Might we be ignoring the other pandemic – slower-moving and less visible than COVID-19 – that afflicts NZ, asks Niki Bezzant

Twenty years ago, Professor Jim Mann wrote an editorial in the medical journal The Lancet, entitled: Stemming the Tide of Diabetes.

It may have been one of the first times diabetes had been described as an epidemic, something for which Mann says the editorial attracted attention, as well as criticism.

At that time it was acknowledged that a number of indigenous populations around the world had especially high rates of diabetes. The editorial called for global action: “In view of the cost, in terms of disability, premature mortality and consumption of health care resources, attempts to reverse the increasing rates of type 2 diabetes should be regarded as major public-health priorities in developing as well as affluent societies,” Mann wrote.

Since then, it’s clear we have not stemmed that diabetes tide. Instead, it’s risen. Mann, who is a Professor in Medicine and Human Nutrition at the University of Otago, Director of Healthier Lives National Science Challenge and co-Director of the Edgar Diabetes and Obesity Research Centre, says it’s now acknowledged type 2 diabetes qualifies as a pandemic.

“Diabetes is global. It meets the criteria for a pandemic, something some of us recognised, and warned of, a long time ago.”

He’s now worried we might be ignoring that pandemic – slower-moving and less visible as it is – in the face of COVID-19, whose potentially long tail we’re dealing with now.

Yet the two pandemics are linked in tragic ways.

We know that if someone suffers from a pre-existing condition, they’re more likely to have a much worse time, should they be unlucky enough to contract COVID-19. And what’s emerging is that obesity and type 2 diabetes are near the top of the list of ‘co-morbidities’ you really don’t want to have.

Depending on the global region, 20–50% of patients in the COVID-19 pandemic were obese or had diabetes, according to a recent report published in the Lancet. And while there’s no evidence yet that having diabetes is a risk factor for contracting the virus, experts agree it seems highly likely.

“Diabetes increases the risk of many infections,” says Professor Mann, “so the likelihood that this applies also to COVID-19 must be very high.”

What there’s no question about is that people with diabetes who have COVID-19 have far worse outcomes than others.

“Again both obesity and diabetes significantly increase the risk that a person with COVID-19 has a more severe illness requiring hospitalisation and admission to ICU”, according to endocrinologist Professor Jeremy Krebs, a Healthier Lives researcher.

They’re more likely to die, too. The Lancet report noted the risk of a fatal outcome from COVID-19 is up to 50% higher in patients with diabetes, who “have an increased risk of severe complications including Adult Respiratory Distress Syndrome and multi-organ failure”.

In a letter just published in the New Zealand Medical Journal, a group of experts from the New Zealand Society for the Study of Diabetes (NZSSD) laid out some more startling statistics: in a Chinese study of 191 hospitalised COVID-19 cases, 19% had diabetes and 54 died, of whom 17 (31%) had diabetes. Similarly, in Italy 32% of 1,890 COVID-19 deaths had diabetes.

While it looks like New Zealand may now have stemmed the tide of COVID-19, we’ve got no guarantee, says Mann. “If people start behaving inappropriately, it’s possible there may be a spike,” he says.

And that means the risk remains that these two pandemics could collide.

Time to address the inequities

Diabetes is not an equal-opportunity condition. Those who are already vulnerable are at higher risk.

Close to a quarter of a million Kiwis have type 2 diabetes and 25,000 have type 1. It’s also thought around one in five Kiwis has prediabetes – the precursor to type 2 diabetes – though some are unaware they have it.

The disease stretches across all areas of society, but rates of diabetes are higher among Māori, Pacific and South Asian people compared with Pakeha, with those living in deprived communities even worse off.

It’s no coincidence that, as noted in the NZSSD report, these groups are especially vulnerable to the far-reaching impacts of the COVID-19 crisis, too. Both pandemics highlight inequities in health care.

We’ve seen this before. During the H1N1 epidemic in 2009, increased rates of diabetes and cardiovascular disease amongst Māori and Pacific peoples may have contributed to a 2.6-fold increased risk of mortality compared with the non-Māori, non-Pacific population.

It’s vital right now, say the experts, that we protect this high-risk group – the NZSSD cites the need for flu vaccination; workplace risk assessment and regular contact with health care providers, as well as employing a very low threshold for coronavirus testing in people with diabetes.

Professor Mann says while better management is important, directing our attention to diabetes prevention is vital too. And both of those things need to be looked at through the lens of inequity.

In the Lancet editorial of 2000, Mann wrote that research was “urgently needed to develop effective interventions to reduce the devastating effects of diabetes and its complications on many populations worldwide.”

Research has been happening here. It’s been the focus of the Healthier Lives National Science Challenge, a national research collaboration with a mission: to equitably reduce the overall burden of disease associated with four major non-communicable diseases: cancer, cardiovascular disease, diabetes and obesity.

Several projects are aimed directly at reducing inequities in the treatment and management of type 2 diabetes.

Mana Tū is one example. Co-designed with whānau, clinicians, health service planners and whānau ora providers, the programme offers prevention and better management of people living with pre-diabetes or poorly-controlled diabetes. It’s a grass-roots intervention, using case managers, or Kaimanaaki-whānau, as clinical ‘champions’ who work with people with type 2 diabetes and their whānau. Together they work on things that can affect people’s ability to live a fulfilling life, which can range from poverty and housing to people’s engagement with the health system and the discrimination they face in that system.

Another Healthier Lives project, He Pikinga Waiora, takes a similar but broader approach to improve health equity for Māori communities. The wide-ranging project developed a new framework for health interventions based on cultural-centredness and community engagement – both key to making changes that stick. It’s a co-design process with a whole community, rather than a ‘top down’ intervention from a group of health experts.

It’s this kind of thinking we’ll have to embrace in a post-COVID world, where we’ll be far more aware that we just don’t know what’s around the corner, including the possibility of another pandemic, or a re-emergence of the current one.

The NZSSD report says of diabetes and COVID-19 that “while of different aetiologies, both are significant public health challenges requiring commitment from governments and partnership with public health practitioners, the healthcare workforce and communities.”

This is further evidence we need to take the diabetes epidemic seriously, says Professor Mann.

He says right now we don’t know exactly why people with obesity or diabetes are so badly affected by COVID-19. “The bottom line is we don’t really know yet. It’s very unclear, and there are probably multiple mechanisms.

“But in the meantime it’s in all of our interests to work on diabetes prevention.”

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