What Fuels the Athlete With Type 1 Diabetes?

A phenomenon that was virtually impossible just a couple of decades ago is now becoming increasingly commonplace: Athletes with type 1 diabetes are not only competing at elite levels in just about every sport, but in many cases are actually beating nondiabetic competitors. Gary Hall Jr. won three Olympic Gold medals in swimming after his diagnosis in 1999. Natalie Strand, an anesthesiologist, won the TV extreme-sport reality show Amazing Race with her partner last December. And bicycle racers Team Type 1 won the Race Across America in 2009 and 2010.

Of course, exercise is encouraged for people with both type 1 and type 2 diabetes as a way of improving glycemic control, cardiovascular health, and quality of life. But in competitive sports, milliseconds count and physical perturbations of any kind can mean the difference between winning and losing. With type 1 diabetes, aerobic exercise can result in hypoglycemia, while anaerobic exercise can cause glucose levels to rise. Many sports involve a combination of the two. The athlete with type 1 diabetes must perform frequent glucose checks and eat or take insulin as needed to maintain normal or near-normal glucose, while at the same time performing the athletic feat itself. It seems nearly impossible, yet they do it … with the help of both new technology and devoted health care professionals.

“I take each athlete, learn their sport and find solutions,” said Dr. Anne Peters, the endocrinologist who managed Gary Hall Jr.’s diabetes regimen during the Olympics and is now doing the same for professional racecar driver Charlie Kimball. “Each athlete is unique and requires individualized care.”

Javier Megias of Team Type 1 checks his blood sugar while warming up for a time trial at a race in Italy. Photo courtesy of Team Type 1

New research is aimed at understanding the physiology of these athletes better in order to improve that care. Team Type 1, sponsored by Sanofi, is funding a study in which data are being collected on about 10 bike racers with and 10 without type 1 diabetes. The athletes are being evaluated before, during, and after races using continuous glucose monitors and devices placed on the bicycles that measure variables such as power, heart rate, energy expenditure, speed, and altitude. Data on the athletes’ diet, insulin doses, and other variables are also being collected in a total of five major cycling events, each of which includes 4-8 individual races. “Bottom line, it’s a lot of data,” said Team Type 1 director of research Dr. Juan Frias.

Interestingly, blood glucose values of up to 200 mg/dL - far above “normal” – have been recorded in the nondiabetic riders during very intense portions of races. This “stress hormone” effect had been seen previously in the lab and in some hospitalized patients, but has not been well documented in field-based, real-world studies of healthy people. “Ultimately we hope that this feasibility study will provide data that will help us begin to better understand the optimal glucose concentrations needed to maximize athletic performance, Dr. Frias said.

Findings from the TT1 study will likely be announced at scientific conferences during 2012 and ultimately published, he told me.

Another research project, led by Nate Heintzman, Ph.D., of the University of California, San Diego, is studying athletes who are part of Insulindependence, an organization that promotes physical fitness and sport for people with type 1 diabetes. One of Insulindependence’s recreation-specific clubs, Triabetes, trains people with type diabetes to compete in triathalons. The UCSD-supported project, called the Diabetes Management Integrated Technology Research Initiative (DMITRI), is looking at many of the same variables as in the TT1 study, but is also collecting other data, including behavioral and cognitive information and biospecimens for DNA sequencing.

Insulindependence Captains starting their track workout at UCSD in June. Every person in this photo has type 1 diabetes. Courtesy of Nate Heintzman, Ph.D.

“The idea is to use emerging wireless and device technology as well as genetics and genomics to understand more about the personalized basis of blood glucose management. I think we’ll uncover trends to help tailor therapeutic regimens, and also develop technology on a personal level,” Dr. Heintzman said.

The DMITRI project began in June, and data will begin to emerge in the coming months. In the meantime, if you’re a health care provider or person with diabetes interested in learning more, Dr. Peters recommends Sheri Colberg-Ochs Ph.D.’s Diabetic Athlete’s Handbook. And if you’re seeking inspiration, you can follow Team Type 1 founder and CEO Phil Southerland’s efforts to enter the team in the 2012 Tour de France, professional cycling’s most elite event.

Bottom line, according to Dr. Peters, “The truly gifted athletes I have known seem to be born with an ability that compels them to compete, diabetes or not.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

Are You Serving Your LGBT Diabetes Patients?

Are most health care providers attuned to the needs of their diabetes patients who are lesbian, gay, bisexual, and transgender (LGBT)? Does it matter? No and yes respectively, according to certified diabetes educator Theresa Garnero.

Rauchdickson photo via Flickr Creative Commons

More than half of medical school curricula include no information about LGBT people, and most multidisciplinary professionals have not received tools to care for LGBT individuals, Ms. Garnero said at the annual meeting of the American Association of Diabetes Educators.

A number of factors that increase the risk for developing diabetes are highly prevalent among people who are LGBT. For example, obesity and polycystic ovary syndrome (PCOS), both strong risk factors for type 2 diabetes, are more common among lesbians than among heterosexual women. Indeed, in one study, PCOS was identified in 38% of lesbians vs. just 14% of heterosexual women.

Antiretroviral drugs used to treat HIV/AIDS often lead to insulin resistance and type 2 diabetes. Men on HIV treatment have four times the risk of diabetes as do HIV-negative men. Moreover, cigarette smoking, alcohol abuse, and illicit drug use, all of which particularly endanger the health of those with diabetes, are frequent behaviors among LGBT individuals.

Depression is common in both LGBT individuals and people with diabetes. Withholding of insulin among closeted LGBT youth with type 1 diabetes could be a suicidal gesture rather than diabulimia.

How many LGB people have diabetes? It’s extremely difficult to obtain statistics – and there are virtually none for transgendered people – but based on self-reported health data, roughly 1.3 million LGB people have diabetes, a number approximately equal to that of type 1 or gestational diabetes, Ms. Garnero said.

So why does it matter? Lack of awareness and presumption of heterosexuality can lead to mistakes that alienate patients, such as lecturing a young lesbian with diabetes about the need for birth control or expressing negative attitudes toward patients who want to bring their same-sex partners to diabetes-education classes.

Importantly, patients who perceive that they can’t be open with their health care provider about sexual orientation may be reluctant to share other health-related information.

“Individuals who approach the health care system are already vulnerable from their illness … Intolerance is the last thing anyone wants when seeking health care. It is certainly not a part of the caring diabetes professional culture,” Ms. Garnero said.

What can the health care provider do? Placing a rainbow flag sticker or nondiscrimination statement that specifically mentions sexual orientation in the waiting room is a simple way providers can let patients know that they are LGBT-friendly. Other helpful information for providers can be found here.

Bottom line, she said: “All people with diabetes deserve the benefit of our expertise and access to ongoing support.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

Diabetes Intervention Showdown: Humans vs. Technology

Which is more effective in helping people who are at high risk for diabetes avoid the disease: a face-to-face “lifestyle intervention”? An Internet-based version? The same thing on a DVD? Or letting patients choose the version they want to pursue? And when you factor in the costs, which one is most cost-effective?

Image by Kevinsendi (Wikimedia Commons)

Such are the questions upon which health policy may rely. At the American Diabetes Association meeting, researchers from the University of Pittsburgh provided some answers that may surprise you.

The prospective Rethinking Eating and ACTivity (REACT) study enrolled 434 overweight adults with abdominal obesity in eight rural communities in southwestern Pennsylvania. Already I’m thinking, not exactly Silicon Valley, but what do I know about their technological experience?

Participants were randomized to one of four groups with various versions of a “group lifestyle balance” program that aimed to educate them about physical activity, weight loss techniques, and other ways to make healthy changes to their lifestyles. The face-to-face version (119 people) involved weekly group education sessions for 12 weeks. The 113 participants in the DVD group watched 12 group lifestyle balance sessions on DVD and met with healthcare workers four times for debriefing about the DVDs. The Internet group (101 people) experienced 12 group lifestyle balance sessions that were incorporated  into an online format with blogging and e-mail capabilities.

The final 101 participants were randomized to a “self-selection” group that allowed each person to decide which format to use. Sixty percent chose the Internet program, 40% chose face-to-face group meetings, and not a single person picked the DVD. (Sign of the times? I think I’ll put my CD/DVD shelves on eBay before they become worthless.)

The good news is that all versions of the lifestyle intervention worked, said Shihchen Kuo of the university’s department of epidemiology, who focused on a cost-effectiveness analysis. Elsewhere at the meeting, his associates presented separate analyses of 6-month follow-up data suggesting that letting patients choose the type of program provided the best outcomes. Participants in the self-selection group showed the largest improvements in physical and mental functioning and were 1.5 times less likely to have impaired fasting glucose compared to the other groups, though at least half of each group met the goal of losing 5% of their weight. Among those who lost weight, 80% kept it off at the 6-month follow-up, according to a university press release.

But effectiveness is only half the story when setting policy. Cost is the other half. Using preliminary data from the first 3 months of follow-up to model results at 3 and 5 years, the face-to-face program dominated the others in cost-effectiveness, Mr. Kuo reported. Adherence rates were 76% in the face-to-face program, 57% with the DVD, 53% in the self-selection group, and 38% using the Internet. The Internet-based program cost the most to operate, he said.

Projected out to 5 years, the face-to-face program would cost $63,377 per quality-adjusted life year compared with no intervention, he estimated, well within the range of many commonly accepted medical interventions.

It will be interesting to see if the cost-effectiveness results change when considering 6-month outcomes and become more closely aligned with the 6-month results for effectiveness. For now, though, “the face-to-face group lifestyle balance strategy delivered in rural communities is a sound investment” when choosing between the three models, Mr. Kuo concluded, “and appears to be economically reasonable” compared with doing nothing.

For those of you keeping score at home, I’d call this a tie — Humans 1, Technology 1. Would you agree?

–Sherry Boschert (@sherryboschert on Twitter)

Worldwide Diabetes Burden Swelling

Like the unstoppable tide of aging Baby Boomers and the worldwide flood of obesity-related problems, the burden of diabetes is expected to hit tsunami proportions. The number of people with diabetes hasn’t crested yet, but there already may be more people “under water” than expected.

Photo by Sherry Boschert

While the World Health Organization suggests that more than 220 million people around the world have diabetes, and one study estimated 285 million people had diabetes in 2010, a more recent analysis calculated that 347 million people worldwide have diabetes, investigators reported in The Lancet. That’s more than double the 153 million cases worldwide 3 decades ago.

Type 2 diabetes typically begins in middle age, so aging populations play a role, as do rising rates of obesity, a major risk factor for the disease. Using the World Health Organization’s more conservative numbers, an estimated 3.4 million people died in 2004 from problems related to diabetes, 80% of them in low-income and middle-income countries.

It’s no wonder that I heard languages from all over the world being spoken at the American Diabetes Association (ADA) annual scientific meeting. The 17,600 attendees were invited to place push-pins on a world map to show where they’d come from. Some did, providing a snapshot of the international participation in the meeting.

Photo by Sherry Boschert

Affluent countries whose physicians can more easily afford international travel to the meeting are more heavily represented, but the map still gives the impression of one world fighting a common disease. The keys to preventing or slowing diabetes are known and well shared — don’t smoke, eat a healthy diet, be physically active regularly (like 30 minutes of brisk walking 5 days per week), and maintain a normal body weight. If there’s one solution to this one-world problem, it may lie in finding a way for people of all nations to follow that advice.

Easier said than done. But as a major study presented at the meeting calculated, treating people at high risk for diabetes in the United States by either enrolling them in a lifestyle intervention program (to change eating and exercise habits) or by prescribing the drug metformin was extremely cost-effective compared with doing nothing.

Teaching people to “swim,” as it were, or throwing them a pharmaceutical life jacket, may be cheaper and better than expecting them to surf a tsunami.

–Sherry Boschert (@sherryboschert on Twitter)

Obesity, Diabetes are the Epidemics; Is Bariatric Surgery the Cure?

The quick answer to this question is yes, at least for many (as opposed to all) patients, and at least according to the bariatric surgeons I heard and spoke with at their society meeting in mid-June. My take from that meeting was that bariatric surgery is working wonders these days–of course for obesity, but for type 2 diabetes too. It’s remarkably safe, yet way underused. Will that change soon? Is a golden age of bariatric surgery dawning, and will the big, two-headed medical epidemic now rampaging get tamed as a result?

Roux-en-Y gastric bypass; courtesy NIDDK, Wikimedia Commons

It’s a tall order, but my bet is on bariatric surgery, and there are hints that its long-standing status as the wallflower of surgical interventions may be shifting.

Last March, the International Diabetes Federation issued a position statement on bariatric surgery saying that it should be “considered earlier in the treatment of eligible patients.” The statement called bariatric surgery “an accepted option in people who have type 2 diabetes and a body mass index of 35 kg/m2 or more.” And for patients with a BMI of 30-35 kg/m2 the statement said that bariatric surgery “should be considered an alternative treatment option” for patients inadequately controlled by optimal medical therapy, especially when they also have major cardiovascular disease risk factors.

To someone like me, previously unfamiliar with where bariatric surgery stood these days, some of the facts I gleaned at the meeting were eye-opening. The perioperative mortality rate for laparoscopic gastric bypass surgery (Roux-en-Y), the type of bariatric surgery considered most practical and effective for treating types 2 diabetes by most surgeons I ran into, fell to a rate of 6/10,000 patients treated in 2009 at about 360 U.S. academic medical centers and affiliated hospitals. The non-fatal complication rates and need for repeat hospitalization was also low, placing the risk from bariatric surgery these days squarely in the ranks of many ”routine” surgeries, such as hip replacement, appendectomy,  and gallbladder removal for stones. Gastric band placement is safer still, though not as effective for resolving type 2 diabetes.

The diabetes effect from gastric bypass is also impressive. One recent study compared 46 patients with diabetes who underwent laparoscopic gastric bypass at the Gundersen Lutheran Health System in La Crosse, Wis., with 41 matched patients with type 2 diabetes who remained on their standard medical treatment during 2001-2005.  One year after surgery, the average hemoglobin A1c in the surgery patients stood at a normal 5.8%, compared with their average baseline value of 7.4%. Twenty-seven of these 46 (59%) were in full diabetes remission, meaning they were off all diabetes medications and their HbA1c was below 6.0%. In contrast, just 2 of the 41 conventional-treatment patients (5%) went into remission a year after their baseline.

“If there was a pill that achieved remission rates like this and had a safety profile like this and you didn’t offer it to your patients it would be unethical,” said Dr. Shanu N. Kothari, director of the minimally invasive bariatric surgery center at Gundersen and lead author of this study.

Yet bariatric surgery is neglected by most patients–be they just obese or obese with type 2 diabetes–and by their physicians. At the meeting I heard that about 200,000 U.S. bariatric surgeries are done annually now, a scope dwarfed by the number of patients who are candidates.

Why the neglect? Several surgeons at the meeting noted the disconnect between acceptance in the medical community of bariatric surgery relative to just about every other type of medically driven surgery out there.

What’s also striking is that bariatric surgery’s success contrasts with the problems that medical weight loss and maintenance has faced recently. During the past year or so, the Food and Drug Administration has shot down lorcaserin (Lorqess), the combination of phentermine and topiramate (Qnexa) , and another combination, bupropion and naltrexone (Contrave), all because of concerns that these agents might cause cardiovascular adverse events. In contrast, a report at the bariatric surgery meeting showed that all forms of bariatric surgery actually led to significant reductions in cardiovascular disease events as well as increased patient survival.

With medical management of obesity in sorry shape, and lots of evidence building for surgery’s safety and efficacy, the ascendance of a surgical solution to obesity and diabetes may have begun.

—Mitchel Zoler (on Twitter @mitchelzoler)

In the Developing World, Diseases Defy Definition

Before last week, I thought I knew the definition of “noncommunicable disease.” Then I attended “The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion.”

 Held on the campus of Harvard Medical School in Boston March 2^nd and 3^rd, the 2-day conference was sponsored by Partners In Health, an international nonprofit organization that conducts research, does advocacy, and provides direct health care services for people living in poverty around the world. The “Bottom Billion” of the meeting’s title refers to the world’s poorest people living on less than $1 per day.

 In a 2008-2013 action plan, the World Health Organization refers to “the four noncommunicable diseases – cardiovascular diseases, diabetes, cancers and chronic respiratory diseases and the four shared risk factors – tobacco use, physical inactivity, unhealthy diets and the harmful use of alcohol.” Together, these conditions account for approximately 60% of all global deaths, of which 80% occur in low- and middle-income countries. 

A cancer patient in Rwanda receives chemotherapy as her husband and physician discuss her treatment / Photo courtesy of Partners In Health

But as I learned at the conference, among the Bottom Billion, rheumatic heart disease is often the result of an untreated streptococcal infection early in life, diabetes is frequently associated with malnutrition rather than over-nourishment, and cervical cancer due to human papillomavirus is far more common than in the developed world, where women routinely receive PAP screenings and a vaccine can now also prevent the infection.   

And most startling to me: Among the world’s poorest, smoking is not the most common cause of chronic obstructive pulmonary disease. Cooking with biomass fuels is.   

Individually, these and other so-called “endemic NCDs” including Burkitt’s lymphoma, sickle cell disease, and tropical diseases are far less common than those within the WHO’s “four-by-four” definition. But together, that “long tail” of chronic conditions contributes to a great deal of suffering. 

In May 2010, the United Nations announced that it would hold a high-level meeting on NCDs in 2011, now set for September 19-20. It will be only the 29^th such meeting that the UN has ever held (formerly called “special sessions“), and just the second pertaining specifically to a health issue. The first one, the 2001 Summit on HIV/AIDS, is credited with focusing global attention and obtaining public and private funding for that cause. 

Speakers at the Partners In Health meeting stressed that the NCD movement should not be undertaken as an “us against them” competition with infectious disease for scarce resources. In a statement that will be presented to the heads of government at the UN summit, the group called instead for “strengthening and adjusting health systems to address the prevention, treatment, and care of NCDs, particularly at the primary health care level.”

—Miriam E. Tucker (@MiriamETucker on Twitter)

The Top-Viewed Posts of 2010

Well, it’s that time of year: A time for reflection, a time for too much fattening food and drink, and probably way too much togetherness with relatives you spend the rest of the year trying to avoid. Here at Notes From the Road, we’d like to take a moment to reflect on the bounty that medicine has provided us in 2010 by sharing our most-viewed posts, as nearest as we can determine.

Via Flickr Creative Commons user yoppy

10. Would an Artificial Pancreas be a Diabetes “Cure?” By Miriam E. Tucker

The Juvenile Diabetes Research Foundation’s announcement yesterday of a partnership with Animas Corp. and DexCom Inc. to develop a first-generation automated insulin delivery system brought to my mind a question that is often debated in diabetes circles: Would a fully automated “artificial pancreas” represent a “cure” for type 1 diabetes? (Read more.)

9. Placebos vs. Antidepressants: Not Quite a Draw By Bob Finn

There’s a fascinating study in today’s Journal of the American Medical Association. It’s a meta-analysis of randomized controlled trials comparing antidepressants vs. placebo. And it showed that the placebo effect is so strong in depression that placebos work as well as paroxetine (Paxil) and imipramine (Tofranil) for all patients except those with major depressive disorder that’s classified as “very severe.” Placebo tied active medication for “mild,” “moderate,” and even “severe” depression. (Read more.)

8. Tocilizumab Approval Causes Buzz by Diana Mahoney

One year after asking the Roche group to submit additional data for its monoclonal antibody tocilizumab, the FDA has approved the biologic agent for the treatment of moderate to severe rheumatoid arthritis. (Read more.)

7. Head Injuries Predict Persistent, Bad Headaches by Sherry Boschert

Like many of the neurologists attending the annual meeting of the American Headache Society, I slipped into the hotel lobby during breaks in the program to watch World Cup soccer in bits and pieces. The images of players heading the ball caught my eye in a new way after hearing a couple of presentations about the associations between head injuries and persistent, more frequent, and disabling headaches. (Read more.)

6. Using Hemoglobin A1C to Diagnose Diabetes: What’s Your Take? By Miriam E. Tucker

The American Diabetes Association’s decision earlier this month to officially endorse hemoglobin A1c as a diagnostic test for diabetes is either timely, inappropriate, or long overdue, depending on whom you talk to. (Read more.)

5. Can Hemoglobin A1C Go Too Low? By Miriam E. Tucker

A new study showing increased mortality among type 2 diabetes patients at hemoglobin A1c levels below 7.5% raises a new question: Should diabetes guidelines be revised to include a minimum hemoglobin A1c level? (Read more.)

4. New Clues to the Root of Basal Cell Carcinoma by Doug Brunk

Findings from a novel investigation published in the Jan. 5, 2010, edition of Cancer Prevention Research are helping researchers better understand what causes basal cell carcinoma tumors. (Read more.)

3. Rheumatoid Arthritis 5.0 by Mitchel Zoler

Rheumatologists have remade rheumatoid arthritis, a pretty big deal for them if only because it’s “the major systemic rheumatic disease that we as a specialty treat,” said Dr. Michael E. Weinblatt, a Harvard rheumatologist, at the end of a 90-minute session on Sunday afternoon that unveiled a new definition of rheumatoid arthritis to the world. (Read more.)

2. Doctors Attend to Burning Man by Sherry Boschert

Next week more than 40,000 people from around the world will migrate to Black Rock Desert in Nevada to create a week-long community where clothing is optional, illicit drugs are common, and fantastical artwork is everywhere. Dr. Marc Nelson will be one of them at an event called Burning Man. (Read more.)

1. Doctors: Help Them Understand That “It Gets Better” By Mark Lesney

Any growing tolerance of a person’s right to his or her own sexuality that is evidenced in the mainstream culture has yet to impact the Lord of the Flies scenarios that exist for gay, lesbian, bisexual, transgendered, or questioning students in many schools across the country—something that is comically but bitingly portrayed in the Fox hit series “Glee.” (Read more.)

Thanks for following us in 2010. We hope you’ll be back for more in 2011.

— Alicia Ault (on Twitter @aliciaault)

China’s Diabetes Problem

China may be an economic superpower, but diabetes is taking away some of that wealth.  

 Approximately 13% of the country’s total medical expenditures—totaling 173.4 billion Renminbi, or $25 million (U.S.)—is spent on the condition, according to a new report from the Chinese Diabetes Society (CDS) and the International Diabetes Federation (IDF),

A public diabetes screening held in Shanghai / Photo courtesy of IDF

The report, based on preliminary data from a survey of 5,000 people at 12 sites, also documented that health expenditures for people in China who have had diabetes for 10 or more years are 460% higher than for those who have had the condition for just 1 to 2 years.

Of  the survey respondents with diabetes,  89% reported having health insurance. However, they spent 11% of their income on medical care — 9 times more than did those of the same age and sex who didn’t have diabetes.

The CDS/IDF survey is a followup to a study published earlier this year in the New England Journal of Medicine, which found that the prevalence of diabetes in China was 9.7% of the total population, or 92.4 million adults. Another 148.2 million adults in the country were found to have prediabetes,  the China National Diabetes and Metabolic Disorders Study Group reported. 

Diabetes threatens China’s prosperity, IDF executive director Ann Keeling said in September. “One in 10 people in China now has diabetes. They’re getting it in their 40’s and 50’s, the most productive years. In a generation, there will be cities full of sick people and a sick workforce. It has huge implications for competitiveness.”

The Chinese Ministry of Health recognizes the problem. This year it has introduced several new education and awareness programs, including a three-year project to train 100,000 community-level physicians across the country in diabetes prevention and treatment, a Web-based learning platform for diabetes training expected to attract over 400,000 subscribers a year, and a glucose management training program aimed at 1,000 community-based healthcare providers.

Also, BRIDGES, a $400,000 research project run by the IDF in the city of Tianjin, aims to translate a proven gestational diabetes care protocol into routine obstetric practice.

“Help is needed from both inside and outside the country to prevent and control diabetes in China,” CDS president Professor Linong Ji said in an IDF statement.

—Miriam E. Tucker (@MiriamETucker on Twitter)

Is Global Health Funding Fair?

Leaders in the noncommunicable disease community often state that international donor spending on chronic conditions such as heart disease, diabetes, and cancer far underrepresents their burden in developing countries. Now, a new report from the nonprofit Center for Global Development provides stark data to back up the claim.

Photo by Lawrence OP via Flickr Creative Commons

“Where Have all the Donors Gone? Scarce Donor Funding for Non-Communicable Diseases” examines the trends in public and private donor resources from 2004 to the present. The work was supported by PepsiCo.

Contrary to widespread belief, the impact of chronic, noncommunicable diseases (NCDs) exceeds that of infectious/communicable disease in the developing world as well as the developed. In 2008, NCDs contributed 48% to morbidity and mortality in developing countries, compared with 39% from infectious diseases (with the remainder due to injury). For mortality, those proportions were 59% vs. 31%, according to World Health Organization (WHO) data quoted in the report.

At a panel event held at the CGD’s headquarters in Washington last week, report coauthor Rachel A. Nugent, Ph.D., said $503 million was spent on NCDs in 2007, accounting for less than 3% of the $22 billion in total development assistance for health. In contrast, nearly a third of the total — $6.3 billion — was devoted to HIV, tuberculosis, and malaria.

By disease burden, this works out to less than one U.S. dollar – just 78 cents – per disability-adjusted life year (DALY), compared with $23.9/DALY for the three infectious diseases. “That’s fairly staggering. … It’s a significant disparity in level of effort,” Dr. Nugent commented.

Approximately 15% of health funding in low-income countries comes from external donor sources. The WHO contributed the greatest amount in 2007, $812 million. Other top donors include the Wellcome Trust UK, the World Bank, the Bloomberg Family Foundation, and the Gates Foundation.

Funding for noncommunicable disease will be the focus of a high-level United Nations NCD Summit scheduled for September 2011. The idea is not to take away money from infectious disease, Dr. Nugent said.

Rather, “I hope that growing attention to this issue stays focused on achieving greater health for the money that’s being invested already and additional money that may eventually be invested to increase flexibility in health delivery across sectors and across health conditions, because I think that’s where we’re going to get the most bang for the buck and the best development results.”

Dr. Rachel Nugent and Dr. Derek Yach / Photo by Miriam E. Tucker

And why is PepsiCo interested in this? I asked the company’s senior vice president for global health policy Dr. Derek Yach, who also spoke at the CGD event. His reply: “We are committed to addressing major nutritional and other underlying causes of ill health and NCDs as part of a broad commitment to health and the environment. It is in our long term interests and represents a convergence between opportunities for PepsiCo to build a profitable business based on healthy products.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

European Parliament Members Weigh in on NCDs

With the United Nations summit on noncommunicable disease less than a year away, Members of the European Parliament (MEPs) have now contributed to a growing number of voices worldwide calling for urgent action to address the chronic disease epidemic.

Image by Pacopus via Flickr Creative Commons

In a statement sent this week to the Presidency of the European Union, four MEP groups wrote, “Chronic non-communicable diseases account for 86% of deaths in the WHO European Region. They include heart disease, stroke, hypertension, diabetes, kidney disease, cancers, respiratory and liver diseases. Because most are treatable but not always curable, they generate an enormous financial burden due to treatment costs, care costs and loss of productivity.”

Signatories are the MEP Heart Group, the EU Diabetes Working Group, the MEP Group for Kidney Health and MEPs Against Cancer, informal groups of parliament members engaged in fighting the diseases and conditions in those health areas.

The MEPs note that chronic noncommunicable diseases (NCDs) affect more than a third of Europe’s population, comprising over 100 million citizens, and that four preventable health determinants – tobacco use, poor diet, alcohol consumption, and lack of physical activity – account for most of chronic illness and death in Europe. Prevention costs less than disease management and treatment, yet 97% of health expenses currently are spent on treatment and only 3% invested in prevention.

The statement advises EU member states to follow recommendations from a policy paper entitled “A Unified Prevention Approach.” That 20-page document was issued in July by the Chronic Disease Alliance, a coalition of 10 separate European nonprofit professional medical organizations, including those representing hepatology, oncology, cardiology, nephrology, respiratory medicine, and diabetology.

The Alliance’s recommendations include a call for harmonization of tobacco taxation across Europe, standardization of cigarette packaging with 80% of the package devoted to pictorial health warnings, and a ban of tobacco sales via the Internet and vending machines.

They also recommend a ban of added trans fat to foods, introduction of a traffic light color coding system to food labels (with green being the most healthful and red the least), increased access to affordable fresh fruit and vegetables, and EU measures to prohibit marketing of unhealthful food to children. Other recommendations address the promotion of physical activity and the reduction of alcohol consumption and dependence.

According to the Alliance, “Simple policies could save millions of lives and cut billions of euros in direct and indirect costs…By acting now, the European Commission will be doing something that transcends anything else it may accomplish.”

–Miriam E. Tucker (@MiriamETucker on Twitter)