EH 3_2015

EUROPEAN HOSPITAL Vol 24 Issue 3/15 16 DIABETES GERMANY’S APPROUnanimous: The country urgently needs a national diabetes plan Germany’s 2015 Diabetes Congress Diagnostics manufacturers declare support Diabetology news THE epid This year’s German medical diagnostics manufacturers association (Verband der deutschen Diagnostica- Hersteller = VDGH) congress, focused on diabetes. The panel discussion that closed the evening session revealed unanimous support for the adoption of a German national diabetes plan, Bettina Döbereiner reports The focus of the 2015 Diabetes Congress held in Berlin this May was ‘Personalised diabetes treatment: innovative – individual – sustained’. Bettina Döbereiner reports on points aired during the supporting press briefing. Estimates suggest there are 387 million diabetics worldwide, a figure expected to rise by almost 35% to reach 592 million by 2035, according to the 2014 Diabetes Atlas published by the International Diabetes Federation (IDF). This prognosis is probably not far off the mark: the Robert Koch Institute reports that, between 1998 and 2011, the number of diagnosed diabetes cases in Germany rose by 38% to a currently estimated six mil- lion. These recent figures support an idea bandied about for decades: the development of national diabe- tes strategies to complement supra- regional approaches. In the so-called St Vincent Declaration of 1989 a group of experts, convened by WHO Europe and the International Diabetes Federation (IDF) Europe, demanded national diabetes plans (NDPs). Since then, several institutions have endorsed this demand and, in 2012, the European Parliament asked all member States to initiate NDPs according to the ‘Addressing the EU diabetes epidemic’ resolution. For the highest number of diabetics, Germany ranks number eight in the top 10 countries; and the incidence of type 2 diabetes is among the highest in Europe (Diabetes Atlas & Diabet Med. 2009 Dec; 26 (12):1212-19), so it’s not surprising that the country’s experts have long been calling for a German NDP. However, although 17 out of 28 EU Member States have officially adopted an NDP (Library of National Diabetes Plans, as of December 2013) in Germany the call has gone unheeded . Sustainability of diabetes treatment –To date, scientific studies have ade- quately proved that early protection and thus ideally the supply of insu- lin-producing beta cells can, in some cases, avoid the manifestation of dia- betes in patients with pre-diabetes or the first manifestation of Type 2 diabetes, said Professor Norbert Stefan, President of the Diabetes Congress, but, he added, ‘above all it can significantly improve the course of the disease over a period of ten years. Reason? The body’s own insulin production is maintained for longer.’ Thus he puts forward the case for early treatment and aggressive blood glucose reduction. Stefan rec- ommends a target blood glucose level of around 100 mg/dl (HbA1c 5.6%), which he achieves with the help of the drug metformin. He decidedly advises against the use of so-called sulphonylureas, because ‘They “squeeze” the pancreatic cells dry, making them produce ad infini- tum and this eventually leads to a long term loss of function, which is therefore not sustainable.’ This preventive strategy is only suitable for non-obese patients. Bariatric surgery to treat obese patients, particularly if they do not respond to other treatments, has been hotly debated recently. Several studies have shown that, within two years, 60-80% of obese dia- betics who have undergone this surgery experience a diabetes remis- sion. However, the probability of remission after ten years is only 35%, according to Professor Dirk Müller-Wieland, press officer at the German Diabetes Association (DDG) and Senior Consultant at the Department of General Internal Medicine at the Asklepios Clinic St. Georg in Hamburg. He emphasised that results also suggest that, par- ticularly in cases that are very dif- ficult to treat, the diabetes remission rate after ten years is only 10-15%. Müller Wieland therefore demands that this option as a secondary indi- cation for obese diabetics should only be considered after careful, individual clarification and that, in view of possible side effects such as changes in gastrointestinal motility and long-term consequences (key word increased suicidal tendencies), should only be carried out with appropriate, structured preparation and aftercare. Independent of this gastric surgery, where organs are partially and irreversibly removed, there are currently three further treatment concepts that try to utilise the same mode of action – which is still not understood – but which are less invasive than the surgical reduc- tion of stomach size. Up to now, all studies show that probably the upper part of the small intestine and the duodenum are responsible. Müller-Wieland mentioned three different, promising treatment con- cepts. In the first, an impermeable sleeve, also called ‘gastric condom’, is inserted, preventing food coming into direct contact with the intestinal wall when passing through. The second concept consists of a selective ablation of the mucosa to partially disable it (see EH article on page 1 – duodenum ablation). With the third concept, gastro- intestinal motility is changed via electric modulation through inter- action with the vegetative nervous system. Initial experimental data for these three approaches con- firm their success and, said Müller- Wieland, point toward the develop- ment of ‘Interventional Diabetology’. However, we must first wait for the results of larger, more meaningful studies. Soon, the so-called closed-loop- systems may help to further custom- ise treatment, particularly for Type 1 diabetics, and notably to avoid the often underestimated hypoglycae- mias, which frequently occur during the night. For this procedure, the current- ly available continuous blood glu- cose monitoring systems, which are implanted subcutaneously into the adipose tissue where they measure the glucose in the interstitial fluid (and transmit data to a mobile tel- ephone), are to be combined with insulin pumps – also already avail- able – through a complex algorithm in such a way that the system auto- matically and continuously calcu- lates and dispenses the amount of insulin required. ‘We believe that the first closed- loop blood glucose monitoring sys- tems will be available within the next two, maximally three years,’ said Professor Thomas Forst, Director at It may well be that finally the time has come: last year, the German Federal Assembly called on the gov- ernment to adopt a Prevention Act and a national diabetes plan and, in January 2015, the German daily FAZ reported that the Christian Democratic Party (CDU) confirmed being in the process of drafting an NDP (FAZ, 02.01.2015). In view of these developments in the political arena, the focus on diabe- tes at the annual VDGH congress is no coincidence: the medical diagnostics manufacturers want to contribute to the current public health debate and to encourage dialogue between poli- tics, healthcare institutions, research and industry. Above all, however, the players in the medical diagnostics industry want to be part of the NDP development project. ‘We favour a round table which brings together all disciplines – and I consider indus- try a discipline in this context – to jointly develop a national diabetes strategy,’ said Matthias Borst of Becton Dickinson and VDGH Chairman of the Board, during the panel discus- sion. The medical diagnostics industry offers a wide variety of highly sensi- tive tools for the early detection of diabetes and of disease management devices that allow diabetes patients to measure glucose levels thus helping them to lead a ‘normal’ life. Finally yet importantly medical diagnostics firms invest in new tech- nologies to improve early detection and treatment of diabetes. The evening session began with a personal account of type 2 dia- betic Udo Walz, a society hair stylist, followed by an update on diabetes research from Professor Oliver Schnell, Executive Manager of Forschergruppe Diabetes e. V. am Helmholtz Zentrum München (see information on diabetes research from the Diabetes Congress, also reported here). The highlight of the evening was the closing panel discussion with Professor Schnell, VDGH Member of the Board Matthias Borst, Dietrich Monstadt (Member of the German Parliament, CDU) and Dr Günther Jonitz, President of the Physicians’ Association Berlin. During this discussion, organised by TV host Susanne Kluge, Dietrich Monstadt, himself an insulin-depend- ent diabetic and among the initiators of the NDP draft to be presented by the Christian Democratic Party, sum- marised the state of affairs. The draft is currently being discussed with the Social Democratic Party, the CDU’s coalition partner in the German gov- ernment, aiming to submit it for con- sideration by the German parliament. Monstadt proposes a comprehen- sive diabetes strategy that not only integrates federal, state and municipal levels but, above all, follows a multi- ministry approach: diabetes preven- tion, in this strategy, is not limited to the department of health but requires the cooperation of inter alia the minis- try of education (e.g. regarding physi- cal education in schools), agriculture (healthy food and diet) and urban development (no fast-food restaurants next to schools). There was unanimous agreement among panel members unanimously agreed about the need for an NDP and a diabetes strategy that integrates the different stakeholders, including the patients. Moreover, they agreed ‘the sooner, the better’ – maybe even within 2015. However, it remains to be seen whether Borst’s wish to have the industry, represented by VDGH, which was invited to participate in the NDP process, will be fulfilled. In 2013, the Library of National Diabetes Plans in Europe compared the European NDPs and noticed: ‘None of the NDPs mention industry involvement.’ According to the International Diabetes Federation (IDF) in recent decades the development of diabetes mellitus (DM) warrants the conclusion that this is among the most important global epidemics, Walter Depner reports. Figures illustrate the dramatic situa- tion: in 2014, diabetes mellitus preva- lence in Europe in the 20-79 years age bracket ranged between 15% (highest valuation) in Turkey to 5.5% in the UK (lowest value). Between these end points of the scale are Germany (11.5%), Spain (10.5%) and Austria (9%), Italy (close to 8%), Switzerland, the Netherlands, France and Poland (slightly above 7%) and Belgium and Sweden (around 6%). In 1994, when an estimated 110 million people suffered from diabe- tes, the prognosis for 2010 was 239 million patients. However, in 2010 more than 285 million diabetes cases were reported. Three years on, in 2013, the number had risen by almost 100 million to 380 million – a figure epidemiologists expected for 2025. IDF points out that the projections had to be repeatedly revised up; esti- mates from 2014 expect as many as 600 million diabetes cases by 2035. Ninety to 95% of all diabetes patients have type II diabetes. A look at Germany illustrates the financial dimensions of this epidemic. Today, an estimated 20% of total expenses of statutory health insurers are incurred for diabetes treatment and its concomitant and secondary diseases: €40 bln yearly – and count- ing. The root cause of this develop- ment is not the list of ‘usual suspects’ – wrong or malnutrition, unhealthy lifestyle, e.g. lack of exercise, over- weight, or environmental effects – but the fact that most patients find it far easier to ‘manage’ the disease with medication instead of changing their lives in a controlled and sus- At the VDGH congress event ‘Challenge Diabetes – Are we prepared?’ panellists included Professor Oliver Schnell (diabetes researcher), Dietrich Monstadt (healthcare policy expert and Member of Germany’s Parliament), Susanne Kluge (organiser and TV host), Dr Günther Jonitz (President of the Physicians’ Association Berlin) and Matthias Borst (VDGH Chairman of the Board). Source:VDGH,photographer:HenningSchacht Professors participating in the press conference, from Dirk Müller-Wieland, Norbert Stefan and Thomas For Photographer:DirkDeckbar,©DDG

EH 3_2015

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