Richard Smith on why diabetes envies cancer

Richard Smith Those who campaign on diabetes envy those who campaign on cancer because cancer gets so much more attention than diabetes. Indeed, the diabetes campaigners are very frustrated that diabetes is so consistently neglected. Around 250 million people globally have diabetes, and because of the pandemic sweeping the world that number will increase to 380 million by 2025. Then at least half of the people who have diabetes are undiagnosed, and in countries like Nigeria and India around 90% are undiagnosed. How is that governments can be so lackadaisical?The diabetes campaigners are driven to grand statements. The pandemic of chronic disease is as bad as anything the world has seen since the plagues of the 14th century, says John Bell, regius professor of medicine in Oxford. More people have diabetes than have AIDS, says Charlotte Ersboll, a corporate vice president of Novo Nordisk, a company that makes many products for people with diabetes.

In doing so she opens herself up to the objection that one disease shouldn’t do down another. She insists that she isn’t doing so, but in a world of finite resources she is. “Diabetes takes off more legs than land mines,” says David Mathews, professor of diabetes medicine in Oxford, presumably remembering Princess Diana in her flak jacket with the world’s press at her heels. Diabetes seems to lack a glamorous celebrity, although it does have my brother, an ugly (but still very attractive to women) comedian.

These statements don’t do the trick so now Novo Nordisk, the International Diabetes Federation, and the Oxford Health Alliance (both of which are funded by Novo Nordisk) are trying measurement. That was the point of the “Changing diabetes barometer international seminar” that I’ve attended in Oxford this week. Some 120 people from 20 different countries were there. The mantra is that “if you can’t measure it you can’t manage it,” a favourite saying of the business world and more true than untrue.

Measurement was on of the factors that helped get cancer to the front in the disease stakes. Chris Carrigan, head of the UK National Cancer Intelligence Network co-ordinating team, explained how cancer registeries had been going for 30 years and how international comparisons of cancer survival showing that Britain did badly had goaded the British government into producing the national cancer plan.

He also conceded, however, that cancer has a special status as a dread disease and a considerable grassroots movement.

Diabetes isn’t dreaded in the same way. Lots of people think of it as a raised blood sugar in people who though moral weakness have let themselves get too fat. Plus it affects largely old people—as does cancer, of course, although many people think that breast cancer is commoner in young women than in older women.

Measurement of prevalence, outcomes, costs, and quality of care of patients with diabetes could help shove diabetes up the national agenda, and through sharing the information, and experimenting with improvements it could help produce better outcomes for patients and slow down the pandemic. Because we know well that intensive lifestyle changes can reduce diabetes incidence by 50% and that effective treatment can both dramatically reduce complication rates and reduce overall costs. We are less sure, however, about how to implement lifestyle changes in whole communities and even in our own children (guilty as charged).

Unfortunately measuring diabetes is much harder than measuring cancer, and international comparisons are difficult—and can be dismissed as wholly unreliable by the pernickity. Plus there doesn’t seem to be an obvious link between measurement and the likelihood of governments acting. Thus the UK, which has the lowest prevalence in Europe (4% among adults), has a national plan for diabetes, whereas Germany, which has the highest prevalence (11.8%), does not. Indeed, many of the 13 member states of the European Union that do not have plans have the highest prevalences—not only Germany but also Bulgaria, Estonia, Hungary, Latvia, and Slovenia.

I believe strongly that governments — and employers, schools, and others — should pay more attention to diabetes and that measurement is essential. But as I sat among the converted in an overheated room in the Said Business School I imagined a whole series of rooms full of campaigners on cardiovascular disease, dementia, sexual health, respiratory disease, kidney disease, maternal and child health, and a thousand other conditions all scrambling for attention and resources.

And I imagined harassed government officials meeting with group after group and needing a strong group at the end of the day. Truly, as the American politician Daniel Moynihan said, “We live in a world of competing sorrows.”

Competing interest: I was put up in the Old Bank Hotel in Oxford, a very upscale hotel, by Novo Nordisk. I discovered in a glossy magazine that a single room cost £170 a night. I suspect that Novo Nordisk probably got something off because they had bought many rooms. I had a pleasant breakfast of oranges, berries, and melon followed by one slice of delicious bread and a slice of good cheese, all paid for by Novo Nordisk. The company paid for my Guardian, which may have been an error on the part of the hotel. I was treated, like everybody else at the conference, to a high calorie dinner at the 1786 Harris Manchester College and was sung to by six fine singers, including two counter tenors. The company also paid for a Christmas cracker, which included a spinning top, a bad joke, and a funny hat, which I wore with pride and a certain air of defiance through the wet streets of Oxford. The company would have paid my expenses if I could have been bothered to have claimed them. I like to think that none of this influenced what I’ve written, but all the evidence suggests that the hospitality will have made me more sympathetic to the messages of Novo Nordisk than I might otherwise have been. But then other evidence, which I helped to generate, suggests that readers will discount what I write because of my conflicts. I’m not sure where the final balance lies.

I also need to declare that together with other authors I have just submitted an article to another journal that identifies “Competing interest bias,” whereby those with private sector connections are deemed to have competing interests, whereas those who work for universities do not — which is clearly nonsense.

We all have competing interests and should declare them — but not perhaps at this length and in this detail.