EPIDEMIOLOGY OF DIABETES

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EPIDEMIOLOGY OF DIABETES ITS HISTORY IN THE
LAST 50 YEARS

• Professor Paul Zimmet, AO, MD, PhD, FRACP,
  FRCP(UK)
• International Diabetes Institute, Melbourne,
  Australia

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Abstract
The application of epidemiology to the study of
diabetes mellitus has provided new insights into
many aspects of this major public health problem
including its natural history, prevalence,
incidence, morbidity and mortality in diverse
populations around the globe.
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MAIMONIDES - THE FIRST DIABETES EPIDEMIOLOGIST?
Diabetes mellitus was seldom seen in cold
Europe, whereas it was frequently encountered in
warm Africa.
I, too, have not seen it in the West, nor did
any of my teachers under whom I studied mention
that they had seen diabetes. However, here in
Egypt, in the course of approximately ten years,
I have seen more than twenty people who suffer
from this illness.
(1135-1204AD)
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Introduction (cont.)
In between sifting and synthesizing this
voluminous information, West made a number of
insightful and noteworthy suggestions with regard
to the future direction of diabetes research, and
set a number of challenges for his colleagues.
He was also somewhat prophetic in predicting
some of the issues that are under critical (and
sometimes not so critical) debate today,
particularly with respect to classification and
criteria of the diabetes syndrome.
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The first WHO Expert Committee on Diabetes
Mellitus
was convened in Geneva in 1964 (6). The report of
this group includes one of the first attempts at
international consensus on a classification.
While there have been a number of sets of
nomenclature and diagnostic criteria proposed for
diabetes including the 1964 attempt, no
systematic categorization existed until just over
20 years ago. The contemporary classification of
diabetes and other categories of glucose
intolerance, based on scientific research on this
heterogeneous syndrome, was developed in 1979 by
international workgroups, the National Diabetes
Data Group (7) of the National Institutes of
Health, USA, and the WHO Expert Committee on
Diabetes in 1980 (8).
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Yet another important milestone was the first
WHO/IDF training course in epidemiology of
diabetes held in Cambridge UK in 1980. This was
the first of several courses that have boosted
the numbers of diabetologists from many countries
around the globe becoming infected and joining
the epidemiology ranks. One of my sole
recollections of the first course was missing the
televising of the Royal Wedding of Prince Charles
and Princess Dianne as a result of being hauled
off by the notable anti-Royalist, John Jarrett,
to be thrashed on the tennis court!
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Another major initiative in diabetes
epidemiology, spurred on by Ron LaPorte and the
Pittsburgh Group in the early 1980s, was the
concept of diabetes registers. Their creativity
and enthusiasm saw over the next decade or so the
development of Type 1 diabetes and insulin
treated diabetes registers established in many
countries. I estimate the number of such
registers now exceeds well over 200. These
registers were not only important in terms of
descriptive epidemiology but form the basis of
investigative studies on both the genetic and
environmental risk factors for Type 1 diabetes.
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Major early epidemiology studies
Clearly the Pima Indian (11) and our Pacific
Island studies (12) have been of inestimable
value in understanding not only the aetiology and
natural history of Type 2 diabetes but also the
development of approaches for prevention. Other
important early studies include Bedford (Harry
Keen), Whitehall (John Jarrett), San Antonio
Mexican-American (Michael Stern), San Luis Valley
Hispanic (Richard Hamman), Rancho Bernardo
(Elizabeth Barrett-Connor), Japanese American
(Wil Fujimoto) and the Paris Prospective (Eveline
Eschwege).
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Estimated global prevalence of type 1 and type 2
diabetes
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A personal perspective of an introduction to
epidemiology
In the early 1970s I was completing a PhD in the
Department of Biochemistry at Monash University
in Melbourne. We had a theory that fragments of
human growth hormone might be involved in the
regulation of the insulin sensitivity and we
developed biological assays for a number of
peptides (16). Intuitively I thought that the
only way to show their real significance would be
to test them in an epidemiological framework!!
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Harry Keen and John Jarrett in the early 1970s
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A personal perspective of an introduction to
epidemiology (cont.)
It was then that I had my first experience of the
difficulties and logistics of undertaking a
survey thousands of miles from home, on a remote
island, with virtually no back-up facilities and
with untrained staff. Nauru was a seven hours
flight from Melbourne and there was only one
flight a week on Air Nauru (but they did serve
Chateau Mouton Rothschild with the meals!).
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Where to now?
I have to confess to a certain degree of cynicism
about the relevance most animal models being used
to understand the aetiology of diabetes and in
particular Type 1 diabetes. It has always been
my belief that the epidemiological studies in
human populations provide the best direction for
such research and the development of new
hypotheses. This view may well upset some of my
laboratory-based colleagues.
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Conclusions
Epidemiology has come a long way since those
early years. The study of epidemiology involves
much more than number counting.
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