ReviewThe Berlin Declaration: A call to improve early actions related to type 2 diabetes. Why is primary care important?
Introduction
Diabetes currently affects approximately 451 million adults (18–99 years old) worldwide and this epidemic is projected to worsen, with an anticipated 693 million adults affected by 2045; the majority (∼79%) reside in low or middle income countries [1]. In addition, globally up to 50% of adults with diabetes remain undiagnosed and their condition therefore remains unmanaged, with complications developing unmonitored [1]. Furthermore, an estimated 352.1 million adults (7.3%) globally have impaired glucose tolerance, placing them at high risk of developing T2D, with this number also expected to increase over time [1]. Although good quality evidence exists that progression to T2D can be delayed or prevented in these individuals if they are identified and managed early enough, many go unidentified [2], [3], [4]. In addition to preventing T2D, there is a need to also prevent cardiovascular disease (CVD), as people with T2D are at a higher risk for CVD, the main cause of death [5], [6].
Thus, a huge burden is placed on healthcare systems worldwide with the global cost estimated to be ∼850 billion US dollars (∼705.5 billion Euros) [1]. These costs will rise as life expectancy increases and the number of people with T2D rises in parallel. The majority of this expenditure is related to hospitalization (43% in the US) and management of the complications of type 2 diabetes (T2D) (18% in the US), with about 34.7% of the overall burden related to indirect costs (ranging from 33.5% in low-to-middle income countries to 40.0% in high income countries) [7]. The greatest impact on costs can therefore be made by reducing the risk of complications, and the most effective way of achieving this is through early detection and prevention and timely risk factor management [8], [9], [10], [11], [12]. Diabetes complications also have a severe negative impact on quality of life, which provides another important rationale for driving initiatives to prevent them [13], [14]. The Early Action in Diabetes initiative aims to translate current scientific evidence into practical, action-oriented policies that can be implemented by decision makers globally. The first output of the initiative was The Berlin Declaration which called for early action in diabetes with short-, medium- and long-term international targets [15], [16]. The development of the Berlin Declaration is described in Table 1.
Section snippets
How should the Berlin Declaration be used
The Berlin Declaration builds upon the work of earlier calls for improvements in healthcare, including the 1978 Declaration of Alma-Ata, which called for primary health care for all [17]; and the St Vincent Declaration (1989), which proposed a number of healthcare goals specifically for patients with diabetes [18]. The Berlin Declaration predominantly focuses on national policy, in particular the development of national diabetes plans and guidelines. Implementation of the policies in the Berlin
The Berlin Declaration and prevention of T2D
Primary, secondary and tertiary prevention refer to prevention at different time points in the course of a disease. Primary prevention aims to prevent disease before it occurs (prepathogenic period), secondary prevention aims to reduce the impact of disease that has already occurred (prevent or postpone complications), while tertiary prevention aims to reduce the impact/progression of a condition that has lasting effects, including chronic complications [21]. It is important that a combination
The Berlin Declaration and primary care
There is increasing emphasis globally on patients being managed in primary care [40], [41]. Although the provision of primary care remains inadequate in many parts of the world [42], in countries where primary care professionals make up the backbone of the healthcare system they will provide medical care and support to the majority of people with T2D, as well as providing lifestyle advice aimed at preventing the development of T2D and diagnosing the condition [43], [44]. The Berlin
Conclusions
The prevalence of T2D has risen dramatically and is continuing to do so as our population ages and as ever younger people develop T2D, making T2D a major epidemic which is worsening each year. T2D is associated with increased mortality and healthcare costs, and represents a major burden on healthcare systems worldwide. Although T2D cannot be prevented by a single intervention or policy [58], it is possible to prevent progression to T2D in high risk individuals and reduce the risk of
Conflicts of interest
KK has received funds for research, honoraria for speaking at meetings and/or served on Advisory Boards for Amgen, Astra Zeneca, BMS, Lilly, Novartis, Pfizer, Servier, Sanofi Aventis, MSD and Novo Nordisk.
JRG has received honoraria for speaking at meetings and/or served on advisory boards for AstraZeneca, Boehringer Ingelheim, Lilly, Sanofi, Janssen, Merck, Novo Nordisk, and Abbott Diabetes Care.
AJMB has received funds for research, honoraria for speaking at meetings and/or served on Advisory
Acknowledgements
We would like to thank the members of the four international working groups and all of the diabetes experts who ratified the proposed policies and also those who have signed up to the declaration and are supporting the drive towards implementing its recommendations.
Prevention: Rick Blickstead (Chair), Xavier Cos, Gerardo Medea, Alexandre Hohl and Stephen Colagiuri.
Early detection: Margaret McGill (Chair), Denise Franco, Rick Blickstead, Gerardo Medea, Nabil Sulaiman and Kamlesh Khunti.
Early
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