摘要：The diabetes and obesity epidemics are closely intertwined. International randomized controlled trials demonstrate that, in high-risk individuals, type 2 diabetes can be prevented or at least delayed through lifestyle modification and, to a lesser degree, medication. We explored the relative roles of science, surgery, service delivery, and social policy in preventing diabetes. Although it is clear that there is a role for all, diabetes is a complex problem that demands commitment across a range of government and nongovernment agencies to be effectively controlled. Accordingly, we argue that social policy is the key to achieving and sustaining social and physical environments required to achieve widespread reductions in both the incidence and prevalence of diabetes. In developed countries, chronic diseases are the leading cause of premature mortality and reduced quality of life. In developing countries, chronic diseases are increasingly matching, and in some cases overtaking, communicable diseases in contributing to a dual burden of ill health. Prevention is increasingly seen as a major strategy for combating chronic diseases. Type 2 diabetes, with its common risks and repercussions and complex relationship with sedentariness, obesity, cardiovascular disease, hypertension, dyslipidemia, stress, depression, and socioeconomic status, makes an ideal model for chronic disease prevention (Figure 1 ▶ ). 1 We discuss the broad categories of prevention that are applicable to type 2 diabetes and related chronic diseases through common risk factors and comorbidities and acknowledge the need for comprehensive solutions across these areas. Open in a separate window FIGURE 1— Factors associated with type 2 diabetes as a “composite” chronic disease. Diabetes is now cited by many as a global epidemic alongside and intertwined with the obesity epidemic. The International Diabetes Federation estimates that there were 189 million people with diabetes in 2003 and predicts an increase to 324 million in 2025. 2 Estimates from the World Health Organization (WHO) are similar, projecting an increase from 171 million in 2000 to 366 million in 2030. 3 Approximately 70% of this growth is predicted to occur in the developing world and will increasingly affect people aged younger than 65 years who are still in the productive stages of their life cycle, 4 thus posing an economic threat over and above the more direct disease cost to the public purse. Type 2 diabetes is a complex metabolic disorder triggered by lifestyle factors superimposed on a genetic predisposition, is responsible for approximately 90% of all diabetes, and accounts for most of the public health and cost burden attributable to diabetes. Further, although type 2 diabetes is mainly a condition of adults, recent studies highlight its increasing prevalence in adolescents and children. 5 The rapid rise of childhood obesity and its causal link to diabetes has led Olshansky et al. to forecast that type 2 diabetes has the potential to result in a decline in the overall life expectancy of the population within the first half of this century. 6 The principal risk factors for type 2 diabetes include aging, obesity, and low levels of physical activity. There is also accumulating evidence that shows that sedentary behavior, particularly watching television, is an independent risk factor for obesity and type 2 diabetes. 7 , 8 Some ethnic and cultural groups have an increased susceptibility to developing diabetes. In some Pacific Islander and Native American populations, type 2 diabetes affects up to 40% of adults. 9 , 10 Increasing worldwide urbanization, with its attendant sedentary lifestyle and readily available energy-dense foods, elevates the prevalence of risk factors for type 2 diabetes. Beaglehole and Yach 11 note positive effects of globalization on health but point out that these beneficial effects are offset by other, detrimental effects. Other recent reports that examine the interplay between macroeconomic forces and health also note the rising chronic disease risk attributable to urbanization. 12 Prevalence of type 2 diabetes is also linked to socioeconomic status. In developed countries, diabetes prevalence is significantly higher in the lowest socioeconomic groups. 13 However, in developing countries, this situation may be reversed because the lower socioeconomic sectors of society continue traditional lifestyles long after their more affluent counterparts have shifted to sedentary lifestyles and energy-dense diets. Given the increasing prevalence of depression worldwide, prospective data suggesting that depression is associated with twice the risk of future development of diabetes 14 is also noteworthy. The complications of diabetes include coronary heart disease, stroke, lower limb amputation, impotence, renal failure, and visual impairment up to and including blindness. People with diabetes also suffer a considerable psychological burden, 15 including depression rates that are 2–3 times higher than their nondiabetic counterparts 16 ; an increased likelihood of anxiety states 17 ; high self-reported rates of poor quality of life, especially in the presence of diabetic complications 18 – 20 ; and high rates of poor well-being. 21 The World Health Report 22 cites diabetes as accounting for almost 1 million deaths annually, but these figures underestimate the true burden, because diabetes is known to be underreported on death certificates. Further, diabetes undoubtedly contributes to the burden of mortality from cardiovascular diseases, which accounted for some 17 million deaths globally in 2002. 22
