The global prevalence of type 2 diabetes has quadrupled over the past 25 years. The factors driving this dramatic rise are our modern physically-inactive, sedentary behaviour and associated obesity.
The prevalence of diabetes in Malta is very high at 14 per cent. Our annual health bill for diabetes is estimated at €65 million (the International Diabetes Federation). Reducing the prevalence of type 2 diabetes is clearly a matter of urgency.
The WHO appropriately chose global action to halt the rise in diabetes as the theme for this year’s World Health Day (April 7), which celebrates its founding in 1948. It was also very good to learn that two of our MEPs – Therese Comodini Cachia and Marlene Mizzi – have joined a European parliamentary group that will urge the European Commission and the Council to prioritise diabetes as a major concern.
The pivotal causative factors of diabetes are excess consumption of sugar (or refined carbohydrate), obesity and lack of exercise.
Malta’s per capita consumption of sugar is the highest in the EU and we have also been shown to be the least physically active country in the world. In addition to possible hereditary factors, both our diet and lack of exercise conspire to make us fat and predisposed to diabetes. Our children, too, are the fattest and the least active in the EU. They therefore start life already programmed for ill-health later on.
The health costs of physical inactivity have not been estimated in Malta. Extrapolating from calculated health costs in other countries, our annual cost of physical inactivity would amount to as much as €100 million. These costs are largely accounted for by excess diabetes, heart disease, blood vessel disease, stroke, bowel cancer and others.
The impact of exercise is particularly dramatic in diabetes and the benefits of exercise on lowering the prevalence of diabetes probably exceeds the benefits from the prevention of heart disease, stroke and other diseases. A review of 66 large-scale systematic prevention programmes confirmed that interventions which combined physical activity and modest weight loss can lower risk of type 2 diabetes by as much as 58 per cent in high-risk populations as in Malta.
The question of diet receives attention in Malta but we continue to lag behind with exercise
The question of diet receives attention in Malta but we continue to lag behind with exercise. Nothing effective is being done to create opportunities for healthy exercise that should normally be readily available to everybody on a national basis. This was concisely summed up by the WHO Director-General: “If we are to make any headway in halting the rise in diabetes, we need to rethink our daily lives: to eat healthily, be physically active and avoid excessive weight gain. Even in the poorest settings, governments must ensure that people are able to make healthy (lifestyle) choices and that health systems are able to diagnose and treat people with diabetes.”
The WHO recommends health-promoting environments to reduce diabetes risk factors. In its report ‘A physically active life through everyday transport with a special focus on children and older people and examples and approaches from Europe’, the WHO states that walking and cycling as part of daily activities should become a major pillar of the strategy to increase daily levels of physical activity as part of reducing the risk of coronary heart diseases, diabetes, hypertension, obesity and some forms of cancer.
But Malta stubbornly goes the other way. The nature of our urbanised environment has continued to be systematically degraded by the profit motive of estate developers with little regard for the negative social and public health implications. The result is urban areas of monotonous ‘low human-scale’ streets of poor aesthetic quality that serve only as conduits for motor traffic and in which nobody wishes to walk.
Successive administrations have failed, and continue to fail, in providing an environment which encourages people to be physically active by incorporating exercise into their daily routine.
At the same time, Malta’s transport philosophy remains modelled on 1950s car-orientated practices. Modern approaches to mobility by successive administrations have been persistently ignored, and Malta’s unhealthy policies continue to this day. We remain oblivious to how other countries started long ago to provide conditions and infrastructure for multi-modal transportation.
Our children are growing triply impaired. They are growing up constrained by their overbuilt living (urban) environment without access to opportunities for healthy exercise and denied the freedom of bicycle mobility. Beside compounding our excessive childhood obesity, this results in early conditioning to lifelong car-dependency because children remain dependent on transport in their parents’ car until they are old enough to be transport-independent – usually by owning a car themselves.
However, the greatest threat to growing children in Malta is to their lungs from our street-level pollution. The European Respiratory Society and the European Lung Foundation have launched a Healthy Lungs for Life campaign aimed at reducing the prevalence of respiratory disease. Again, the main emphasis of the campaign is on physical activity.
A further bonus from lifestyle improvement is a decrease in the prevalence of dementia. Recent evidence has shown that the risk of developing it can be reduced by as much as 30 per cent by regular exercise over the lifespan. There is a lot to be done in creating conditions which encourage people to become more physically active.
There are three main forms of diabetes: type 1, type 2 and gestational diabetes. Type 1 diabetes (known variously as juvenile, early-onset and insulin-dependent ) is as yet unpreventable. Type 2 diabetes is largely the result of excess sugar and refined carbohydrate intake, obesity and physical inactivity. Until recently it only occurred in adults but is now starting to be seen in children. Gestational diabetes is a temporary condition that may occur during pregnancy. It carries long-term risk of type 2 diabetes.
George Debono is the lead author of the think-tank report‘ The environmental dimension of Malta’s ill-health and action to prevent obesity, diabetes, cardiovascular disease and dementia’.