Navigating the global diabetes epidemic: Challenges, projections, and solutions for the 21st century

In an era where unchecked health conditions can pose grave threats to individuals worldwide, diabetes mellitus emerges as a formidable adversary. This chronic ailment, characterized by fluctuating and persistently elevated glucose levels, can unleash significant havoc on the human body. A chilling prophecy recently published in the Lancet scientific journal in June 2023 warns of a staggering statistic: by the year 2050, an estimated 1.3 billion individuals across the globe could find themselves grappling with the burdensome weight of diabetes.

This metabolic disorder, primarily known for its association with high blood sugar levels, divides into two distinct types, each presenting its unique challenges. Yet, amidst the sobering statistics and the mounting urgency to address this health crisis, one resounding truth emerges: the key to combating diabetes lies in effective self-management. The importance of this self-guided journey cannot be overstated, as it serves as the front line of defense against the dire consequences that diabetes can impose.

From the spectre of blindness to the looming threat of heart disease, kidney failure, and even limb amputations, the stakes are undeniably high for those living with diabetes. However, the path to successful self-management often proves to be a difficult one, riddled with obstacles that many struggle to surmount.

Global diabetes landscape: An alarming rise and urgent concerns

The global prevalence of diabetes presents a growing concern, with a startling statistic revealing that only 55% of individuals with diabetes are aware of their condition. This global surge in diabetes is primarily fuelled by the escalating incidence of Type 2 diabetes, closely intertwined with the rising tide of obesity and shifting demographics.

Type 2 diabetes, which accounts for the majority of diabetes cases, can often be more manageable if detected early. The International Diabetes Federation (IDF) emphasizes the potential for “reversal” when diabetes is diagnosed in its initial stages or even during prediabetes. Prediabetes is characterized by elevated blood sugar levels that are higher than normal but not yet at the diabetes threshold.

Zooming in on the Asian continent, India stands at the forefront of the diabetes epidemic, with over 101 million people currently living with diabetes—a significant increase from 70 million in 2019, as reported by the Indian Council of Medical Research. Alarmingly, an additional 136 million individuals in the country teeter on the edge of prediabetes. Meanwhile, in China, diagnosed cases of Type 2 diabetes are expected to climb at a compound annual growth rate (CAGR) of 2.21%, surging from 57.4 million in 2022 to an estimated 63.3 million by 2028.

Diabetes in Africa: A looming crisis requiring urgent attention

Africa faces an alarming diabetes crisis. With 24 million adults affected, which translates to one in every 22 individuals, the continent is grappling with a severe diabetes burden. This burden is projected to surge by a staggering 129 percent to reach 55 million by 2045, marking the most significant increase globally, as reported by the International Diabetes Federation (IDF). Moreover, the dire consequences of this epidemic are evident, with 416,000 diabetes-related deaths occurring in Africa in 2021 alone. Notably, one in every eight live births in Africa is affected by hyperglycaemia in pregnancy, emphasising the profound impact of diabetes on maternal and child health. Zooming in on specific countries, Egypt ranks among the top 10 nations globally with the highest prevalence of diabetes in adults aged 20–79 in 2021. Algeria and Morocco also make the top 10 list for countries with the highest proportion of people aged 0–19 with type 1 diabetes. These statistics underscore the widespread nature of the diabetes crisis across the continent.

As the world gears up for World Diabetes Day 2023, Kenya is confronting a diabetes crisis, with a staggering 821,500 people currently living with the condition. According to the World Health Organization (WHO), diabetes prevalence in Kenya currently stands at 3.3%, a number projected to rise to 4.5% by 2025.

In South Africa, diabetes has emerged as the second-leading cause of death, closely following tuberculosis. The country is witnessing a concerning surge in the number of individuals living with diabetes, with estimates suggesting around 4.6 million South Africans are affected, according to the WHO.

Perhaps one of the most pressing issues is Africa’s status as a world leader in undiagnosed diabetes. Shockingly, only 46 percent of individuals living with the disease in Africa are aware of their status, in stark contrast to the global average of 55 percent. This discrepancy highlights the urgent need for improved awareness and healthcare infrastructure.

Adding to the complexities of the diabetes challenge in Africa is the region’s second-lowest expenditure globally on diabetes-related healthcare, totalling a mere US$13 billion. This lack of financial resources presents a significant barrier to managing and treating the disease effectively.

While Type 2 diabetes garners significant attention due to its prevalence, the plight of those with Type 1 diabetes, particularly children, often remains overlooked in Africa. Shockingly, only one in every two individuals with Type 1 diabetes, the most common form of childhood diabetes, has access to insulin treatment in the region. Over the past decade, Africa has witnessed a fivefold increase in Type 1 diabetes incidence among children and adolescents under 19, soaring from 4 per 1,000 youngsters to over 20 per 1,000. Furthermore, Type 2 diabetes, historically an adult affliction, has begun affecting younger populations, raising concerns about its long-term impact.

Gestational diabetes, a form of diabetes occurring during pregnancy, presents additional challenges in Africa. Women with gestational diabetes often encounter issues such as high blood pressure, preterm birth, and labour complications, further underscoring the urgency of addressing diabetes comprehensively.

Combatting the rising tide of diabetes in Africa

The rising tide of diabetes in African countries, encompassing both type 1 and type 2 cases, presents a significant challenge worsened by a lack of widespread diagnosis. In response to this escalating challenge, Kenya’s Ministry of Health has taken substantial steps by establishing diabetes clinics in all county hospitals and strategically placing six centres of excellence across the nation. These centres, located at Kenyatta National Hospital, Moi Teaching and Referral Hospital, Nakuru Provincial General Hospital, Machakos County Referral Hospital, Coast Provincial General Hospital, and Kakamega County Referral Hospital, are designed to provide high-quality diabetes prevention, screening, diagnosis, and care. Kenya’s dedication to diabetes management has even drawn patients from neighbouring African countries, including Uganda, Rwanda, Burundi, the Democratic Republic of Congo, Tanzania, Ethiopia, South Sudan, and Nigeria.

Furthermore, Kenya’s Ministry of Health has made significant strides by developing comprehensive guidelines and manuals, including the National Clinical Guidelines for the Management of Diabetes Mellitus (2nd edition, 2018) and the Competency-Based Training Curriculum on Diabetes Mellitus for healthcare providers. These resources empower healthcare professionals with the latest knowledge and skills to deliver effective diabetes care. Additionally, Kenya has collaborated with partners such as the Kenya Diabetes Management and Information Centre, Novo Nordisk, and Roche Diabetes to launch the Changing Diabetes in Children (CDiC) program. This initiative has transformed diabetes care for children and adolescents by providing insulin and essential medical supplies at no cost.

In Ghana, the Ministry of Health, in collaboration with Sanofi, recently launched the Access to Diabetes Care program. As part of this initiative, the IDF School of Diabetes is providing training to over 170 healthcare professionals in Ghana through an online course designed for diabetes educators. This course equips healthcare professionals with the knowledge and competencies to educate people with diabetes, promote healthy lifestyles, and support optimal diabetes control.

Pharmaceutical companies are playing a pivotal role in diabetes management by collaborating with healthcare providers and local regulatory agencies. These partnerships empower patients with the necessary tools and medical information to make informed decisions about their diabetes. In South Africa, the National Strategic Plan (NSP) for the Prevention and Control of Non-Communicable Diseases (2022-2027) sets ambitious targets for diabetes care, encompassing screening, treatment, and control.

Furthermore, the World Health Organization (WHO) is also making substantial efforts. This includes the inclusion of human insulin cartridges and pre-filled human insulin pens in the Model List of Essential Medicines, which is expected to benefit individuals with diabetes not only in Africa but worldwide. Additionally, WHO supports African countries through the PEN Plus initiative, which seeks to enhance access to diagnosis, treatment, and care for chronic diseases, including diabetes.

Transformative collaborations beyond Africa

Beyond Africa, innovative collaborations are making significant strides in diabetes care. In Lebanon, OptiFreight Logistics and Journey Biosciences, Inc. have joined forces to enhance point-of-care diabetes care by improving transportation and visibility across all modes. In the Middle East, Nabta Health, a women’s healthcare platform in the United Arab Emirates, has strategically partnered with GluCare.Health to combat gestational diabetes and launch a weight management pilot program targeting chronic conditions, collaborating with Novo Nordisk.

In recent developments, the World Health Organization (WHO) took a significant step by including long-acting analogue insulins in its Model List of Essential Medicines (EML). This addition recognises the importance of these insulins for diabetes patients globally and promotes increased competition in the market. However, analogues still remain more expensive than human insulin and represent a minority of insulin usage in low- and middle-income countries (LMICs). To bridge this gap, a concerted effort is needed to expand access to all insulin types, ensuring healthcare professionals can offer the best treatment options for their patients.

Furthermore, the expiration of patents on certain analogue insulins opens doors for biosimilar versions, potentially leading to more competitive pricing in LMICs. The WHO’s Global Diabetes Compact, launched in 2021, aims to improve global access to diabetes care, set clear goals, and provide a framework for change. The World Health Assembly has ratified the first-ever global targets for diabetes, including the goal of achieving 100% access to affordable insulin and blood glucose self-monitoring for people with type 1 diabetes by 2030.

In addition to these efforts, initiatives like the “SUGAR-FREE JUDE” diabetes animation movie by the Merck Foundation aim to raise awareness about diabetes prevention and early detection, particularly among children and youth. Novo Nordisk’s collaboration with Aspect Biosystems to develop bio-printed tissue therapeutics represents an innovative approach to improving the lives of individuals with diabetes and obesity.

Diabetes Day, observed annually on November 14, serves as a global platform to highlight the importance of diabetes awareness and action. The theme for World Diabetes Day 2023, “Know your risk, Know your response,” aligns with the International Diabetes Federation’s (IDF) emphasis on Diabetes Awareness Month, showcasing the significance of local and global initiatives and collaborations in advancing the fight against diabetes and offering hope to those living with this chronic condition.

Aspen pharmacare’s low-cost government tender system is set to produce 16 million vials of insulin in the coming year, each priced at a guaranteed ceiling of just us$3 per vial.


Advances in diabetes management

Advances in diabetes management are transforming the global landscape, with a focus on expanding access to innovative biosimilar insulin products for both Type 1 and Type 2 diabetes. GlobalData forecasts a positive outlook for the Type 2 diabetes market, particularly in major markets like the United States, France, Germany, Italy, Spain, the United Kingdom, Japan, China, and India. In 2019, this market was valued at US$45.9 billion, and it’s expected to reach US$136.2 billion by 2029, primarily driven by the development of biosimilar therapies, particularly from India and China.

Despite concerns about rising insulin costs, key manufacturers like Sanofi, Novo Nordisk, and Eli Lilly are addressing pricing issues. Sanofi, for example, has announced a 78% reduction in the US list price of Lantus, along with a price cap of US$35 for commercially insured individuals, starting January 2024. Eli Lilly and Novo Nordisk are also reducing the US prices of their insulins.

Smart insulin pens are a notable advancement in diabetes technology, connecting to smartphone apps and using continuous glucose monitoring (CGM) data to provide dose recommendations and reminders. These technologies offer real-time insights into insulin management. Companies like Guidepost and Dexcom are introducing AI-powered chatbots and advanced CGM systems, respectively, to enhance diabetes management.

Automated insulin delivery (AID) systems are revolutionising diabetes care by leveraging data and algorithms to improve blood glucose control and reduce the risk of hypoglycaemia. Additionally, innovations in insulin injection practices are reshaping the diabetes landscape.

Novel pharmaceutical developments like SGLT-2 inhibitors and GLP-1 agonists are significantly impacting glucose management while reducing the risk of cardiovascular disease and weight gain. Advanced injectable medications are also being introduced for individuals with Type 2 diabetes and obesity.

Data-driven approaches are leading to interconnected digital solutions that empower individuals with diabetes to manage their health more effectively. Promising developments in the prevention and reversal of Type 2 diabetes through digital therapeutics are on the horizon.

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Poorer populations miss out on access to insulin and treatment choice in LMICs

The global diabetes crisis looms large, with projections painting a bleak picture: by 2030, an astounding 643 million people will grapple with this condition, and that number is set to skyrocket to a staggering 783 million by 2045. However, the brunt of this disease falls disproportionately on low- and middle-income countries (LMICs), where a staggering 80% of the 463 million adults with diabetes reside.

At the heart of this dire situation lies a stark and troubling reality: access to insulin, a life-saving medication crucial for managing diabetes, remains profoundly unequal in LMICs. A report by the Access to Medicine Foundation underscores the pressing need for pharmaceutical companies that produce insulin to address this stark disparity.

Insulin, a medical marvel discovered a century ago, has transformed Type 1 diabetes from a certain death sentence into a manageable, long-term condition. Yet, this transformation has not reached everyone. In LMICs, a vast number of people still lack access to essential diabetes products, especially insulin, which is vital for their survival and well-being.

The situation is particularly dire in 24 countries where no insulins are even registered, representing the first critical step toward making insulin available in a country. This alarming lack of access disproportionately affects poorer populations, particularly in LMICs.

Daily access to insulin is not a luxury; it’s a necessity for survival, particularly for patients with Type 1 diabetes and many with Type 2. Regrettably, insulin products are often out of reach for those residing in LMICs. Even when available, they are frequently unaffordable. The harsh reality is that without access to insulin, countless diabetic children and adults will endure needless suffering and premature death due to this life-long, chronic disease.

The unending struggle for insulin access worldwide

This problem of unequal access to insulin is not new; it has persisted since insulin’s discovery, manufacture, and sale. However, it is becoming increasingly acute. Managing diabetes imposes a staggering global burden, as evidenced by the total health expenditure due to diabetes in adults reaching US$966 billion in 2021. The number of people with diabetes is projected to reach a daunting 643 million worldwide by 2030, with Type 2 diabetes cases surging most rapidly in LMICs. Poverty, conflict, and disease outbreaks exacerbate the situation. Local and global disruptions disrupt supply chains, damage fragile healthcare systems, and jeopardize the availability and affordability of insulin.

The affordability of insulin exacerbates this crisis. While analogue insulins, vital for diabetes management, are readily available in high-income and upper-middle-income countries, 15 of the 27 low-income countries lack any registered analogue insulin, limiting treatment options for patients.

Analogue insulins, often priced significantly higher than human insulins, present formidable barriers, especially in LMICs. Historically, pharmaceutical companies have focused on expanding access to human insulins in LMICs, with less attention given to analogues. However, the importance of ensuring access to both human and analogue insulins is gaining recognition, alongside the need for biosimilar products to encourage competition.

Quality-assured biosimilar insulins hold immense potential to enhance both availability and affordability. As several patents on long-acting insulins have recently expired, biosimilar versions can emerge as viable alternatives. While global insulin manufacturers continue to dominate the market, several biosimilars companies already produce and market insulin products in LMICs. Nevertheless, these companies face significant challenges in scaling up, competing with established brands, and navigating complex regulatory requirements.

In essence, addressing the glaring insulin access gap in LMICs is not just a healthcare imperative; it’s a moral obligation. Pharmaceutical companies, global health stakeholders, and regulatory bodies must join forces to ensure equitable access to life-saving insulin for all individuals living with diabetes, regardless of their geographic location or economic status.

Exploring local insulin production for sustainable access

In the last decade, insulin manufacturers have made concerted efforts to enhance insulin access in Low- and Middle-Income Countries (LMICs). However, these initiatives have often been fragmented and project-based, focusing on product types (e.g., human insulins), or patient groups (e.g., children). As a result, sustained access for insulin-dependent patients, who require lifelong treatment, has remained elusive. Nevertheless, there is a growing shift towards adopting more sustainable and systemic approaches to expand insulin access in LMICs.

This shift entails the development of targeted strategies tailored to the unique needs of populations lacking effective healthcare access. Collaborative partnerships are also emerging to strengthen local health systems and supply chains, recognizing that access to insulin should be complemented by access to monitoring and delivery devices, such as glucometers and needles, essential for effective diabetes management.

In response to this pressing healthcare crisis, African nations are taking significant steps to bolster their medical diagnostics capabilities and domestic expertise. Square Pharmaceuticals, for instance, is poised to establish a production facility in Kenya, with the aim of reducing the cost of essential diabetes medications. Similarly, Aspen Pharmacare has partnered with Novo Nordisk to create South Africa’s first insulin production facility, marking a significant stride towards self-sufficiency in medication production.

Katrine DiBona, Novo’s corporate vice president for global public affairs and sustainability, highlights the severity of the global insulin shortage, with an estimated 60 million people worldwide in dire need but unable to access it, particularly in lower- and middle-income countries. Aspen Pharmacare’s low-cost government tender system is set to produce 16 million vials of insulin in the coming year, each priced at a guaranteed ceiling of just US$3 per vial. This initiative reflects a broader commitment to ensuring that life-saving insulin is within reach for people living with diabetes in Africa.

Eli Lilly, in a commendable move, has partnered with Egypt’s EVA Pharma to provide insulin’s active pharmaceutical ingredients (API) at a significantly reduced cost. This collaboration facilitates faster and more affordable production of this vital medication. Furthermore, it includes pro-bono technology transfer to empower EVA Pharma to handle insulin vials and cartridges, with the goal of delivering 30 million insulin doses by 2030.

Dr. Bente Mikkelsen, Director of the Non-Communicable Disease (NCD) Programme at the World Health Organization (WHO), commends these initiatives. She emphasizes that controlling diabetes is pivotal for achieving Sustainable Development Goal (SDG) targets on NCDs, underlining the importance of early diagnosis, treatment, and universal health coverage, given that 74% of global deaths result from NCDs.

These local manufacturing initiatives align seamlessly with governments’ aspirations for improved health and economic outcomes, aligning with the 2030 Agenda and its health-related Sustainable Development Goals. As access to insulin expands and local production capacity strengthens, Africa takes significant strides toward ensuring equitable healthcare access for all, particularly those living with diabetes.

This feature appeared in the June 2022 issue of Healthcare Middle East & Africa. You can read this and the entire magazine HERE