International Journal of Epidemiology 2002;31:878
© International Epidemiological Association 2002
Book Review |
The Epidemiology of Diabetes Mellitus: An International Perspective.
J-M Ekoé, P Zimmet, R Williams (eds). Chichester: John Wiley, 2001, pp. 437, £120. ISBN: 0-471-97448-X.
Once considered primarily as a risk factor for heart disease, diabetes has now become a high profile public health concern in its own right, due to the escalating epidemic of diabetes in older people, and the emergence of type 2 diabetes in children.
The number of people with diabetes worldwide is set to double in the next 20 years, as a result of increasing obesity and longevity. While some of this increase will be observed in Europe and North America, it is clear that the bulk of the epidemic will be observed in non-European origin populations, in countries undergoing rapid westernization. If anything, the European origin populations are the anomaly, being substantially protected from type 2 diabetes compared to other world populations. This is reflected in our current understanding of the epidemiology of diabetes, derived mainly from the study of non-European populations, such as the Pima Indians and Naruans. But it is clear that diabetes risks, manifestations, natural history and even the criteria for the definition of diabetes itself, may vary considerably by population.
These considerations are being addressed by epidemiological studies of diabetes and its complications in several different populations, but despite the greater burden of diabetes in non-European populations, the majority of participants in trials of pharmacological agents are of European origin: little attempt is made to consider whether intervention efficacy, and thresholds for treatment can, and should, be identical in all patient groups.
The Epidemiology of Diabetes Mellitus: An International Perspective is a long overdue, and welcome response to these population differences. Epidemiological study has made a major contribution to our understanding of diabetes and its complications. Observations of international variations, and in particular migrant studies, have for decades furthered our knowledge of the aetiology of diabetes. Recent epidemiological developments, such as the changing definition of diabetes, and also the ultimate promise of interventions which can now reduce the risk of diabetes itself, are all intelligently and comprehensively dealt with here.
However, despite the emphasis on the international aspects of disease, the population groupings are handled in a curious manner, using a combination of geography, race and ethnicity. The chapters on non-Caucasian populations, for example, include people from middle and south-east Asia, who are, at least in part, of Caucasian descent. A book chapter on each of these diverse populations presents a challenge to the authors, as it requires inclusion of material on the differing aetiology of diabetes, and a discussion of all the long-term complications of diabetes, including risks and risk factors for microvascular and macrovascular complications, and of neuropathy at the very least. The contribution on African Americans rises well to the challenge, but not all sections are as comprehensive.
Welcome chapters for a book of this kind include a review of the health economics of diabetes, and an emphasis on the evidence for prevention of both type 1 and type 2 diabetes. Even more usefully, for both the established and neophyte epidemiologist, there is a chapter on the theoretical and practical aspects of field surveys for diabetes. Included are such vital but seldom addressed areas as questionnaire development, sampling, investigations, and also practical issues such as ethics, funding, staff recruitment, and even the importance of a reliable electricity supply to the survey site. The key environmental risk factors for diabetes are known to be lack of physical activity and poor diet. An excellent chapter summarizes the tools available for the assessment of physical activity, and discusses their pros and cons, but disappointingly, this has no counterpart for dietary assessment.
No book could be wholly comprehensive for such a complex disease as diabetes, but there are some striking omissions. Little is made of the work demonstrating that early life influences, including poor growth in utero and childhood growth velocities, appear to be important in determining the risk of diabetes, and its associated vascular complications. Some discussion of the inflammatory/infectious aspects of aetiology, and endothelial dysfunction, particularly the role of nitric oxide, and other aspects of vascular biology, which are now of increasing relevance even to epidemiological studies unravelling the aetiology of the vascular complications of diabetes, might also have been anticipated. Finally, apart from a detailed discussion of interventions designed to reduce the risk of diabetes per se, and a discussion of the UK Prospective Diabetes Study (UKPDS), there is no section on interventions designed to reduce the risk of diabetes-related vascular complications, even though epidemiology has been at the forefront of some of these studies, and many have reported only recently, quite substantially changing the way we treat diabetes. The section on retinopathy, for example, while discussing the impact of the Diabetes Control and Complications Trial on the perceived value of tight glycaemic control in retinopathy risk in type 1 diabetes, bemoans the lack of similar data in type 2 diabetes, despite a whole chapter on the UKPDS. A common feature of most medical texts is that they are out of date even on publication. This is no exception. The Diabetes Prevention Project, one of the largest and most definitive studies of the prevention of diabetes in high-risk groups, was reported too late for inclusion here.
This book is a welcome and innovative addition to the lamentably few texts available on the subject, and in particular it is essential reading for those interested in the public health and economic aspects of a condition soon to be of epidemic proportions worldwide.
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