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Nowhere in Europe has seen as large an increase in diabetes over the past two decades as Turkey. Investigators of the cross-sectional, population-based Turkish Diabetes Epidemiology Study [TURDEP-I] found that 7·2% of adults in the country had diabetes in 1998. 12 years later, the follow-up Turkish Epidemiology Survey of Diabetes, Hypertension, Obesity and Endocrine Disease [TURDEP-II] found that rates had risen to 13·7%. “There is no doubt that the prevalence of diabetes has by now reached epidemic proportions”, concluded the investigators.
It is an epidemic laid bare by the statistics. About 7·2 million Turkish adults are thought to have diabetes, roughly 3 million of whom have not been diagnosed. The disease causes roughly 60 000 deaths every year, and consumes almost a quarter of the country’s health-care expenditure. Two-thirds of adults are either obese or overweight—a prevalence similar to that of the Gulf states. Turkey is home to just 400 endocrinology and metabolic disorder specialists: one for every 18 000 individuals with diabetes. They are predictably overworked—some report seeing 900 patients per month. 28% of Turkish patients with diabetes have retinopathy, and more than half have experienced at least two diabetes-related complications.
The sharp increases in diabetes and obesity (which rose from 22% to 31% between the two TURDEP surveys) are almost certainly related to the nation’s equally abrupt societal changes. “Diabetes has emerged as a health challenge due to the new living model brought on by the 21st century”, notes Temel Yilmaz (Istanbul University, Istanbul, Turkey), founding president of the Turkish Diabetes Foundation. “The underlying problem is that in countries with rapid industrialisation and development, individuals do not have information on how to manage their health with their new lifestyle.”
Turkey has undergone a precipitous process of urbanisation. Close to 20 million people now live in Istanbul, out of a total population of roughly 75 million. Indeed, about half of Turks reside in one of the country’s ten largest cities. “The migration has many implications, not just for those who are migrating, but also for those who remain in the countryside”, explains Gökhan Hotamisligil from Harvard University (Boston, MA, USA). “As the rural population diminishes, so do healthy cultural practices such as traditional cooking, farming, and organic agriculture.” In urban settings, traditional foods such as meze, with its selection of beans and salads, are being pushed out by foods high in carbohydrates and saturated fats. “The fast food type of nutrition has been enforced”, says Yilmaz. “In Turkey, the Middle East kitchen version of fast food dominates the market—this can be considered one of the important factors for the increase in diabetes.” As in most of the developed world, Turkish youngsters are partial to junk food. “Eating habits are very different now—most families in the cities do not cook at home; at least two of their meals per day are eaten outside, and these do not tend to be very healthy selections”, adds Hotamisligil.
Compounding the problem is an accompanying decline in physical activity. “Smartphones for children and teenage groups, computers in the working group, and TVs in the older generation have entered lives in a concentrated form”, Yilmaz tells The Lancet Diabetes & Endocrinology. “Turkey, as a rapidly industrialising country, has been more intensely affected, compared to other European countries.” According to WHO, more than half of Turks older than 15 years are not adequately active. Urbanisation makes matters worse. “In big cities, kids spend a lot of time commuting to their schools—that is time that could be used for exercise and sport”, points out Hotamisligil. And Turkish cities are not places where children can easily play outside. Moreover, Turkey is a young country, with a third of the population in school—many will find it difficult to relinquish the habits they developed during these formative years. “Young people, even if they do develop obesity, do not immediately go on to develop complications, but in 20 or 30 years’ time, there could be an unmanageable explosion in chronic diseases”, warns Hotamisligil.
Ilhan Satman (Istanbul University), lead author on both TURDEP surveys, points out that Turkey’s hefty diabetes burden cannot be exclusively attributed to the ills of modernity. “Turkish women have traditionally stayed at home, and especially for women older than 50, there is no tradition of exercise”, she said. Since the first survey, Turkish life expectancy has increased by 4 years for women and 5 years for men, so some increase in diabetes was probably inevitable. The country’s successful anti-tobacco campaigns might also have played a part. Turkish men who have stopped smoking have tended to put on weight, although no such effect has been found for Turkish women.
The authorities have been caught unawares. “No one predicted such a rise in diabetes”, notes Yilmaz. Turkish health-care systems have traditionally focused on the management of acute conditions and communicable diseases. “There was a delay in realising the importance of prevention and tackling the risk factors [for diabetes]”, says Yilmaz. But the Government does seem committed. “Several programmes by governmental and non-governmental organisations, many of them in collaboration, are running in Turkey”, Yilmaz explains. The Diabetes Parliament meets regularly, bringing together stakeholders to discuss issues such as the availability of drugs. The Ministries of Health and Education support the Diabetes in School Programme, which raises awareness among both pupils and teachers, and disseminates messages about healthy eating. The programme was established in 2010; by the end of 2011, it had reached more than 7·5 million students. A similar programme, spearheaded by peer advisers and backed by the Turkish Presidency and the International Diabetes Federation, offers patient education sessions in more than 20 cities.
“The Government is engaged”, agrees Hotamisligil. He points out that the previous administration’s minister of health declared diabetes control and prevention a priority, and the present minister, Mehmet Müezzinoğlu, is of a similar mindset. A national strategy for diabetes will run until 2020 (Satman is chairperson of the executive board that oversees the programme). A separate strategy for obesity prevention and control has also been established. “Even in small cities, they are building bicycle lanes, and in other places they are talking about providing free bicycles”, explains Satman. There are plans to increase the amount of time schoolchildren spend in physical education lessons and for public service announcements to emphasise the importance of healthy lifestyles, and the Government has ordered changes to the fare offered by school canteens. “They have officially banned and restricted certain foods, and this is enforced by law”, says Satman. Now that the election period has ended, she hopes to see further progress on matters such as the introduction of traffic light labels for food.
Satman also favours imposing taxes on unhealthy foods. Whether or not the Turkish Government will do so remains to be seen. But Hotamisligil is unconvinced of the usefulness of such measures. “I am not sure those kinds of interventions are very effective or wise”, he says. He believes that concentrating on research would be far more beneficial. “The food industry has not made much of an effort, based on science, to seek better ways to present their products to the public—they are still using the same ingredients and methods that they have always used”, Hotamisligil tells The Lancet Diabetes & Endocrinology. “There is now a great opportunity to encourage food companies to invest in their research enterprises so that they can understand healthy ingredients that can be incorporated into food, and unhealthy ones that can be removed from their products.” He cited the example of iron supplementation. “That really came from basic research, from understanding the importance of iron and iron metabolism, and it meant that iron deficiency has been eliminated in most parts of the world”, he explains.
Nonetheless, nudging industry into this kind of investment is tricky for an individual government, particularly one outside of the European Union, and even if successful, it would take time before the benefits become apparent. In the short term, education remains key. “The number one positive predictor of health is education”, argues Hotamisligil. Ensuring that children learn about healthy lifestyles from nursery school onwards will certainly help. But on its own, it will not be sufficient. “We need to support all living areas, in family living, schools, universities, and working areas”, says Yilmaz. This strategy will mean enlisting sectors such as urban planning, environment, transport, and industry; staunching the flow of people to the cities would also pay dividends—urban living is a risk factor for all kinds of health problems—but is highly improbable. Meanwhile, Turkish health care, which has undergone a major restructuring since 2003, will need to be responsive to the changing needs of the population. “We have to speed up the transformation of the health-care system from reactive to proactive”, says Yilmaz. None of this is easy. But based on current trends, by 2035 there will be almost 12 million people with diabetes in Turkey, more than anywhere else in Europe. If such an eventuality comes to pass, the health-care system could find itself overwhelmed. The time to act is now. [Source]
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