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Diabetes, a danger that is still underestimated
The diabetes avalanche is rolling and what is Germany doing? So far so little, say experts.
There is a lot happening at the same time in different places, little is evaluated, and a lot is
lost in the maelstrom of individual interests.
What types of diabetes are
there?
An unhealthy lifestyle with poor nutrition and lack of exercise, resulting in a person being
overweight, is the cause of many common diseases. The German Federal Ministry of Nutrition,
Agriculture and Consumer Protection and the German Ministry of Health have initiated the
national “IN FORM“ initiative. From 2008 until 2010, 15 million euros a year are to be
dedicated to the objective of improving the nutrition and physical fitness in Germany in the
long term.
The figures are clear
Is a national effort really necessary? Do experts tend to panic-monger? The figures are clear:
The metabolic disease known as diabetes has reached the proportions of a worldwide epidemic.
It not only endangers human health, but also social structures and national economies.
According to the International Diabetes Foundation (IDF), 3.8 million people died in 2007 as a
result of diabetes.
The United Nations lists diabetes as the first non-infectious disease on the list of worldwide
dangers to human health. The chronic disease no longer only affects first world countries;
China and India have also published alarming figures. Estimates predict approximately 300
million diabetes cases worldwide by 2025.
80 percent of the costs of medical treatment occur in the richest countries, the remaining 20
percent are spent in second and third world countries. It is worth noting that in the near future
80 percent of all diabetes patients will live in second and third world countries. Overall, the
cost of diabetes treatment is rising faster than the world population.
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The figures differ in different sources, but all of them point to an “epidemic” © NAFDM
A prosperity disease threatens prosperity
Diabetes and resulting sicknesses are increasingly becoming a danger for national economies, in the opinion of the
International Diabetes Foundation. © IDF
Up until 2015, three percent of global economic performance will be lost as a result of
prosperity diseases if the investment into measures to prevent chronic diseases does not
considerably increase (Price Waterhouse Coopers: Working towards wellness. Accelerating the
prevention of chronic disease, 2007, p. 10). In the European Union (EU) the number of diabetes
sufferers is increasing all the time. The prevalence rate for adults (20 to 79 years) rose from 7.6
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to 8.6 percent between 2003 and 2006, accounting for 31 million affected people. Germany
has the largest number (11.8) of diabetics. Only now is Europe working on European standards
for diabetes prevention (IMAGE: Development and Implementation of a European Guideline
and Training Standards for Diabetes Prevention).
Diabetes type 2: the most expensive chronic disease
In 2006 in Germany, more than seven million people had to undergo diabetes mellitus
treatment, most of them type 2 diabetics who are forced to take more and more insulin.
Diabetes type 2 is the most expensive chronic disease, costing the German health insurance
companies 18 billion euros per year; other sources even talk of up to 60 billion (Prof. Hans
Hauner), when the indirect costs are included.
The deadly quartet
Accompanying and secondary diseases is what makes diabetes so dangerous. © Takeda
Fifty percent of all cardiac infarctions and strokes are the result of diabetes, along with 30,000
amputations. These diseases are accompanying and secondary diseases, and this is what
makes diabetes so dangerous. High blood pressure, elevated blood fat levels and being
overweight are what medical experts refer to as "metabolic syndrome", which is known in
popular lore as the "deadly quartet". The diseases resulting from diabetes not only damage the
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vessels of the heart, brain and legs, but also those of the kidneys and eyes.
The situation might become even worse as a growing number of young adults, including
children and adolescents are becoming victims of diabetes. In addition, there is a direct
correlation between the rising number of overweight people (and here Germany also has the
highest number in Europe) and diabetes. 20 percent of all European children are overweight,
and it is estimated that this number is increasing by 400,000 every year.
One detected case equals one that is undetected
But this is only half the truth. Experts believe that one third of all German citizens faces
diabetes mellitus. Diabetes type 2 is the major problem and accounts for more than 90 percent
of all cases. About five to ten percent of people suffer from diabetes type 1. Diabetes type 2
develops gradually over the years and often remains undetected. Many people are diabetics
without knowing it.
Studies have shown that the cost increases linearly with the diagnosis of diabetes. The highest
costs arise from resultant vascular diseases such as cardiac infarction and stroke. Experts see
the prevention of complications through optimised treatment and diabetes as the best means
to prevent the rampant rise in costs.
Promoting health rather than treating diseases
In order to avoid the cost trap, experts are hoping that there will be a paradigm change – away
from the principles of disease-centred treatment towards the principles of health promotion.
However, the cost-benefit analysis of the health economists has an “undesired side effect”:
successful prevention increases lifespan and hence also the lifelong costs arising from agerelated diseases.
Lack of comparable data in Europe
Despite alarming epidemiological figures – there are no national registers, data or clear
definitions. According to the IDF, diabetes is underestimated on both the national and the
European level. It is estimated that diabetes accounts for about one tenth of all health costs.
Precise, comparable data are lacking. In addition, health policy is “frustratingly slow” to react
(IDF). Less than 50 percent of all EU member states have a national diabetes plan or any kind
of concerted action: It seems very uncertain whether Germany will put such a plan into action
in 2010 (see above).
Drugs against diabetes: many products in the pipeline
The debate in medical science circles as to whether these diseases originate from one cause,
are potentially only of academic importance. If the “deadly quartet” has one single cause, the
current state of knowledge holds that it must be related to insulin resistance.
The hopes of finding a single drug for treating diabetes and the diseases associated with it
have been dashed – whether it be this glitazone, ACE inhibitors or the “poly pill” (see Scott M.
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Grundy, Advancing drug therapy of the metabolic syndrome, in: Nature Reviews, Drug
Discovery, Vol. 8. May 2009, p. 341). Scientific compliance studies will need to show whether the
medical efficiency of a tablet can be increased by combining several substances in one.
Ten drugs in phase III clinical development
Of around 2,500 R&D projects (clinical phases I to III) being undertaken by small and mediumsized biotechnology companies in Europe, 64 projects deal with diabetes (Novumed Life
Science Consulting). The big pharmaceutical companies are also working on the development
of anti-diabetes drugs. It is estimated that approximately eleven diabetes drugs will be
approved by 2012. This estimate is confirmed by the research-based pharmaceuticals
producers (VFA Bio), according to whom ten drugs are in phase III, 20 in phase II and 15 in
phase I of clinical development.
Boehringer Ingelheim hopes to enter the market in 2010
The family-run company Boehringer Ingelheim is expanding its diabetes activities at its
research site in Biberach. The company hopes to launch linagliptin, a dipeptidyl peptidase 4
(DPP4) inhibitor, in 2010. This substance, which belongs to a new substance class, inhibits the
degradation of the hormone glucagon-like peptide 1 (GLP-1) through the enzyme DPP4. GLP-1
induces the release of insulin in the beta cells.
In addition to linagliptin, Boehringer Ingelheim has two SGLT inhibitors in the pipeline, a
licensed one and one from own R&D. In addition, the company is also expanding its activities to
indications that have something in common with diabetes – being overweight, dyslipidemia
and arteriosclerosis.
It is generally agreed that medical treatment should be only initiated if changing one’s lifestyle
does not lead to the expected results. Critics say that most anti-diabetes drugs are based on
studies carried out by the manufacturers themselves. Long-term monitoring and data on
patient satisfaction with the therapy are rare as are monitoring and data on patient adherence
to courses of therapy.
Prevention is better than treatment
More sport, better nutrition, reduction of the time spent in front of TV and PC – the recipe for
diabetes prevention sounds simple but is somewhat more difficult in practice. Although
individuals that are at risk of developing diabetes might be able to sustainably change their
behaviour and adapt their lifestyle to health-promoting activities and prevention, society has
different demands that act in different ways across the board: agriculture, education, sport,
nutrition, consumer protection, health, entertainment, market economy, transport and traffic,
environment and media. Different objectives have to fit together in a constructive way and this
is a clear indication that there must be a strong concerted effort to reverse the current
situation in order to be able to override conflicting individual interests.
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In principle, ideal for prevention
Diabetes type 2 is ideal for primary prevention. People who are physically fairly active can, even
without losing a lot of weight, activate their metabolism and reduce insulin resistance.
International studies have shown that six out of ten people affected were able to successfully
prevent or postpone the onset of diabetes when they changed their lifestyle in the early stages
of the disease. This has been shown in high-risk people (defective glucose tolerance and
elevated fasting glucose levels).
For cost reasons, experts consider that closely and continuously monitored lifestyle change is
the most appropriate means for population-wide prevention. So far it is difficult to tell who
benefits noticeably from lifestyle interventions and who doesn’t. Initial studies, also undertaken
in Tübingen (TULIP) show that a prognosis is possible.
Gaps in diagnosis and treatment
Clinical studies have shown that multifactorial therapies and optimal blood glucose level
adjustments considerably improve the prognosis of diabetes sufferers. The treatment of
diabetes sufferers has improved dramatically over the last few years; but there are still some
shortfalls – in particular with regard to old people, migrants, socially disadvantaged persons,
pregnant women with gestation diabetes, people with rare diabetes types, small children with
diabetes, diabetic adolescents during puberty. The treatment results in Germany are moderate.
Germany comes 19th in a European-wide comparison (Euro Consumer Diabetes Index 2008).
Diabetes type 1 is easy to predict
Diabetes type 1 is often genetic, and has a long preclinical phase. Therefore the progression
and outcome of diabetes type 1 can easily be predicted. The autoantibodies of ß-cell antigens
and genetic markers (HLA) of this organ-specific autoimmune disease can be measured.
Experts hope that the destruction of beta cells can be modulated in the medium to long term
and will enable the primary prevention of diabetes.
Diagnostics is sometimes made difficult through inadequate measurement methods, blood
samples or by only measuring the fasting plasma glucose level. The oral glucose tolerance test
(OGTT) is regarded as the gold standard, in particular in the early phase of the disease. But this
test is only reimbursed by the insurance companies when patients have elevated fasting
plasma glucose values. There are many treatment gaps, including the lack of regular check-ups
or high-risk patient screening.
Differential diagnostics can still be improved
The differential diagnosis of diabetes can also be improved. Diabetes is very heterogenic and
many mixed types are known. Experts are hopeful about molecular biology tests that are able
to determine the type of diabetes and the degree of insulin secretion disturbance and insulin
resistance with greater accuracy.
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European research is slowly becoming standardised
Experts believe that a better understanding of the causes and pathogenesis of diabetes types
and their complications depends on the further development of individualised prevention,
diagnostics and therapy. Since 2008, the EU commission has been supporting coordinated
research funding with DIAMAP – Roadmap for Diabetes Research in Europe, which has enabled
medical associations and drug manufacturers to develop a European-wide research strategy
within the next two years.
Huge demand in all research areas
In Germany, there is huge demand for insights from basic research, epidemiological research
and bedside research. The situation in Germany is characterised by the fact that research
funding is not given jointly by the Ministry of Health and the Ministry of Research. But
nevertheless, the TU Dresden is the first university with a European chair for diabetes
prevention and treatment, sponsored by the insulin manufacturer Sanofi-Aventis.
Analysing the complex interactions
Approaches that take into account the complex interaction between sensitivity genes and the
environment, the psychosocial context, food and physical activity are, according to the current
state of knowledge, of key importance. A lot of hope is placed on progress made in imaging,
measurement sensor technology, the use of adult stem cells and the regeneration of insulinproducing cells.
Walter Pytlik
Diabetes mellitus
Is a syndrome of disrupted metabolism, characterised by elevated blood sugar levels
(chronic hyperglycaemia). The disease leads to high blood glucose levels due to defects in
either insulin secretion or insulin action in the blood, or both defects combined.
Diabetes mellitus type 1
An autoimmune disease characterised by the loss of insulin-producing beta cells of the
islets of Langerhans in the pancreas, resulting in a deficiency of insulin. According to the
current state of research, type 1 diabetes risk is known to depend upon a genetic
predisposition and several genes are believed to be involved in the manifestation of this
disease. Diabetes mellitus type 1 is lethal unless treated with exogeneous insulin (which is
mainly produced artificially).
Diabetes mellitus type 2
Diabetes mellitus type 2 is by far the most common type of diabetes (nine out of ten
diabetics suffer from diabetes type 2). The disease is caused by insulin resistance. The
insulin that is present cannot exert its action at the cell membranes. The pancreas tries to
compensate by producing higher quantities of insulin. This does not work in the long term
and the insulin produced can no longer control the blood sugar level.
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Diabetes is regarded as a typical disease of an affluent society and can either be prevented
or the onset can be delayed by a change in lifestyle. The disease has many causes, and it
is believed that more than a dozen genes are involved. Adiposity is another risk factor for
developing diabetes. Diabetes type 2 is regarded as a model for the complex interplay of
genes, environmental factors, psychosocial environment, nutrition and exercise.
Sources/Literature:
Helmholtz Centre Munich, FLUGS - Information Service Life Sciences , Diabetes mellitus Typ 2 –
Lebensstil und Gene entscheiden, Munich, 28.05.2008
International Diabetes Foundation (IDF): www.idf.org
Gesundheitsziele.de, Forum Health Targets Germany, Diabetes mellitus type 2 workgroup:
www.gesundheitsziele.de
Robert Koch Institute/Federal Statistical Office: Diabetes mellitus. Federal Health Monitoring
System, issue 24, 2005
Robert Koch Institute/Federal Statistical Office: Health in Germany, July 2006.
National Action Forum Diabetes mellitus (NAFDM): 2. draft - National Action Plan Metabolic Syndrome, Adipositas,
Diabetes mellitus: Prevention-Treatment-Research, May 2008
Fraunhofer Institute for Systems- and Innovation Research: Health Technology Assessment, www.inno-hta.eu,
www.metaforum-innovation.de
Forster, Thomas: Krankheitskostenrechnung für Deutschland, Federal Statistical Office, Wirtschaft und Statistik
12/2004;
VFA Bio: Medizinische Biotechnologie in Deutschland 2009
Federation of European Nurses in Diabetes/International Diabetes Foundation Europe: Diabetes. The Policy
Puzzle: Is Europe Making Progress? 2nd edition,
Euradia (Alliance for European Diabetes Research) www.euradia.org
German Diabetes Union/National Action Forum Diabetes Mellitus, Diabetes 2009. Federal Health Monitoring,
Mainz 2008 (November)
Boehringer Ingelheim, R & D Press Conference, 17.10.2008.
About R&D projects for diabetic complications: Calcutt, Nigel/Cooper, Mark et. al, in: Nature Reviews Drug
Discovery, Vol. 8, May 2009, p. 417ff.
German Health Report. Diabetes 2009, presented by: German Diabetes Union and NAFDM, November 2008.
Dossier
11-May-2009
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