Australia in grips of diabetes epidemic
A woman lies in a hospital bed in Cairns, almost blind from the eye disease ravaging her vision and dependent on thrice-weekly kidney dialysis. Her left leg is amputated above the knee. Diagnosed with Type 2 diabetes at nine, the woman is now just 25, but her case is by no means an isolated one.
Type 2 diabetes, which accounts for 90 per cent of all diabetes cases, has traditionally been a condition of older age but is now being diagnosed in children as young as five, and is increasingly seen in adolescents and young adults.
Last month at a meeting at South Brisbane's Lady Cilento Children's Hospital on diabetes in the young, Dr Emily Papadimos detailed the case of a 178kg, nine-year-old Queensland boy diagnosed with Type 2.
Officially, according to the latest figures from the federal government's voluntary registration to the National Diabetes Services Scheme (NDSS), there are 209 children aged 15 years or under with Type 2 diabetes in Australia.
However, Lady Cilento Children's Hospital director of endocrinology Professor Jerry Wales believes "there are probably 10 times that number that aren't recognised".
A recent review of services across Queensland found there are at least 70 children with Type 2 diabetes under the age of 16. "There are likely [many more] that aren't recognised or diagnosed because it's quite silent early on and the parts of Queensland where it is most common, there's nobody looking for it," Wales says.
"Fifteen years ago it was almost unheard of [in children]. At the turn of the century people used to write up cases of Type 2 diabetes at this age as incredible rarities. Now there is a recognition that it is something that happens in childhood."
With 35 years' experience in treating the condition, Wales is blunt with the facts.
"The younger you get it, the worse the outlook," he says.
"It's worse than having insulin-dependent diabetes [Type 1] and worse than many childhood cancers. It's an awful disease. Type 2 diabetes in the young is not mild diabetes. If you get it at less than 30 years of age, your standard mortality rate is six times the average. You are going to lose 20 to 30 years of life.
"It's a terrible, terrible disorder, the commonest cause of renal failure and dialysis in Australia, the commonest cause of blindness and foot amputations. It's contributing to at least 60 per cent of all heart disease. You can name your cause of death, sadly."
Worldwide, diabetes is regarded as an escalating global health threat with the International Diabetes Federation (IDF) estimating one in 11 adults, or about 425 million people, are living with all forms of diabetes - 10 million more than in 2015. On current trends, almost 700 million people worldwide will be affected by 2045.
Diabetes Australia puts it this way - it is the epidemic of the 21st century and the biggest challenge confronting Australia's health system.
THE SILENT KILLER
Before Type 2 diabetes knocked him for six, Joel Wiggins regularly ate his meals from fast food outlets. It was cheap, easy, fast. Wiggins, a contestant on the 2018 season of reality TV singing show The Voice, grew up knowing how to prepare home-cooked food but as a young man living out of home for the first time, he fell into bad habits.
In 2008, Wiggins weighed 98kg. By 2012, his weight had ballooned dramatically to 191kg. At age 24, Wiggins was diagnosed with Type 2 diabetes. Now 28, he says he was shocked, even angry, at the diagnosis and fell into denial.
Wiggins says he was aware of Type 2 diabetes because his aunt and father had already been diagnosed, but he falsely believed he was too young to worry about that. A year ago, Wiggins' older brother Phillip, then 29, was also diagnosed with Type 2.
"Before my diagnosis, I was just eating pretty much junk - Maccas, Hungry Jack's, all that rubbish stuff. I wasn't really cooking anything myself," Wiggins says.
"I knew people got diabetes and I knew there were two different types, but that was kind of it. I wasn't really aware of what could happen. So I wasn't expecting it and I was quite taken aback by the whole thing. Even after my diagnosis, I wasn't eating right. And I'm still not perfect, but I have changed - I am 145kg now.
"About a year after my diagnosis, when I started to lose weight, I had a friend who lost her leg when she was 39 because of Type 2 diabetes. I knew I never wanted to get to that point. The thing I've learned with diabetes is that it's a silent killer. Unlike a lot of other diseases, it doesn't show as quickly or significantly as other conditions."
Wiggins, of Zillmere, in Brisbane's north, works for the Department of Education as an Aboriginal liaison in a state primary and secondary school on Brisbane's northside.
"My goal one day is to become an ambassador for Aboriginal health and education, but I want to get my own health right before I can do that. I believe that education is one of the most powerful things that kids can have."
NOT JUST AN OLDER PERSON'S DISEASE
Philip Rule was also shocked by a diagnosis of Type 2 diabetes at age 37 after going to the doctor with symptoms including feeling thirsty and lethargic.
Rule, of Eastern Heights in Ipswich, is a former fifth-generation coal miner who reinvented himself as a successful massage therapist "to the stars" after he broke his neck in a mining accident in 2000. But in 2012, at age 46, suffering poor circulation in his feet, doctors removed his left big toe.
Then, in February and March 2016, he underwent 13 operations in 30 days as doctors battled to save his legs.
He lost three more toes on his left foot and two on his right, before ultimately undergoing below-knee amputation on his right leg. He is still in danger of losing his left leg.
Rule, now 52 and the director of his candle business (Rule Candle Co Australia), uses a wheelchair and needs to inject insulin three times a day. He says he has also suffered depression.
"Losing my leg was life-changing," he says.
"No one thinks it's going to happen to them. If you had told me 20 years ago I'd be here with an amputated leg, I wouldn't have believed you. I thought I was indestructible.
"I was in hospital for three months and I'm not too shy to admit that during that time, late one night, I snuck up to the roof of the hospital in my wheelchair and I contemplated taking my life. It was only a phone call from my father that stopped me.
"I've never drunk alcohol or smoked. I probably never worried about what I ate because I had a fast metabolism and I've always been sporty.
"I've never been overweight. I'm 5 foot 7 [170cm] and when I was diagnosed I was about 80kg. But if you have it in your genetics, you can't beat it.
"Now I'm pretty good with my diet … my one weakness is soft drink. I still love my soft drink and I'd have a glass every couple of days.
"Anyone who thinks diabetes only affects older people needs to give themselves an uppercut. There are many, many diabetics under the age of 40. It's a growing epidemic."
AN EMERGING PROBLEM
Diabetesmellitus - known simply as diabetes - refers to a group of serious, lifelong conditions where there is too much glucose in the blood.
Type 1 is an unpreventable lifelong auto-immune condition that accounts for about 10 per cent of all diabetes cases. While Type 1 is the less common form overall, it is usually diagnosed in children and young adults.
There is no cure or known prevention, and daily insulin via injections or a pump is required.
Type 2 is influenced by lifestyle choices with risk factors including obesity, level of physical activity, high blood pressure and abnormal blood fats.
There are also significant risk factors from family history, ethnicity and a history of gestational diabetes or polycystic ovarian syndrome. Those at risk from Type 2 are advised to adopt lifestyle modifications such as diet and exercise, though insulin and other medications may also be required.
An estimated 1.1 million Australians have been diagnosed with Type 2 while another 500,000 are undiagnosed. Another 120,000 have Type 1.
Diabetes Australia says cases of gestational diabetes are now also increasing at more than twice the rate of those diagnosed with Type 2, with at least 40,000 pregnant women diagnosed in the past 12 months.
In Australia, the most recent (2013) report estimated the annual cost of diabetes for adults over 30 at $14.6 billion.
Associate Professor Ashim Sinha is director of endocrinology at Cairns Hospital and operates an outreach service that travels to remote communities around the Cape, far north Queensland and the Torres Strait.
In 2000, he was one of the first clinicians to alert the wider community to the emerging problem of childhood Type 2, with a six-year-old boy diagnosed with the condition in a far north community.
Then, in 2013, he had an even younger patient - a five-year-old indigenous girl - with Type 2 that was featured as a case report in prestigious medical journal The Lancet.
The child had been born to a mother with poorly controlled gestational diabetes.
The girl had non-healing sores on her thighs, a diet high in refined carbohydrates and simple sugars, and there was a strong family history of Type 2. Progressively, Sinha says, there have been more cases in very young children.
Sinha is working with the Menzies School of Health Research in Darwin to help set up a database to assess the "real burden of the disease" in communities of far north Queensland, the Northern Territory and Western Australia.
The IDF's most recent Diabetes Atlas 2017 shows the Western Pacific Region, which includes Australia, is home to 37 per cent of all adults with diabetes.
A strong genetic predisposition, that is not fully understood, exists in Aboriginal and Torres Strait Islander Australians, Maori populations, Pacific Islanders, ethnic Chinese and people from the Asian Subcontinent.
The genetic risk is compounded in some areas by adverse socio-economic factors, in-utero exposure to high blood sugar, and poor guidance on food and nutrition.
"The main point is diabetes begets diabetes," Sinha says.
"When we see our cases there is intergenerational diabetes, which means parents have diabetes, grandparents have diabetes. It just runs through the generations. On top of that, if you have a pregnant mother with gestational diabetes, then that's an important risk factor for the child. That's a main focus now … to control the mother's diabetes as effectively and aggressively as possible.
"There is also new research that brings into question paternal imprinting as well - so if the father has diabetes, that may also influence whether the child gets diabetes."
Sinha says children who develop Type 2 often have a "much more aggressive disease compared to adults".
"We see everything from renal failure, cardiovascular disease and amputations at a young age," he says. "A boy I diagnosed with Type 2 at age 13 … I saw him the other day at the Cairns Base [hospital] and he is now 32 and has lost both his legs. We have seen teenagers have minor amputations, losing a couple of toes, for instance.
"People are on dialysis and having heart attacks between the ages of 20 and 25 … within 10 years from the onset of their disease they are developing very aggressive complications that are often quite devastating."
A 2014 Australian Institute of Health and Welfare (AIHW) report found there is an average of 400 new cases of Type 2 diabetes diagnosed in children and young people aged 10 to 24 each year. "It is an emerging problem," Sinha says.
"As clinicians we are getting worried because we haven't put in place actions around how we manage childhood obesity, how to better manage diabetes in pregnancy and how we prevent these kids suffering the devastating complications that they are developing at a very young age.
"If they are below the age of 16, there are only a few medications we can use. We give lifestyle advice and we start them on a tablet called Metformin to control blood sugar levels, then if that doesn't work you have to put them on insulin. You can imagine starting kids on insulin in remote communities; often the parents themselves have poorly controlled diabetes. It's not ideal.
"For the five-year-old patient, we had to start insulin injections because her blood sugars were very high. In most cases patients would need to stay on insulin for life."
A GLOBAL SOCIETAL CATASTROPHE
So why is Type 2 increasing worldwide at such a galloping rate?
The IDF, which describes the rise of diabetes as a "pandemic" and a "global societal catastrophe", says its increasing prevalence is associated with "rapid urbanisation, unhealthy diets and increasingly sedentary lifestyles".
Diabetes Australia advocates a sugar tax or "health levy" on sugar-sweetened beverages - "the largest source of free sugars in the Australian diet" - as part of a comprehensive approach to decreasing rates of overweight and obesity.
In its position statement, Diabetes Australia advocates restricting children's exposure to marketing of sugary drinks, restrictions on their sale in schools, effective public education campaigns, and diabetes prevention programs.
Dr Jerry Wales goes further and believes governments need to legislate exercise targets for children, citing success with Singapore's government-mandated Holistic Health Framework.
This weight management program measures a child's weight and body mass index (BMI), placing those overweight into exercise programs. "The only sensible way that any society can approach Type 2 diabetes is to try to prevent it happening," Wales says. "Most people present when the pancreas is already compromised, and then it's too late to cure and they are going to die early.
"There is a gross failure of exercise, and that is an important component of preventing Type 2, as is diet. Societies need to step in with proper legislation … that means a sugar tax, that means an increase in public health planning to get people to exercise more, walk more, use the car less, spend less time in front of computers. Exercise targets have been done in various countries. It's not rocket science.
"Sugar is added to all sorts of foods - soups, cereals, packaged foods, soft drinks. We need a star rating and clear packaging, all mandated and spelling out exactly what's in there. I know that's not popular in a sugar-growing state but, if we want people to stay alive, it's important."
A recent World Health Organization and Imperial College London study found there had been a more than tenfold increase in childhood and adolescent (aged five to 19 years) obesity in four decades. The study compared the BMI of children, adolescents and adults from 1975 to 2016 and found less than 1 per cent of the world's children and adolescents were obese in 1975, compared to nearly 6 per cent of girls and nearly 8 per cent in boys in 2016.
In total, this is an increase from 11 million obese children and adolescents in 1975 to 124m in 2016. There were also an additional 213m who were overweight but not obese.
The number of obese adults also increased from 100m in 1975 to 671m in 2016, with an additional 1.3 billion adults who were overweight. A 2017 Australian Sports Commission study found more than 80 per cent of children did not meet the recommended activity guidelines of 60 minutes' moderate to vigorous physical activity each day.
There are also more than 50 per cent of adults living sedentary or low-activity lifestyles, with two-thirds of adults and a quarter of children overweight or obese.
CAUSE AND EFFECT
Every year in Australia, there are more than 4400 amputations due to diabetic complications - the second-highest rate in the developed world.
Peter Lazzarini, co-chair of Diabetic Foot Australia and Queensland University of Technology research fellow, says complications include poor circulation and feeling in the feet (peripheral neuropathy) that can lead to developing foot ulcers that don't heal properly, can become infected and eventually have to be surgically excised.
"The worse the control of the diabetes, the higher the chances of having an amputation," he says. "Generally, someone might have an amputation after having Type 2 for over 10 years. After 10 years, those rates increase, even with medication and insulin." Lazzarini says a 2015 Queensland study that examined amputation rates and diabetic foot disease hospitalisation rates from 2005 to 2010 found improvements in rates overall, except in patients aged up to 34 years.
"We're seeing more younger people getting amputations," he says. "The longer you've had diabetes, the more likely it is you are going to have complications and one of those is amputations. The 0-34 year age group is increasing. This includes a number of people who were less than 18 years of age."
For Diabetes Australia chief executive Professor Greg Johnson, the real concern is the undiagnosed diabetes population.
"We have really good evidence that about 60 per cent of Type 2 diabetes could be prevented in those people if we find them and they get a solid dose of prevention," he says. "The problem is we're not finding them. Most of those people are not being identified and they are simply going on and progressing to Type 2 diabetes.
"Once you have been diagnosed with Type 2 you really do have it for the rest of your life. It is a serious and complex metabolic condition that can do really serious damage to your body in every organ."
Johnson recommends people have a simple yearly Type 2 diabetes blood test called the HbA1c (known as haemoglobin A1c), or the average glucose test. It measures glucose attached to the blood cells in your body and provides an average picture over three months. As red blood cells live for up to four months, people with diabetes are advised to undergo the test every three to six months, or more frequently if it is not under control.
The worldwide surge in Type 2, Johnson says, correlates with a rapid change in the world's food supply over the past few decades, with more people consuming cheap processed foods - including anything that's "mass-produced and packaged up", like breads, pastas, cereals - and less fresh fruit, vegetables and home-cooked meals. At the same time, there has been a reduction in exercise.
"You combine what we eat with moving less and we've seen weight gain across the entire population," Johnson says. "We see junk food marketed to kids and young adults and a massive overconsumption of junk food by them … and it's having a really serious impact on their health.
"We have to get much more serious with children and adolescents around marketing and promotion of unhealthy food and drinks. Targeted marketing has been normalised and it's little wonder there is over-consumption.
"In the 20th century - 18 years ago - everyone thought Type 2 diabetes was a disease that only affected older people. More and more it's affecting young people - that trend is in Australia and around the world. We call it the epidemic of this century, and it continues to grow."
World Diabetes Day is November 14.