Diabetes in Society
Diabetes and the
World Health Organization
` Rhys Williams, Gojka Roglic, Hilary King
The aim of the World Health Organization (WHO) is the
achievement of the highest possible level of health for all
the world's people. From its global headquarters in Geneva
and its Regional Offices, it assists national governments
achieve this aim by setting international norms and
standards, and providing leadership and technical support.
WHO has substantial influence and prestige and has
several major accomplishments to its credit, most notably
the global eradication of smallpox in 1979, and major
reductions in the burden of polio, leprosy, river blindness
and tuberculosis.
The formal working relationship between WHO and the IDF
goes back a long way. The two organizations were formed
at about the same time – WHO in 1948 and IDF 2 years
later. They established their official working relationship
in 1957. IDF was only the second such organization to be
recognised in this way.
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39
A global contribution
By virtue of its unique mandate,
WHO's work on diabetes is crucial
in many respects (see box overleaf).
By collecting and disseminating
reliable and impartial diabetesrelated statistics, it has succeeded in
drawing attention to diabetes as a
global health problem and keeping
diabetes on the global health agenda.
On several occasions it has brought
together international experts to
standardize definitions of diabetes
and related conditions, and to agree
criteria for diagnosis. It has
encouraged collection of estimates
of diabetes prevalence in many
countries.
It has also fostered international
research collaborations and,
alongside IDF, has provided
opportunities for health
professionals to be trained in
diabetes epidemiology and health
care. It has also encouraged
countries to formalize and evaluate
their diabetes prevention and
management programmes. In
partnership with IDF, it is now
looking to the future to raise
awareness of diabetes worldwide,
advocate a better world for people
with diabetes, and stimulate action
on their behalf. >>
July 2003
Volume 48 Issue 2
Diabetes in Society
WHO’s contribution to diabetes
Š keeping diabetes on the global health agenda
Š co-ordinating expert opinion on definitions and diagnostic criteria
Š estimating the global burden of diabetes and its complications
Š fostering international research
Š supporting professional training in diabetes epidemiology and
health care
Š encouraging diabetes prevention and control programmes
Diabetes as a global health
problem
In 1964, WHO convened its
first expert committee on
diabetes. The conclusions and
recommendations of this
committee were published a
year later.1 These were
prophetic in that they included
concerns about the increasing
problem of diabetes even though
the data that were to hand
showed prevalences a good deal
lower than those seen in most
countries today. The report
stated that "there was general
agreement about the signs of
increasing prevalence of diabetes
mellitus in most parts of the
world" and "there are now
indications of a rapid increase in
the disease".
Nevertheless, the prevalence
estimates from the studies cited
in the 1965 report are very low
when contrasted with more up
to date values. The latest
estimates indicate that there are
at least 194 million people with
diabetes in the world, and more
than two-thirds of them live in
developing countries.2
July 2003
Volume 48 Issue 2
( )
A recent WHO survey
shows that much
remains to be done to
ensure that all
countries have a
policy for diabetes.
In 1962, the Executive Board of
WHO endorsed its first resolution
on diabetes. In 1985, a WHO Study
Group called for WHO/IDF cooperation at a regional level, and in
1989 (the same year as the St
Vincent Declaration), the World
Health Assembly adopted its first
resolution on the prevention and
control of diabetes.This recognition
of diabetes as a world-wide problem
amenable to prevention and control
was crucial in encouraging nations to
include diabetes, its treatment and
prevention, on their health agendas.
However, as a recent WHO survey
has shown, much remains to be done
to ensure that all countries have a
policy for diabetes amongst their
plans for noncommunicable disease
control. In that survey, 43% of the
world's health ministries claimed to
have a national control plan for
diabetes, ranging from 64% of
40
countries in the WHO Western
Pacific Region to only 13% in Africa.3
More recently, a 'technical briefing'
open to delegates attending the 55th
World Health Assembly in 2002
highlighted the problems of
childhood obesity and Type 2
diabetes. Under the title 'Diabetes:
our failure to deal with a modern
epidemic', data from several
countries were presented.The
experience of one particular country
– the Republic of Mauritius – were
described by its Minister for Health
and Quality of Life.This technical
briefing was a joint project between
WHO's diabetes unit, IDF, and the
International Obesity Task Force
(IOTF).
Definitions and diagnostic
criteria for diabetes and
related conditions
Given the widespread use today of
standard definitions and diagnostic
criteria for diabetes and impaired
glucose tolerance (IGT), it is perhaps
difficult to appreciate how much
confusion existed up to the time
when the first of these standards
were agreed. Kelly West (the
acknowledged father of diabetes
Diabetes in Society
epidemiology) in his classic study
showed that physicians in North
America and in Europe had very
different ideas about the cut-off
levels for blood sugar (glucose) that
were indicative of diabetes.This not
only made for variable therapeutic
decisions, it also made it impossible
to compare, with any semblance of
validity, estimates of the prevalence
of diabetes from different countries.
(
WHO established
internationally
accepted biochemical
criteria for diabetes
and introduced the
term impaired glucose
tolerance.
)
The second WHO expert committee
on diabetes established
internationally accepted biochemical
criteria for diabetes and also
introduced the term IGT and
suggested diagnostic criteria for
that4.These were adjusted by the
report of 19855 and further refined
in 1999.6
Unfortunately, WHO and the
American Diabetes Association
(ADA) have not always seen eye to
eye. Both organisations have revised
their criteria within months of each
other and, unfortunately have not
come forward with the same
conclusions.The latest sets of criteria
from both organisations differ slightly
but at least agree on lowering the
fasting blood sugar (plasma glucose)
cut-off value from 7.8 to 7.0 mmol/l
for the diagnosis of diabetes. Both
WHO and ADA favour the
introduction of a new category of
impaired fasting glycaemia (IFG)
which can be identified on a fasting
blood glucose level alone. However,
the ADA seeks to simplify the
diagnostic and epidemiological test
for diabetes and related conditions
by arguments for reducing the
requirement of the 2-hour oral
glucose tolerance test in favour of
the fasting blood glucose alone.
International research collaboration
The first example of collaborative
international research endorsed by
WHO is the WHO Multinational
Study of Vascular Disease in
Diabetes (WHO MSVDD).This
study, involving 14 centres in 13
countries was prompted by a
conversation, in the early 1970s
between Harry Keen and Eishi Miki
of the University of Tokyo, during
which it was observed that the
coronary artery disease and
peripheral vascular disease, so
characteristic of the long term
effects of diabetes in the USA and in
Europe, were not seen in Japan.
Prompted by this, a research
protocol was developed to collect, in
a standardized fashion, information
on the vascular complications of
diabetes in different countries.
The study was important, not only
for demonstrating the practicality of
collecting complex information in a
standardized fashion in many
locations throughout the world, but
also in highlighting vital differences in
the outcome of diabetes in many of
these locations.The inference drawn
from this was that these adverse
consequences of diabetes were, to a
great extent, preventable.
This study was followed by the
Multinational Project for Childhood
Diabetes (DIAMOND) to investigate
worldwide patterns of the
incidence,7 and the first standardized
41
global prevalence estimates,8 of
childhood Type 1 diabetes.These
were followed by the global
numerical estimates of, and future
projections for, the health-care
burden of diabetes.9
Training of professionals in
diabetes epidemiology
In 1981, the first WHO/IDF Seminar
on the epidemiology and publichealth aspects of diabetes was held
in Cambridge, United Kingdom.This
event was conceived and organized
by John Jarrett and others in order
to bring together health
professionals from a number of
countries to learn the methods of
epidemiology and to apply them to
questions related to diabetes.
No fee was charged for attendance –
members of the faculty provided
their services free of charge.This
was important in facilitating the
attendance of people from lowincome countries and from
organizations unable to afford more
than the cost of travel to and from
Cambridge.The faculty members
included many of the best scientists
in the field of diabetes and public
health.
These highly successful seminars (the
eighth in the series will be held in
April 2003) have provided training
for over 200 health professionals and
have contributed greatly to the
creation of an network of active
researchers throughout the world.
Members of this network, guided by
WHO staff and others have
documented the diabetes epidemic
and provided important information
relating the causes of diabetes,
genetic and environmental, and
improvements in diabetes care.
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Diabetes in Society
Similar seminars are also
organized for WHO regions. So
far, four seminars have been held
in Africa, four in the Western
Pacific region, one in the Eastern
Mediterranean and three in the
Americas.
Diabetes prevention and
management programmes
The World Health Report for the
year 2002 quantifies the
importance of obesity and a
sedentary lifestyle in increasing the
risk of developing Type 2
diabetes.10 Almost two-thirds of
the global burden of diabetes can
be attributed to overweight.
However, even moderate
reductions in current and future
obesity and physical inactivity can
significantly diminish the burden
due to these risk factors. At the
same time, at least one third of
the world's population with
diabetes is unaware of their
condition, and many people with
diagnosed diabetes are
inadequately treated.
WHO has developed guidelines
for the development and
implementation of national
diabetes programmes,11,12 and
has supported several regional
declarations on diabetes (St
Vincent, DOTA, Western Pacific).
Together with IDF, its longstanding ally, WHO will soon
embark on a global campaign to
increase awareness of diabetes,
prevent diabetes and improve the
management and long-term
outlook of people with diabetes.
July 2003
Volume 48 Issue 2
` Rhys Williams, Gojka
Roglic, Hilary King
Rhys Williams is Professor of Clinical
Epidemiology at the University of
Wales Swansea, UK. He is an IDF VicePresident and is currently Chair of the
IDF Task Force on Diabetes Health
Economics.
Gojka Roglic is Technical Officer in the
Department of Noncommunicable
Disease Management, WHO, Geneva.
Hilary King is the Responsible Officer
for Diabetes, Department of
Noncommunicable Disease
Management, WHO, Geneva.
References
1. Diabetes Mellitus: Report of a
WHO Expert Committee. WHO
Technical Report Series 310. WHO,
Geneva, 1965.
2. Global Burden of Disease. WHO,
Geneva, 2003 (in press).
3. Assessment of national capacity
for noncommunicable disease
prevention and control.
WHO/MNC/01.2. WHO Geneva, 2001.
4. WHO Expert Committee on
Diabetes. TRS 646. WHO, Geneva,
1980.
5. WHO Expert Committee on
Diabetes. TRS 727. WHO, Geneva,
1985.
6. Definition, Diagnosis and
Classification of Diabetes Mellitus
and its Complications. Report of a
WHO Consultation
WHO/NCD/NCS/99.2. WHO, Geneva,
1999.
42
7. Karvonen M et al. Incidence of
Childhood Type 1 Diabetes Worldwide.
Diabetes Care 2000; 23: 1516-1526.
8. King H, Rewers M. WHO Ad Hoc
Diabetes Reporting Group. Global
estimates for prevalence of diabetes
mellitus and impaired glucose
tolerance in adults. Diabetes Care
1993; 16: 157-177.
9. King H, Aubert RE, Herman WH.
Global burden of diabetes, 1995-2025.
Diabetes Care 1998; 21: 1414-1431.
10. The World Health Report 2002.
Reducing risks, promoting healthy life.
WHO, Geneva, 2002.
11. Guidelines for the development of
national diabetes programmes.
WHO/DBO/DM/91.1. WHO, Geneva,
1991.
12. Implementing national diabetes
programmes. WHO/DBO/DM/95.2.
WHO, Geneva, 1995.