. Strong initiatives should be identified in order to
push the entire health sector towards a tight control of diabetes.