1 September 2021
Written by Claire Bonneau
As globalization continues to bring everyone and everything closer together, not all of the trade-offs are necessarily positive. As we export our unique cultures and experiences around the globe, we also increase the spread of chronic health problems.
For much of the 20th century, a person’s likelihood of developing a chronic health disease like type II diabetes depended on the wealth of the country they lived in equally as much as their own biology and genetic factors. In wealthy, developed countries, people are much more likely to survive to old age and eventually pass away from diseases of affluence — chronic diseases like cancer, heart disease, and diabetes that primarily impact the ageing population. In contrast, people living in developing nations are much more likely to experience malnourishment, violence, and communicable diseases that have a major impact on their overall health and quality of life.
This distinction has proven to be true across many developed countries, including globalization giants like the United States. Even in the more economically disadvantaged areas of America, hardly anyone dies as a result of communicable diseases like tuberculosis, a disease that is still a serious problem in lesser developed nations. Alternatively, in low to middle-income countries, these types of health concerns are still a going concern. Alongside the increased risk of encountering a communicable disease, people living in these areas are also at a higher risk for developing diseases of affluence such as type II diabetes. In this way, people living in developing nations are more likely to experience cancer while also battling cholera infections, and someone living with diabetes is also more likely to be struggling with chronic malnourishment. This lack of distinction between diseases of affluence and communicable diseases puts people living in developing nations at a disadvantage.
In this new global landscape of health and disease, the impact of diabetes is truly overwhelming. Since 1980, the number of people living with diabetes has almost doubled from 152 million to between 285-347 million (1). As a result of this dramatic increase, health spending and global costs have also had to increase to meet the growing demand for care. In 2019, it is estimated that diabetes caused over 760 billion USD in health expenditures, making up about 10% of all global spending on adults (2).
As the prevalence of diabetes continues to grow around the world, we need to shift our attention to finding global solutions to this invisible epidemic. Understanding the connection between obesity, globalization, and diabetes is a great starting point in order to tackle this ever-growing global health problem.
Type II diabetes is an endocrine disorder caused by the development of insulin resistance (the hormone responsible for controlling our blood sugar levels) (3). Untreated type II diabetes leads to chronically high blood sugar levels, which in turn causes damage to vital organs and long term health problems.
Prior to developing type II diabetes, many people experience a condition called prediabetes. Diagnosed based on blood glucose levels following an eight hour fast and after drinking a sugary beverage, the following results are used to categorize the disease (6):
A blood sugar level less than 140 mg/dL (7.8 mmol/L ) is considered normal. This indicates that your pancreas is functioning properly and that your body is able to properly regulate your blood sugar levels.
A blood sugar level from 140 to 199 mg/dL (7.8 to 11.0 mmol/L ) is considered prediabetes. This can be an indicator that insulin resistance is beginning to develop, and you are at risk of developing full-blown diabetes if no interventions are implemented.
A blood sugar level of 200 mg/dL (11.1 mmol/L ) or higher indicates type 2 diabetes. Readings at or above this level indicate that your body is unable to properly regulate your blood sugar level, and you are at risk for experiencing negative health outcomes.
Type II diabetes is commonly associated with having an elevated percentage of body fat throughout the body. Fat tissue (also called adipose tissue) is more likely to be resistant to insulin, especially when there is a larger amount of it in the abdominal area of the body (3). Because of this, there is an increased risk for people living with obesity and elevated body mass indexes (BMI) to develop type II diabetes over time.
In 2019, approximately 473 million adults around the world are currently living with diabetes. Of this number, only half have been properly diagnosed (2). This number is expected to balloon to 700 million by the year 2045 (2).
According to the WHO, by the year 2030 diabetes will be the seventh leading cause of death worldwide (4).
79% of all adults diagnosed with diabetes live in low-middle income countries (2). This statistic directly shows the impact that your geographical location has on your overall health.
Diabetes and a country’s gross domestic product (GDP) per capita are connected. On average, countries with low GDP below $20,000 (like African, South American, and Oceanic island countries) have a higher percentage of adults living with diabetes (an average of 10-30% of the population aged 20-79) (5). Statistically, countries with a higher GDP per capita have a lower percentage of adults living with diabetes.
Sugar consumption around the world has increased dramatically over time. While the World Health Organization (WHO) recommends that a person should consume no more than six teaspoons of added sugar per day to maintain a healthy weight, on average Americans consume more than 23 teaspoons of sugar every day (7).
As we explore the possible causes for the rise in diabetes cases around the world, the ageing population, urbanization, and economic growth always seem to be connected. As modern society has changed the way we live our day to day lives, fewer people perform manual labour to earn a living. Instead, more sedentary lifestyles have been adapted as many of us sit at a desk and computer all day for work. This decrease in daily activity combined with excess income to be spent on food could be a contributing factor to the increase of obesity around the world.
Research has been able to find a direct correlation between increased income resulting in an increase in obesity. On average, a 1% increase in a country's GDP per capita results in a 1.23% and 1.01% increase in the prevalence of obesity in the men and women of the country, respectively (8).
It is important to note that not all people who are obese develop diabetes and not all people with diabetes are overweight. Although increased urbanization, economic growth, sedentary lifestyles, and total food availability does correspond to higher rates of diabetes, adjusting this data to control for differences in refined sugar consumption shows no significant correlation. This suggests that rather than a direct connection between urbanization and diabetes, the real cause of the problem may be more nuanced.
Is increased urbanization exposing people to a higher daily amount of sugar, which in turn increases the risk of developing prediabetes? Are sedentary lifestyles becoming a major contributing factor to increased weight gain and insulin resistance? Finding a way to curb the growth of the invisible epidemic of diabetes is reliant on finding the answers to these tough questions.
While we need to conduct more research to understand the impact of affluence and urbanization on diabetes rates, it is abundantly clear that a country’s economic status has a direct impact on its access to refined sugar and processed foods. A growing body of health research in developed countries supports that eating more processed foods that are high in sugar increases the risk of developing diabetes. Based on current trends, the demand for animal-source foods and empty calories (processed foods) is projected to steadily increase (9). The higher the intake of processed foods and the increase in excess calorie consumption leads to obesity, weight gain, and a possible risk of developing prediabetes.
This claim is further backed by looking at obesity statistics from the past 50 years. From 1975-2016, developed countries with access to processed foods have experienced a prominent rise in the prevalence of obesity. During this timeline, American obesity rates have increased from 9.5% to a staggering 28% (10). Alternatively, lesser developed countries with limited access to processed foods like Africa and South-East Asia have only seen increases of a few percentage points.
As the diabetes epidemic continues to grow, developing countries continue to be the areas that are the most heavily impacted. With 75% of all people with diabetes living in the developing world, this problem afflicts more than six times as many people as HIV (11).
Why, if infectious diseases persist and life expectancies remain low, has diabetes taken such a toll on the health of the impoverished in developing countries?
Making a Nutritional Shift
As developing countries continue to increase their urbanization, modernized lifestyle and dietary changes have caused negative health impacts.
In Asia (where 60% of all people with diabetes live) traditional dietary habits and meals are being lost as more modern and accessible processed foods are becoming more popular. For example, many Chinese people have had an increase in animal-based foods such as fat and dairy in their diet, compared to the more traditional diet of vegetables and cereal grains (12). This dietary change is supported by a financial component, as unhealthy foods like soda and beer have been creasing in cost over time, while healthy foods like fresh vegetables and fruits have continually increased in price over the past few decades.
As globalization makes our world smaller than ever before, food imports are a large contributing factor to the increased access to processed foods. Foods such as high-calorie refined oils and sugars have become cheap to produce and export, which in turn has resulted in an increase in overnutrition and overconsumption. When paired with more sedentary lifestyle habits, these dietary changes have a massive impact on overall health and the risk of developing diabetes.
Increased urbanization also has an impact on the amount of daily exercise people are participating in. In a study done by the NHS, it was found that more sedentary activities such as watching TV and sitting at a desk for prolonged periods of time increase a person’s risk of developing diabetes (13).
In another example from China, the increase in the use of cars and public transportation has had a direct impact on the amount of physical activity a person gets every day. As the average GDP per capita in China exponentially grows, so does the number of vehicles across the country, jumping from 10 million in the 1990s to over 80 million after 2010.
In addition, rapid shifts toward a service sector economy and the growing use of new technologies have led to an apparent decrease in daily exercise levels. As of 2015, an estimated 40% of people in China are now employed in service-based jobs that revolve around prolonged periods of sitting and deskwork (14).
When paired with dietary changes, this marked decrease in physical activity has a profound impact on the prevalence of diabetes in China and other developing nations. So if we know what two of the largest risk factors of diabetes are, what are we doing to slow the progression of this disease?
The fight against diabetes is just beginning, and now more than ever the need for increased education and treatment options is truly essential. Because of the nature of the disease, many people live with type II diabetes and don’t even know it! While they may report mild symptoms, exposure to chronically high blood sugar levels is linked to an increased risk for serious health conditions like strokes, heart attacks, and heart disease.
As this problem continues to grow, two options of better management of diabetes have come to the forefront:
Because diabetes is a progressive disease, early detection is the key to preventing long term health issues. Increasing access to early diagnostic testing like the oral glycemic test can help people become aware of their diagnosis and will allow for earlier adoption of healthier lifestyle choices and dietary changes.
As this epidemic continues to grow, the global community needs to push towards offering better treatment options for those living with diabetes. To better aid this goal, the United Nations has set a goal as part of their sustainable development plan which calls for a reduction of premature deaths from non-communicable diseases like diabetes of 30% by the year 2030 (15). In addition to this commitment, many governments around the world have committed to the WHO’s Global Action Plan for the Prevention and Control of Non-Communicable Diseases, which has a mission to slow the rise of diabetes cases globally.
With all of this in place, the United Nations and WHO are hopeful that we can start making global strides towards reducing the prevalence of diabetes in both developing and developed nations. Continued research and education about diabetes is the best way to make ground on this very essential mission.
Nearly 350 million adults have diabetes: Study reveals scale of global epidemic from Harvard T.H. Chan: https://www.hsph.harvard.edu/news/press-releases/diabetes-global-epidemic/
About Diabetes from the International Diabetes Federations: https://idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html
Type 2 diabetes from Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193
Diabetes from the World Health Organization: https://www.who.int/news-room/fact-sheets/detail/diabetes
Diabetes prevalence vs GDP per capita 2017 from Our World in Data: https://ourworldindata.org/grapher/diabetes-prevalence-vs-gdp-per-capita?xScale=linear
Prediabetes from the Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/prediabetes/diagnosis-treatment/drc-20355284
World sugar consumption will hit a new high in 2015 from VOX: https://www.vox.com/2014/11/24/7274725/sugar-consumption-obesity
The association between national income and adult obesity prevalence: Empirical insights into temporal patterns and moderators of the association using 40 years of data across 147 countries from PLOS Online: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232236
The ongoing nutrition transition thwarts long-term targets for food security, public health and environmental protection from Scientific Reports: https://www.nature.com/articles/s41598-020-75213-3
Obesity by Our World In Data: https://ourworldindata.org/obesity
The Global Diabetes Epidemic, Brought to You by Global Development from The Atlantic: https://www.theatlantic.com/health/archive/2012/07/the-global-diabetes-epidemic-brought-to-you-by-global-development/259305/
Trade Liberalization, Urbanization and Nutrition Transition in Asian Countries from The Journal of Nutritional Health & Food Science: https://symbiosisonlinepublishing.com/nutritionalhealth-foodscience/nutritionalhealth-foodscience09.php
Globalization and diabetes from the American Diabetes Association: https://care.diabetesjournals.org/content/34/6/1249
GDP per head vs share of services in employment, 1801 to 2015 from Our World in Data: https://ourworldindata.org/grapher/gdp-vs-services-employment?country=~CHN
World Health Day 2016: WHO calls for global action to halt rise in and improve care for people with diabetes from the World Health Organization: https://www.who.int/news/item/06-04-2016-world-health-day-2016-who-calls-for-global-action-to-halt-rise-in-and-improve-care-for-people-with-diabetes
The author, Claire Bonneau, is a medical writer and certified trauma operating room nurse.