Global War on Diabetes

This article is for educational or informational purposes only and does not substitute professional medical advice or consultations with healthcare professionals. Physical activity is important to lower the risk of diabetes, minimum 30 minutes daily walk, but the focus in this article is mainly diet.

Declaration of war on diabetes

It's time to declare an official Global War on Diabetes (GWD). Diabetes is defined here to include type 1, type 2 and prediabetes. Type 2 diabetes accounts for at least 90% of all diagnosed cases of diabetes in developed countries. In the US, about 96 million adults have prediabetes which is risk for developing type 2 diabetes, heart disease and stroke. 537 million people in the world have diabetes, according to the International Diabetes Federation.

Singapore declared its War on Diabetes (WoD) in 2016 to rally a whole-of-nation effort to tackle diabetes. Diabetes was 9.5% in 2020, or over 400,000 adults, and could increase to one million adults by 2050 if no actions are taken. The three key pillars for the WoD are 1 - Healthy living and prevention; 2 - Early detection and intervention; and 3 - Better disease management. The main reasons for the WoD are shown in the figure below.

Figure 1 - Diabetes related complications in Singapore

Hong Kong also has increasing diabetes and has a slightly higher diabetes rate than Singapore.

Chart 1 - Hong Kong number of public health care diabetes patients

Instead of declaring a WoD, in 2018 Hong Kong launched TOWARDS 2025 - Strategy and Action Plan to Prevent and Control Non-communicable Diseases in Hong Kong. One of the action plan's targets is to halt the rise in diabetes and obesity by 2025. The key indicators are shown below.

Figure 2 - Hong Kong key indicators to halt the rise in diabetes and obesity

Hong Kong has developed key indicators for both diabetes and obesity, probably due to the strong link between them. If obesity is higher then the risk of diabetes is higher as shown below. If a country has higher obesity then it usually has higher diabetes. Diabesity is a new medical term meaning that a person has both type 2 diabetes and obesity. The term prediabesity has also been used by experts such as Dr. Mark Hyman, because obesity is also related to prediabetes.

Figure 3 - Obesity and type 2 diabetes

Countries with high diabetes

China now has the most number of people with diabetes in the world, according to the International Diabetes Federation. The number of people with diabetes is expected to increase in 2045 for the countries below.

Figure 4 - Top 10 countries for number of adults with diabetes

Big Food, Big Farming, Big Pharma and diabetes

Dr Hyman wrote the article below in 2010 and it's still applicable in 2022. The Global War on Diabetes is also a war on this Toxic Triad if countries want to reverse the global epidemic of obesity and diabetes. Big Food is focused on profits and is encouraging people to become sick and die because of their toxic foods. The lack of appropriate government policies and the aggressive behaviour of the Toxic Triad have caused the default condition in the US of a human in the 21st century to be obese or overweight. In 2022, over 75% of US adults are obese or overweight.

Dr Hyman has identified 7 main factors driving obesity and related diseases including diabetes, cancer and heart disease.

Figure 5 - Factors causing obesity and related diseases like diabetes

Sugary drink taxes

Rising consumption of sugary drinks have been a major contributor to the obesity epidemic, according to Harvard University FACT SHEET: SUGARY DRINK SUPERSIZING AND THE OBESITY EPIDEMIC. Consequently, many countries have implemented sugary drink taxes which reduce the consumption of sugary drinks. The map below is from the University of North Carolina Global Food Research Program.

Figure 6 - Sugary drink taxes around the world

Singapore does not have a sugary drink tax but instead as a part of Singapore's WoD, the Ministry of Health and HPB will introduce mandatory nutrition labels and advertising prohibitions for Nutri-Grade beverages, effective 30 December 2022. Nutri-grade beverages include prepacked beverages that are ready to consume, prepacked beverages that are powders of concentrates that are diluted before consumption and beverages dispensed from automated beverage dispensers. The grading system, shown below, will use a single set of thresholds for sugar and saturated fat content. Only Grade A and B beverages will receive healthier choice symbols.

Figure 7 - Nutri-Grade beverage grading system

Australia has no sugary drink tax but last month the Australian Medical Association (AMA) started a #Sickly-Sweet campaign which proposes a sugary drink tax of $0.40 per 100 grams of sugar. This rate was recommended by the World Health Organisation and would raise the price of sugary drinks by 20% and also reduce consumption of sugary drinks by 12% to 18%. It should also reduce obesity by 2%, decrease diabetes and reduce healthcare expenditure. There has been confirmed success in many countries including United Kingdom, Mexico, France, Chile, Spain and South Africa. A sugary drinks tax is similar to a tobacco tax which has worked. The AMA has also proposed some additional actions to tackle junk food and its negative impact as below.

Figure 8 - AMA additional actions to tackle junk food

An alternative to a sugary drink tax is to ban promotions of sugary drinks. A recent study from Aberdeen University suggests that a ban on promotions dropped spending on sugary drinks by 36%. The Aberdeen University researcher said that "the consumption of high sugar products such as soft drinks are a major cause of obesity and diabetes which is why it is important to explore all ways to reduce the excessive consumption of such foods."

The reality is that the human body does not need any added sugar to function healthily, according to the American Heart Association and others. Sugary drinks are not needed but when they are consumed they mainly represent high calories with few or no nutrients. Too much sugar can raise blood glucose levels potentially causing diabetes, heart disease, colon cancer, kidney disease, liver disease, dementia and retina damage. Excessive sugar intake, made easier by drinking sugary drinks, can cause tooth decay, skin aging, overeating, weight gain, larger waist size and obesity. The strong message is avoid all foods containing added sugars including sugary drinks.

Glycemic index and diabetes

The glycemic index (GI) is a scale that ranks a carbohydrate food by how much it raises blood sugar levels after the food is consumed. Pure glucose has a GI of 100 and foods with no carbohydrates, including meat, poultry and fish, have a GI of 0. Eating low GI foods may help to prevent diabetes, manage diabetes, lose weight and reduce likelihood of cardiovascular disease. Some low GI foods are listed below. Low GI usually means under 55.

Figure 9 - Low GI foods

This is a video on the glycemic index and the glycemic load by the Canadian Diabetes Association.

Nutrient dense foods

Diet is important for lowering the risk of diabetes. From above, eating low GI foods should help decrease diabetes risk. In addition, eating nutrient dense foods which are whole, minimally processed, locally grown and preferably organic can reduce the risk of diabetes further. A nutrient dense food contains a high amount of essential nutrients relative to the calories of that food. Permanent changes to your diet will most likely be needed to reduce the risk of diabetes and obesity. Rather than avoid foods that don't meet these criteria, it's sometimes simpler and easier over the long term, to eliminate certain foods from your diet.

An example of a food which could be permanently eliminated is boiled white rice which has a GI from 60 to 80, which is not low. China and India are the first and second biggest consumers of rice in the world. There could be a link to China and India having the first and second biggest number of diabetics in the world, as shown in Figure 4.

Figure 10 - Rice consumption in 2021, 1,000 metric tons, Statista.com

White rice is a processed food because the husk, bran and germ are removed, leaving mostly the starchy endosperm. This process reduces the amounts of vitamins and minerals creating a low nutrient food. Cronometer.com is a free application which can give indications of the nutrient levels for different foods. There are many different types of white rice but 100 grams of boiled white rice has the following essential nutrient amounts below. The recommended daily percentage amounts of these nutrients are also shown for an adult. The boiled white rice has 70% water and 25% starch. Fiber is very low at about 1 g. An adult male needs about 30 grams of fiber a day. Note that the rice does have good amounts of B1, B3, folate, iron, manganese and selenium.

Figure 11 - Essential nutrient amounts for 100 g boiled rice, cronometer.com

According to the Cleveland Clinic, if you have been diagnosed with prediabetes or diabetes then white rice should be eliminated. Based on the criteria above, if you want to have a healthier diet then eliminate white rice because it is low in nutrients, is not low GI, is processed and is not a whole food.

In contrast to boiled white rice, a food which is nutrient dense is cooked kidney beans, also a low cost food.

Figure 12 - Essential nutrient amounts for 100 g cooked kidney beans, cronometer.com

Chicken liver is also low cost and is so nutritious that it deserves to be called a super food. Usually chicken liver is cooked which may reduce some of the Vitamin C amounts.

Figure 13 - Essential nutrient amounts for 100 g raw chicken liver

Diabetes remission

Diabetes Canada states that a low-carb diet can cause higher rates of diabetes remission, improved triglyceride levels and medication reduction in the short term. They also state long term remission is less clear because many individuals have difficulty following a low-carb diet over time.

Diabetes UK states type 2 diabetes can often be put into remission by losing weight. Two suggested ways to lose weight is to follow the Mediterranean diet or a low-carb diet. The video below summarises how a UK study by Dr Unwin by changing the diets of a group of diabetics caused 46% of type 2 diabetics (T2D) to go into remission and 93% of prediabetics into remission. The new diet rules are shown in Figure 14 and you can personally modify your own diet using those diet rules.

Dr Unwin low carb diet rules and questions are shown on this five page document.

Figure 14 - Dr Unwin's low-carb diet rules for diabetics to go into remission

Below is the original study by Dr David Unwin using his patient population, summarised in Diabetes.co.uk. His patients aged between 24 and 91 took part in the research, following a low-carb diet over two years.

Eating mostly foods from this long diabetes food list can help reduce risk of diabetes and obesity, source diabetesmealplans.com. Protein food examples include lean meats, poultry, fish, seafood, game meats, organ meats, eggs and dairy products. Carbohydrate food examples, preferably with only low GI, include low GI vegetables, leafy greens, beans, legumes, herbs (fresh or dried), flours (from almonds, coconuts, chickpea and sesame) and low GI fruits. Fat food examples include oils (virgin olive, avocado and macadamia), avocados, olives, nuts, seeds, tahini and oily fish. Omega-3 fats can be increased by eating more salmon, sardines, herrings and mackerel. Other fats include full fat dairy products, coconut oil and butter.

The UK Diabetes Remission Clinical Trial & other global trials

The link below contains slides for March 2019 presentation discussing the outcomes of the 2 year Diabetes Remission Clinical Trial (DiRECT).

DiRECT shows that the focus on preventing and treating type 2 diabetes (T2D) should be higher as shown in the slide below, which strengthens the case calling for a Global War on Diabetes.

Figure 15 - Type 2 diabetes 10 year survival rate

The trial methodology is shown below.

Figure 16 - DiRECT methodology

The total diet replacement (TDR) was a diet of about 800 calories/day. DiRECT used the TDR COUNTERWEIGHT-PLUS which aims to help lose at least 15 kg over 3 months, leading to remission of type 2 diabetes for many people.

The remissions results were outstanding after 24 months, especially for those who lost more than 10 kg.

Figure 17 - Remissions over 24 months (%)

However, there was some weight gain in the second year as foods are reintroduced.

Figure 18 - Weight change over 24 months

To reduce the likelihood of weight gain in the second year, rescue plans were implemented which included brief total diet replacement.

Figure 19 - Rescue plans

The Diabetes Remission Clinical Trial (DiRECT) in the UK happened over 2 years of 2017 and 2018, for just under 300 people with type 2 diabetes (T2D). The results were published in Mar 2019. The link below has a video with presentation slides, for a November 2021 update.

Reverse the weight gain to weight loss which causes T2D to reverse into remission.

Figure 20 - Obesity related diseases

The high T2D remissions of 86% for those who lost more than 15 kg in the first year is a great result.

Figure 21 - Remissions by weight loss groups and year

The Dr Unwin trial is the same as the Dr Unwin trial above. 46% of the 128 patients who persisted with the diet went into T2D remissions. DIADEM-I trial in Qatar showed a high remissions rate of 61%.

Figure 22 - Other T2D remissions trials

Global T2D remissions programs are under way.

Figure 23 - Global remissions programs

After losing weight, the challenge is the focus on long-term maintenance by adhering to the new diet.

Figure 24 - Summary of DiRECT

This video is an example of Kathleen's story of T2D remission as a result of being in the DiRECT trial.

NHS England diabetes remission pilot for 5,000 people

On Sep 1, 2020, NHS England started offering its Soups and Shakes diet to 5,000 people to help put type 2 diabetes into remission.

On Jan 31, 2022, the Soups and Shakes diet has helped over 2,000 people improve their health with participants losing an average of 13.4 kg in three months. From this month, thousands more will get access to the diet. Diabetes is estimated to cost the NHS ￡10 billion a year, with treatment making up one in 20 prescriptions written by GPs.

The NHS also has a dedicated website called Diabetes My Way - Make remission a reality.

Tracking essential nutrients and calories

DiRECT showed that one of the toughest challenges in long term weight loss maintenance, after the weight is lost. To improve weight loss maintenance DiRECT introduced rescue plans to help lose the weight which gained in DiRECT year two. Up to 86% of dieters regain weight in two after losing it, according to the link below.

The link below states 26 easy ways to maintain your weight. 26 ways is not that easy as that's a big number. Some of the ways include a focus on diversity, be positive and balance is key. Tamar Samuels RD says that people lose weight by dieting which produces only short term results. Sustainable results require lifestyle changes.

Instead of using all 26 ways, a potential solution is education about the 40 essential nutrients combined with using an essential nutrient and calorie tracker. A tracker combines these selected 26 easy ways: create structure, measure your progress, food portion control, drink enough water, eat the right macro-nutrients including fibre and track your food intake in a journal.

A simple way to educate yourself about the essential nutrients is by reading Chapter 1 of Mickey Trescott's book: The Nutrient Dense Kitchen. She describes the essential nutrients, symptoms of deficiencies and sources. For example, zinc is a micro-mineral essential nutrient and only about 10 mg/day is needed. Zinc is important for energy production, bone structure, immune function, taste sensation and blood sugar regulation. Sources of zinc include crab, oyster, liver, beef meat and lamb meat.

Mickey Trescott on her blog autoimmunewellness.com defines tracking as the process of recording symptoms, health metrics and interventions over time. She categorises tracking tools into health metric trackers, nutrition trackers and wearable trackers. The nutrition tracker recommended is cronometer.com and the other two categories are excluded since the focus of this article is on nutrition.

Cronometer is free with ads and customises essential nutrient targets according to age, sex and weight. Cronometer also tracks calories consumed and burned including calories used by exercise. You can also set some health targets including weight and macronutrient targets including protein, carbohydrates and fats. I initially used cronometer on a daily basis but now I use it for one day a week to check that I'm not getting nutrient deficiencies. I also use it to identify low nutrient high energy foods to avoid. For example, I avoid white rice, cola and deep fried chips. Although cronometer calculates essential nutrient amounts, it is important to chew your food well helps the gut to absorb more nutrients and can help to reduce obesity.

Below is an example of tracked foods in cronometer. These nutritious foods cost less than $15 as some fruits were frozen and the salmon was tinned. Calories burned are more than consumed which should indicate weight loss.

Figure 25 - Selected foods eaten in a day

The essential nutrient targets are shown in green when they are met and in yellow if not met. There were deficiencies in Vitamin C and Iodine. There was also a good amount of fiber which is important for gut health and to give a feel of fullness which helps prevent overeating.

Figure 26 - Calculated essential nutrient amounts from food amounts above

Children and diabetes

The Global War on Diabetes includes children as well as adults. Diabetes type 2 (T2D) is linked to obesity and many more children are becoming obese. In the US childhood obesity continues increasing, partly to the lack of exercise during COVID19. The graph below shows the rise childhood by age from 1963 to 2018. US average childhood obesity has increased from 19.3% in 2019 to 22.4% in 2020, according to the US Centers for Disease Control and Prevention. In 2022, childhood obesity could be closer to 25%.

Figure 27 - US Childhood obesity trends

Although childhood T2D is low compared to adults, in the US childhood T2D has increased by 95% from 2001 to 2017, according to the link below.

It is estimated that up to 80% of obese children become obese adults in the US, source https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3005642/. Childhood obesity is also on the rise in UK to about 20%. In response, the UK National Health Service recently established 15 new specialist clinics for children who have severe obesity. Children will receive specialist treatment, developed with their family, which could include diet plans, mental health treatment and coaching. NHS early action can prevent type 2 diabetes, heart attacks and cancer.

Therefore, it should be a priority for young children to be empowered about taking ownership of what they eat through essential nutrient education and using a food tracker like cronometer. Children today are technologically advanced and would find cronometer easy to use and it could be turned into a game with prizes. This could happen as early as high school year 7, when the children are about 12 years old.

Conclusions

Singapore successfully kept obesity the same at 10.5% (BMI>30) in 2020 as in 2010, but diabetes still increased. Their food environment includes fast food restaurants, unhealthy foods sold in supermarkets and marketing campaigns for unhealthy food. The food environment in many countries is not likely to be changed because there are high profits in unhealthy foods and governments are not willing to create a healthy food environment due partly to pressures from the toxic triad of Big Food, Big Farming and Big Pharma. Consequently, Singapore's Health Promotion Board has decided for its mission to be empowering individuals to take ownership of their health. Education about a healthy diet including essential nutrients and food tracking should help individuals, preferably starting as young children, be empowered and take ownership of their health, eating quality foods. These foods should be chewed well and be mainly foods that are low GI, whole, minimally processed, local, nutrient dense and preferable by organic.

The Global War on Diabetes is making its first successes as shown by the reversal of type 2 diabetes in the DiRECT and other global trials. Losing weight and maintaining the weight is challenging but can be done with the right support. Other countries could follow Singapore's official statement of a War on Diabetes or a similar high focus on diabetes. If countries do not do this then diabetes will continue increasing in the world as shown in Figure 4. Countries need to treat diabetes as a similar priority as tobacco in the past and climate change now to win the Global War on Diabetes.