Do governments give diabetes the attention it deserves?

In recent months, the United Kingdom (UK) Government has called for evidence for a ‘major conditions strategy’.1 The press release highlights diabetes as an example: ‘The major conditions strategy signals the government's intention to improve care and outcomes for those living with multiple conditions and an increasing complexity of need. For example: people with diabetes are twice as likely to have depression’. Yet, diabetes appears to be a low priority in the call. It is subsumed, along with stroke, within the category of ‘cardiovascular disease’. From there on, diabetes is absent from the main text and questions of the call for evidence, and diabetes is mentioned just once (type unspecified) in the 41-page ‘easy read’ version (Figure 1). Globally, 1 in 10 adults live with diabetes. The diabetes-related global health expenditure is both considerable and growing; estimated at USD $966 billion in 2021, representing a 316% increase over 15 years and expected to reach USD $1.03 trillion by 2030.2 The UK has the sixth highest total health expenditure due to diabetes relative to other countries.2 About 80% of that is spent treating complications, and one in five hospital beds are occupied by people with diabetes.3 Clearly, diabetes is not invisible to the many individuals living with the condition or to the National Health Service. So, why is it practically invisible in the UK Government's ‘major conditions strategy’? Perhaps this is an example of diabetes stigma and discrimination.4 In Australia, the current government inquiry into ‘Diabetes in Australia’ is investigating five areas (abbreviated): causes of diabetes; evidence-based advances in prevention, diagnosis and management of diabetes; impact of diabetes on health systems and economy; the relationship between diabetes and obesity, including causes, prevention, diagnosis and management of obesity; and effectiveness of government policy and programmes.5 Consequently, diabetes, obesity and health organisations, professional associations, experts, advocates and communities are directing their attention to potentially resource-intensive submissions. Diabetes peak bodies are raising awareness of the inquiry and inviting community contributions. Necessarily, the five terms of reference are in the public eye. While weight is an important health issue, the explicit integration of an obesity inquiry within a diabetes inquiry may come at a cost to the community. The conversation in Australia during National Diabetes Week moved quickly from the unmet needs of people with diabetes to the relationship between diabetes and a single risk factor. This, again, appears to be an example of diabetes stigma and discrimination. Where is the focus on ageing, genetics, ethnicity, social inequities, all equally valid risk factors? Or on the health of Indigenous people with diabetes, who are greater risk of developing diabetes and its complications than the general population? To turn it around, does a diabetes inquiry afford sufficient respect to the complexity of obesity and community needs surrounding this separate disease? It is already evident that diabetes stigma can negatively impact public and political support for diabetes prevention, care, treatments, programmes and research. In 2017, the American Diabetes Association criticised the stigmatising view of diabetes expressed by the US budget director, who said the healthcare plan provides a ‘safety net’ for people who get cancer, but ‘that doesn't mean we should take care of the person who sits at home, eats poorly and gets diabetes’.6 This real-world evidence both reflects and reinforces broader prejudicial community attitudes, and a social narrative of blame and individual responsibility.4 For example, a UK survey (N = 738) found that while public support for type 2 diabetes prevention programmes was strong, it was lower than for human immunodeficiency virus and human papillomavirus infections and lowest when the question wording included attribution of diabetes to ‘unhealthy eating and inactive lifestyles’.7 Similarly, a 2007 US study (N = 2490) identified that support for public health policies was reduced when type 2 diabetes was framed as caused by behavioural choices or social determinants, compared with ‘genetic disposition’ or no causal framing.8 Public funding of diabetes research has been described as ‘in crisis’,9 with a mismatch between dollars/per population invested in diabetes research relative to some other conditions.10 People with diabetes wait years for public inquiries and government strategies (and longer still for their implementation). These inquiries and strategies have the power to make a major difference to the care and resources they can access to support them to live well with this challenging long-term condition. But, instead of diabetes getting the attention it deserves—instead of people with diabetes getting the attention they deserve—diabetes is too often ignored or stereotyped, and public consultation is biased. Diabetes stigma is all around us. It is not just about how people feel. Diabetes stigma goes to the heart of policy and funding decisions. Diabetes stigma needs to stop. But, to bring an end to diabetes stigma, we all need to play our part to achieve collective action.4 JS and EHT are supported by core funding to The Australian Centre for Behavioural Research in Diabetes (ACBRD) derived from the collaboration between Diabetes Victoria and Deakin University. JS and EHT have received competitive research grants from the Diabetes Australia Research Program, the Medical Research Future Fund Targeted Translational Research Accelerator, and the National Health and Medical Research Council of Australia. JS and EHT have received an investigator-initiated research grant from Sanofi Diabetes and an unrestricted educational grant from Diabetes Australia. JS has also received a competitive research grant from the Ian Potter Foundation, a research contract from the Australian Government Department of Health, and a consulting fee from Diabetes Canada. JS received honoraria to present at educational meetings from Novo Nordisk and Sanofi Diabetes, honoraria for participating in Advisory Boards from Insulet and Sanofi Diabetes, and support for attending meetings (including travel) from the Novo Nordisk Foundation. EHT received honoraria for presentation at educational meetings from Roche Diabetes Care. All payments have been made directly to their research centre (ACBRD). The ACBRD owns the copyright of the type 1 and type 2 Diabetes Stigma Assessment Scales. JS and EHT were advisors to Diabetes Australia on the ‘Heads Up on Diabetes’ campaign and co-authored the associated campaign report, focused on diabetes stigma. JS is the Chair and EHT is a member of the international PsychoSocial Aspects of Diabetes Study Group (unpaid roles).

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