Diabetes: a defining disease of the 21st century

New estimates published this week in The Lancet indicate that more than 1·31 billion people could be living with diabetes by 2050 worldwide. That's 1·31 billion people living with a disease that causes life-altering morbidity, high rates of mortality, and interacts with and exacerbates many other diseases. The increase in prevalence (up from 529 million in 2021) is expected to be driven by increases in type 2 diabetes, which in turn will be caused by a rise in the prevalence of obesity and by demographic shifts. In 2021, type 2 diabetes accounted for 90% of all diabetes prevalence. Most of this burden is attributable to social risk factors—such as high BMI, dietary risks, environmental and occupational risks, tobacco use, alcohol use, and low physical activity—that thrive on the obesogenic way our environments are designed and the inequitable way we organise our resources and societies. Timed to coincide with the American Diabetes Association's 83rd Scientific Session, The Lancet and The Lancet Diabetes and Endocrinology publish a Series on Global Inequity in Diabetes. Two papers—one global and one focused on the USA—together tell the unhappy and inequitable story of diabetes. By 2045, as many as three in four adults with diabetes will be living in low-income and middle-income countries. Currently, only 10% of people with diabetes living in these countries receive guideline-based diabetes care. Regardless of economic category, in every country, those who are discriminated against and marginalised suffer the most and worst consequences of diabetes. In the USA, where the burden of type 2 diabetes in young people has nearly doubled in the past 20 years, the highest burden is seen among Black or Indigenous American populations. Paper 1 in the Series conceptualises why this might be. It shows how structural racism and geographical inequity amplify and compound the social determinants of health and affect the care and treatment to which people with diabetes have access. This leads to greater prevalence of type 2 diabetes and worse clinical outcomes in populations who experience current and historical racism and oppression. Although The Lancet Commission on Diabetes highlighted the broad social and environmental factors that lead to type 2 diabetes and called for population-based prevention strategies, racism was not considered. At this year's World Health Assembly, the role that structural racism as a driver of diabetes and other non-communicable diseases was not a focus. Another paper in the Series, on possible interventions, highlights the importance of equitable partnerships, building community capacity and trust, changing the ecosystem, and improving the clinical practice environment. These initiatives remain limited and finding funding for them is often hard. A much broader and more ambitious programme is required to address centuries of injustices that have followed the well-trodden paths of power and colonisation. Instead, the focus remains on biomedical interventions and new devices. Estimates for the global type 2 diabetes drugs market over the next decade vary widely, with some reaching more than US$100 billion. Overall, global diabetes-related health expenditure is estimated to rise to $1054 billion by 2045. The excitement and utility surrounding GLP-1 agonists and newer drug combinations that help to control blood sugar as well as reduce body weight is understandable. But as Rupa Marya and Raj Patel write in their book Inflamed Deep Medicine and the Anatomy of Injustice, the solution to unhealthy and unfair societies is not more pills but to re-evaluate and re-imagine our lives to provide opportunities to tackle racism and injustice, and to prevent the major social drivers of disease. Addressing structural racism must become a core component of preventive strategies and health promotion—areas that invariably receive too little investment. For example, EU countries spent an average of 2·8% of health expenditure on preventive care in 2018. Although COVID-19 offered an opportunity to reconsider how health ministries spend their money, little seems to have changed in terms of how much is invested in public health. Diabetes will be a defining disease of this century. How the health community deals with diabetes in the next two decades will shape population health and life expectancy for the next 80 years. The world has failed to understand the social nature of diabetes and underestimated the true scale and threat the disease poses. The GBD 2021 estimates and the Lancet Global Inequity in Diabetes Series are an urgent call to course correct. For more on diabetes health expenditure see Diabetes Res Clin Pract 2022; 183: 109119 For more on diabetes health expenditure see Diabetes Res Clin Pract 2022; 183: 109119 Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021Diabetes remains a substantial public health issue. Type 2 diabetes, which makes up the bulk of diabetes cases, is largely preventable and, in some cases, potentially reversible if identified and managed early in the disease course. However, all evidence indicates that diabetes prevalence is increasing worldwide, primarily due to a rise in obesity caused by multiple factors. Preventing and controlling type 2 diabetes remains an ongoing challenge. It is essential to better understand disparities in risk factor profiles and diabetes burden across populations, to inform strategies to successfully control diabetes risk factors within the context of multiple and complex drivers. Full-Text PDF Open AccessEfficacy and safety of once-daily oral semaglutide 25 mg and 50 mg compared with 14 mg in adults with type 2 diabetes (PIONEER PLUS): a multicentre, randomised, phase 3b trialOral semaglutide 25 mg and 50 mg were superior to 14 mg in reducing HbA1c and bodyweight in adults with inadequately controlled type 2 diabetes. No new safety concerns were identified. Full-Text PDF Efficacy and safety of oral orforglipron in patients with type 2 diabetes: a multicentre, randomised, dose-response, phase 2 studyIn this phase 2 trial the novel, oral, non-peptide GLP-1 receptor agonist orforglipron at doses of 12 mg or greater showed significant reductions in HbA1c and bodyweight compared with placebo or dulaglutide. The adverse event profile was similar to other GLP-1 receptor agonists in similar stage of development. Orforglipron might provide an alternative to injectable GLP-1 receptor agonists and oral semaglutide, with the prospect of less burdensome administration to achieve treatment goals in people with type 2 diabetes. Full-Text PDF Retatrutide, a GIP, GLP-1 and glucagon receptor agonist, for people with type 2 diabetes: a randomised, double-blind, placebo and active-controlled, parallel-group, phase 2 trial conducted in the USAIn people with type 2 diabetes, retatrutide showed clinically meaningful improvements in glycaemic control and robust reductions in bodyweight, with a safety profile consistent with GLP-1 receptor agonists and GIP and GLP-1 receptor agonists. These phase 2 data also informed dose selection for the phase 3 programme. Full-Text PDF