THE LANCET and THE LANCET DIABETES & ENDOCRINOLOGY: “Cascade of widening inequity” accelerating the global diabetes crisis

Peer-reviewed /Review and Opinion/ People

• New estimates predict that the number of people living with diabetes worldwide will more than double from 529 million in 2021 to more than 1.3 billion in 2050, with no country expected to see a decline in age-standardised diabetes rates over the next 30 years.
• Structural racism and geographic inequity are accelerating this global crisis of diabetes, with rates of diabetes among minority ethnic groups in high-income countries, such as the USA, 1.5 times higher than among their white counterparts; and diabetes death rates in low- and middle-income countries double that in high-income countries.
• A new joint Series published in The Lancet and The Lancet Diabetes & Endocrinology provides scientific evidence to describe and counter these concerning trends with tried and tested programmes and policies that have shown real-world promise, and calls for more high-impact, high-quality, real-world research to reduce diabetes inequities. 

**For regional and individual-level country data, see notes to editors**
***Infographics available – see notes to editors***

Despite increased awareness and ongoing multinational efforts, diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally, according to a new Series published in The Lancet and The Lancet Diabetes & Endocrinology journals. Worse still, structural racism experienced by minority ethnic groups and geographic inequity experienced by low-and middle-income countries (LMICs) are accelerating soaring rates of diabetes disease, illness, and death around the world.  

New alarming estimates, published in The Lancet alongside the Series by the GBD 2021 Diabetes Collaborators, project that without an effective mitigation strategy, more than 1.3 billion people will be living with diabetes by 2050, one of the leading causes of death and disability worldwide. 

No country is expected to witness a decline in age-standardised diabetes rates over the next three decades, with the worst affected regions of Oceania and north Africa and the Middle East expected to reach levels of diabetes that exceed 20% in many countries, along with Guyana in the Caribbean.

The new collection of Series papers also highlights how the ever-growing global burden of diabetes is further exacerbated by large-scale inequity in diabetes prevalence, illness, and death. Estimates indicate that more than three-quarters of adults with diabetes will live in LMICs by 2045, of whom fewer than 1 in 10 will receive guideline-based comprehensive diabetes care [1].

Similarly, in high-income countries (HICs) like the USA, rates of diabetes are almost 1.5 times higher among minority ethnic groups (i.e., American Indians and Alaska Natives, Black, Hispanic, Asian) compared to white populations, fuelled by structural racism [2]. 

The Series finds that people from marginalised communities around the world are less likely to get access to essential medicines like insulin and new treatments, have worse blood sugar control, and have a lower quality of life and reduced life expectancy. The COVID-19 pandemic has amplified diabetes inequity globally, with people with diabetes 50% more likely to develop severe infection and twice as likely to die compared to those without diabetes, especially those from ethnic minority groups.

Against this background, the authors of The Lancet–Lancet Diabetes & Endocrinology Series on global inequity in diabetes highlight real-world interventions that have shown potential in reducing inequitable diabetes care and outcomes among racially and geographically marginalised groups and communities, and call for more high-quality, real-world research.

“Diabetes remains one of the biggest public health threats of our time and is set to grow aggressively over the coming three decades in every country, age group, and sex, posing a serious challenge to health-care systems worldwide,” says Series leader Dr Shivani Agarwal, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine and Montefiore Health System, USA. [3]

She continues, “A central focus and understanding of inequity in diabetes is vital to achieve the UN’s Sustainable Development Goal to reduce non-communicable diseases by 30% in less than 7 years and to curtail the increasingly negative effects on the health of marginalised populations and the strength of national economies for decades to come. This Series offers an important opportunity for concerted, pragmatic action to transform approaches to diabetes care and outcomes for marginalised populations around the world.” [3] 

Structural and social factors play an outsized role in shaping diabetes outcomes and care

The Series outlines how the large-scale and deeply rooted effects of structural racism and geographic inequity lead to unequal impacts of social determinants of health (the social and economic conditions in which people live and work) on global diabetes prevalence, care, and outcomes over the life course. Negative impacts of public awareness and policy, economic development, access to high-quality care, innovations in management, and sociocultural norms are felt widely by marginalised populations and for generations to come.

“Racist policies such as residential segregation affect where people live, their access to sufficient and healthy food and health care services,” explains co-author Professor Leonard Egede, Medical College of Wisconsin, USA. “This cascade of widening diabetes inequity leads to substantial gaps in care and clinical outcomes for people from historically disenfranchised racial and ethnic groups, including Black, Hispanic, and Indigenous people.” [3]

In Australia, for example, longstanding structural racism and inequity have led to Aboriginal and Torres Strait Islander populations experiencing rates of type 2 diabetes that are three times higher than the general population and some of the highest rates of youth-onset type 2 diabetes worldwide. “Transgenerational trauma may affect mental health and wellbeing as well as the home environment that people are living in, increasing diabetes risk,” explains co-author Professor Louise Maple-Brown, Menzies School of Health Research, Australia. “Food insecurity in remote communities and overcrowded housing also greatly impede diabetes self-management and care.” [3]

Structural racism and structural conditions in the places people live and work have far-reaching, trans-generational negative effects on diabetes outcomes across the world. “In sub-Saharan Africa, lower spending on healthcare, lack of human resources, food insecurity, and limited access to essential medicines contribute to poorer outcomes, while lack of public awareness and specific diabetes policy has limited initiatives to drive population-level change,” says co-author Associate Professor Alisha Wade, University of the Witwatersrand, South Africa. “It is vital that the impact of social and economic factors on diabetes is acknowledged, understood, and incorporated into efforts to curb the global diabetes crisis.” [3]

A Series article published in The Lancet Diabetes & Endocrinology adds further weight to these findings, highlighting the large disparities in diabetes burden and management that exist between and within race and ethnic groupings in the USA. For example, Black people born in Africa or the Caribbean are 25% less likely to develop diabetes than US-born Black individuals; and Asian, Black, and Hispanic individuals and those on low incomes are less likely to receive diabetes treatment with GLP1 receptor agonists than their white or wealthier counterparts.

“Current race and ethnicity categories are inadequate to describe the nuances of lived experiences and to fully illuminate inequities that are entrenched in societal structures including health care,” says co-author Dr Saria Hassan, Emory University School of Medicine, USA. “What’s more, focusing solely on adults overlooks the degree to which the accelerating epidemic of type 2 diabetes in children and adolescents is contributing to the growing burden of disease and worsening disparities across the USA.” [3]

Wide-ranging strategies needed to eliminate inequities in diabetes 

Building on recommendations from the 2020 Lancet Diabetes Commission [4], together with WHO’s 2021 Global Diabetes Compact and the UN Sustainable Development Goals, the Series outlines action plans to tackle racial inequities in diabetes care and improve outcomes by including the most affected communities in the development and implementation of interventions, and incorporating multi-layered strategies to address structural and social determinants of health that are the root causes of inequity globally.

The authors highlight international examples of how to address diabetes inequity in the real world by changing the ecosystem (societal and policy-level factors), building capacity, and improving the clinical practice environment. 

Insulin access is an important part of the ecosystem for millions of people with diabetes who cannot obtain or afford the necessary supplies to self-manage their diabetes. One intervention in sub-Saharan Africa, developed in partnership with governments, industry, and patient groups, is the Diabetes CarePak “co-packaging” solution to increase access to safe insulin and supplies. The month’s supply of test strips, alcohol swabs, needles and syringes and a glucose meter has resulted in more frequent blood glucose monitoring as well as an average haemoglobin A1C decrease of 2.8% over two months—a reduction which compares favourably to medication use.

Another promising programme to build capacity across the USA, IMPaCT (Individualized Management for Patient-Centered Targets), harnesses the power of locally recruited community healthcare workers to provide advocacy, social support, and health coaching, and has been shown to improve chronic disease control and reduce hospital stays while providing a good return on investment—with every dollar invested returning US$2.47 to an average Medicaid payer.

“These international examples demonstrate that approaches addressing the individual within a larger social context, as well as structural inequity, have the greatest potential for creating sustainable and equitable change in diabetes globally," says Dr Ashby Walker from The University of Florida, USA, and Chair of the American Diabetes Association’s National Health Disparities Committee. [3]

Ultimately, the Series solidifies the need for more high impact, high-quality, real-world research to ensure that all people with diabetes receive the care they need where and when they need it. “While research has focused on describing these inequities, it is critical to develop and test interventions to address them. There is a dearth of on-the-ground approaches published in high-impact journals. We must stop admiring the problem and start fixing it,” says Dr Agarwal. “We hope this Series will galvanise increased research funding to identify and develop more effective measures to address disparities in diabetes care and outcomes, as well as inform policies, that are sustainable at a population level. Failure to act will put the health of current and future generations in jeopardy.” [3]

NOTES TO EDITORS

The Series was conducted by researchers from Albert Einstein College of Medicine-Montefiore Medical Center, USA; University of the Witwatersrand, South Africa; University of Yaoundé, Cameroon; KEM Hospital Research Centre, India; Christian Medical College, India; Medical College of Wisconsin, USA; Charles Darwin University, Australia; University of Florida, USA; University of Pennsylvania, USA; Corporal Michael J Crescenz VA Medical Center, USA; T1D Exchange, USA; Indiana University School of Medicine, USA; Emory University, USA; Rollins School of Public Health, USA; and Morehouse School of Medicine, USA. 

The GBD Paper was conducted by the GBD 2021 Diabetes Collaborators. It was funded by the Bill & Melinda Gates Foundation.

[1] The state of diabetes treatment coverage in 55 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 680 102 adults - The Lancet Healthy Longevity
[2] Diabetes Complications in Racial and Ethnic Minority Populations in the USA (nih.gov)
[3] Quotes direct from authors and cannot be found in text of Commission.
[4] The Lancet Commission on diabetes: using data to transform diabetes care and patient lives

The labels have been added to this press release as part of a project run by the Academy of Medical Sciences seeking to improve the communication of evidence. For more information, please see: http://www.sciencemediacentre.org/wp-content/uploads/2018/01/AMS-press-release-labelling-system-GUIDANCE.pdf if you have any questions or feedback, please contact The Lancet press office pressoffice@lancet.com  
 

IF YOU WISH TO PROVIDE A LINK FOR YOUR READERS, PLEASE USE THE FOLLOWING, WHICH WILL GO LIVE AT THE TIME THE EMBARGO LIFTS: www.thelancet.com/series/global-inequity-diabetes

Tables - age-standardized diabetes prevalence in 2021 and 2050

Top 10 countries (worldwide)
2021	%	2050	%
Marshall Islands (Oceania)	22.2	Marshall Islands (Oceania)	28.9
American Samoa (Oceania)	21.4	Niue (Oceania)	27.5
Cook Islands (Oceania)	19.3	American Samoa (Oceania)	27.2
Niue (Oceania)	18.3	Cook Islands (Oceania)	25.4
Tokelau (Oceania)	17.6	Tokelau (Oceania)	24.9
Palau (Oceania)	17	Qatar (North Africa and the Middle East)	23.7
Fiji (Oceania)	16.3	Bahrain (North Africa and the Middle East)	23.6
Nauru (Oceania)	16	Kuwait (North Africa and the Middle East)	23.5
Samoa (Oceania)	15.8	Libya (North Africa and the Middle East)	23.5
Guyana (Caribbean)	15.5	Fiji (Oceania)	23.4

 

Bottom 10 countries (worldwide)
2021	%	2050	%
Austria (western Europe)	3.1	Mongolia (central Asia)	4.6
South Sudan (eastern sub-Saharan Africa)	2.9	Austria (western Europe)	4.4
Burundi (eastern sub-Saharan Africa)	2.9	Belarus (Eastern Europe)	4.4
Uganda (eastern sub-Saharan Africa)	2.8	Djibouti (eastern sub-Saharan Africa)	4.3
Madagascar (eastern sub-Saharan Africa)	2.8	Madagascar (eastern sub-Saharan Africa)	4.2
Belarus (Eastern Europe)	2.7	Malawi (eastern sub-Saharan Africa)	4.1
Tanzania (eastern sub-Saharan Africa)	2.6	Ethiopia (eastern sub-Saharan Africa)	4
Rwanda (eastern sub-Saharan Africa)	2.3	Rwanda (eastern sub-Saharan Africa)	3.7
Malawi (eastern sub-Saharan Africa)	2.1	Burundi (eastern sub-Saharan Africa)	3.6
Kenya (eastern sub-Saharan Africa)	2	South Sudan (eastern sub-Saharan Africa)	3.4

 

Top 10 countries (central Europe, high-income North America, Australasia)
2021	%	2050	%
USA (high-income North America)	9	USA (high-income North America)	10.8
Bosnia and Herzegovina (central Europe)	6.9	Serbia (central Europe)	10.3
North Macedonia (central Europe)	6.9	North Macedonia (central Europe)	9.5
Canada (high-income North America)	6.6	Bosnia and Herzegovina (central Europe)	9.1
Serbia (central Europe)	6.4	Montenegro (central Europe)	8.6
Montenegro (central Europe)	5.9	Canada (high-income North America)	7.9
Bulgaria (central Europe)	5.6	Hungary (central Europe)	7.8
Czechia (central Europe)	5.5	Croatia (central Europe)	7.5
Poland (central Europe)	5.5	Czechia (central Europe)	7.5
Hungary (central Europe)	5.2	Bulgaria (central Europe)	6.8

 

Bottom 10 countries (central Europe, high-income North America, Australasia)
2021	%	2050	%
Poland (central Europe)	5.5	Croatia (central Europe)	7.5
Hungary (central Europe)	5.2	Poland (central Europe)	6.8
Croatia (central Europe)	5.1	Bulgaria (central Europe)	6.8
New Zealand (Australasia)	4.4	Australia (Australasia)	6.4
Slovakia (central Europe)	4.2	New Zealand (Australasia)	6.3
Slovenia (central Europe)	4.2	Slovenia (central Europe)	6.1
Greenland (high-income North America)	3.9	Slovakia (central Europe)	5.7
Australia (Australasia)	3.8	Romania (central Europe)	5.3
Albania (central Europe)	3.6	Greenland (high-income North America)	4.8
Romania (central Europe)	3.6	Albania (central Europe)	4.6

---

---