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World Health Organisation (WHO)
Study Guide
© London International Model United Nations 2015 LIMUN | Charity No. 1096197 www.limun.org.uk
Table of Contents
Welcome Letters .......................................................................................................................................... 1
Introduction to WHO .................................................................................................................................. 2 Topic A: Utilizing social media and big data to improve world health ...................................... 3
Topic B: Reducing impact of diabetes on world health by 2030 .............................................. 13
© London International Model United Nations 2015 LIMUN | Charity No. 1096197 www.limun.org.uk
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Welcome Letters
Honorable delegates,
I am Tassilo Vogel and I will co-‐chair the World Health
Organisation committee with Dipen. Arguably the WHO has had
the biggest impact on the world out of all UN institutions by saving
so many lives through interventions such as vaccines. The
underlying reason is in my opinion that it relies on science and
evidence based policy making. I studied pharmaceutical sciences in Munich, Germany, my home
country, and now study MSc. International Health Management in London and want to do a
doctorate to fortify scientific research on mobile health and link it to real-‐time application. I take
part in MUN to meet and be inspired by diverse international students interested in changing the
world and look forward to the great ideas which will be floating around our committee.
Honorable delegates,
My name is Dipen Patel and I be will one of the chairs for the World
Health Organisation. I am very excited to be chairing the WHO as it
involves issues on public health which are of great interest to me. I
am in my second year studying for a BSc Biochemistry at the
University of Nottingham. I was born in London to parents who are
originally from India. I hope we can have fruitful debate and come up with ingenious solutions, but
most importantly that we enjoy this experience.
We look forward to meeting you, see you at LIMUN.
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Introduction to WHO
The World Health Organisation (WHO) is the arm of public health for the United Nations. Health is
defined by the WHO as “a state of complete physical, mental and social well-‐being and not merely
the absence of disease or infirmity.”1 The WHO was established in 1948 as a specialized UN agency
to help tackle health challenges across the world.2 It is composed out of the Secretariat, an
Executive Board consisting of 34 Members and its Member States and their workforce that is
spread across regional offices and headquartered in Geneva, Switzerland.
The WHO manages global health, addressing and coordinating research, education and policy
matters of its member countries. It supports countries with evidence based policy-‐making
strategies and continuously monitors and assesses trends in health3. To better manage resources
and align itself with the needs of an increasingly complex and rapidly changing international
environment it is in ongoing reform. Part of the reform addresses the need to be flexible as well as
to set and streamline efforts towards measurable goals4. Both topics addressed for LIMUN will try
to incorporate these elements within their approach.
We are technically holding a simulation for the World Health Assembly (WHA). The WHA is
composed of all the WHO member states and is a forum to meet, discuss and come up with
resolutions to health issues. The results of such meetings involve the creation of new policies and
recommendations to Member States and other Organisations including UN bodies and
collaborative partners to help tackle global health issues. We recommend you have a look at the
Constitution of the WHO as well as at outcomes of the annual World Health Assembly found in the
bibliography of this guide. For the sake of simplicity we will only include Member States as
committee members and be calling our committee the WHO.
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Topic A: Utilizing social media and big data to improve world health Social Media Social media can be defined as “a group of Internet-‐based applications that build on the ideological
and technological foundations of Web 2.0, and that allow the creation and exchange of user-‐
generated content. “ The last decade has seen a huge growth in the different types of applications
available that connect people and allow them to share data and present it in new attractive ways.
Another trend this has coincided with is the trend towards smartphones. People enjoy sharing
information, emotions and experiences and social media and mobile technology empowers them to
do so. This considerably increases the actuality, accessibility, breadth and depth of data available
on and fed back from social groups and if consented, individuals. One mobile app can assemble as
many as 100 million users, extract relevant and useful data and deliver services to the benefit of
various stakeholders. In fact there are already dozens of services which, although they only exist
since a decade, unite more than 50 million users in one app. The diagram below shows a large
number of such applications and the functions they allow.
Diagram 1: Social Media Networks5
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The amount of time spent on these platforms has risen and over time the data we post on these
platforms has increased hugely. When we talk about data accumulating on such mediums as the
internet we are not far from delving into the topic of big data.
Big Data
Big data is the term given to the huge amounts of data collected and the process of making sense of
that to generate useful results. The difficulty with such large amounts of data is searching what you
are finding for and making use of that information. This requires complex analysis of data that
requires a huge amount of information technology infrastructure. 6 By looking for and connecting
the right data we can find links and trends that were unknown even a decade ago. This is known as
data mining. Especially businesses are using the large amounts of data available on the internet as
well as from other inputs such as sensors, devices and machines to unlock further economic value.
By finding the right algorithms and applying them correctly a lot of problems and obstacles can be
overcome.
The United Nations and Big Data
The United Nations is involved in the Global Pulse Initiative. Developed in 2009, the UN created this
working group to tackle problems such as humanitarian aid and sustainable development. It puts
forth the idea of big data being a renewable resource of this planet and the group’s vision is “a
future in which big data is harnessed safely and responsibly as a public good” 7. It is concerned with
gathering data and collaborating with businesses that collect data in public private partnerships.
Importantly it advocates anonymization of data as to protect the privacy of individuals.
Furthermore it means to improve awareness and develop analytical tools for big data that can be
harnessed across the entire United Nations ecosystem. As discussed in the committee introduction
the UN means to improve performance indicators regarding global development. By gathering and
analyzing the right data it plans to analyze human well-‐being and trends in real time in order to
better respond to emerging crises and vulnerabilities.
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UN Pulse Research
UN Pulse research is diverse and the group is involved in several projects that collaborate with a
large range of institutions including universities, startups, companies and governments. One
example is that mobile phone data from an East-‐African country was used as a poverty indicator:
the airtime credit purchases (top-‐ups) of mobile phones made were used to estimate food security.
This research was undertaken by the UN World Food Programme and Université Catholique de
Louvain as well as Real Impact Analytics. The amount of partners shows the increasing need of
people to work together in multidisciplinary groups to tackle complex problems. Looking at the
setting also helps us see why such projects are of importance: mobility, shortage of human and
financial resources and communication can all be addressed by correctly applying big data analysis.
The internet and mobile phones allow us to study a large number of people irrespective of their
geographic location. As of now, 3 Billion people use the internet8 and the large technology
companies are investing heavily to ensure that all people are connected. Even when looking at
smartphone users we already reached 1.75 Billion users, nearly 25% of the world’s population,
exactly 1 year ago9. Out of this reason social media, one of the main activities done on smartphones
is becoming increasingly attractive for the United Nations Pulse Initiative. For example, it is
currently working with the Brazilian Ministry of Health and UN AIDS to test the efficiency of remote
monitoring and detection of HIV using social media. 10
Social Media and Health
Facebook is the most prevalent social media site. This site has 800 million daily active users with
subgroups of e.g. 200,000 people liking a health relevant subject such as “hypothyroid mums”11,12.
This outlines the potential for combining mobile applications with health, a market that is predicted
to generate USD 23 Billion in revenue by 2017.13 Facebook has been used in conjunction with
health education to improve nutrition among low-‐income women14. Also Twitter has been used to
find and analyse cancer patients’ tweets with the eventual goal to provide better personalized
care15. The most shared science article this year was a study with N=689,003 users carried out on
Facebook investigating emotional contagion by altering the Facebook newsfeed. 16,17
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Finding Collaborative Partners and Financing
Access to data and analytics is one of the challenges experienced by the United Nations.18 The
main stakeholders gathering new data of interest are telecom providers, social media and
technology companies which provide e.g. the operating systems such as Android or iOS and
Windows. A major task of Global Pulse is to find contractual agreements that benefit both parties
involved. The information analysed is sensitive and could be of value to competitors. One of the
trends playing into the cards is increasing consumer awareness and a desire for data to become
transparent and open source. There is a hope that data philanthropy will become more common
but addressing this problem will still be difficult.
One of the ways around this is working together with young businesses involved with data
analytics. By involving entrepreneurs together with the United Nations there can be a win-‐win
situation created as the startup benefits from the reputation of the UN and the UN from the
expertise and access to new ideas and tools. Health is still a market with many barriers to entry for
local as well as global entrepreneurs and thus policies have to be created that help push forward
young talent to take up the risk of starting a business also for the good of the society-‐ social
entrepreneurship.
Another potential entry route to data is via the increasing corporate social responsibility programs
rolled out by companies and partnering up with influential charity Organisations. For example,
major collaborative partners of UN Pulse include Amazon and Microsoft. Another major funding
partner of worldwide health programs is the Bill and Melinda Gates Foundation. This Organisation
has invested heavily into improving healthcare having already donated 31.6 Billion USD for
charitable causes since its inception. Its mission is to “help all people live health and productive
lives”19. Gates himself is heavily involved in using social media to advertise the concept of helping
people in the developing world and promoting entrepreneurship to help solve challenges across the
globe. The foundation has focused on collaborating with a wide variety of partners and promoted
evidence-‐based policy making and thus has recurring dialogue with the World Health Organisation.
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Global Healthcare and Big Data
One of the main goals of the World Health Organisation is eliminating diseases such as HIV,
Malaria or Tubercolosis as well as handling epidemics such as Ebola. For all diseases an
important step is knowing the geographies affected by the disease. Once this is known it
becomes easier to streamline efforts of health interventions by tackling the disease from the
right angle. Another factor is knowing the human body; here genomic analysis place a large
role. Our DNA is composed out of 4 base pairs. Computer technology is composed out of 0s and
1s. Therefore analysing DNA is not too different from analysing for instance internet sites. A
combination of biotechnology and computing power has enabled us to decode the human genome.
This makes genomic data of individuals an input of interest. Through social media and mobile
applications a lot of data can be collected about human behavior. Furthermore, more and more
countries are moving towards electronic health records. All such data can be analysed by big
data analytics to gain insights on health and improve outcomes as well as save costs through
smarter decisions. This is higlighted in the diagram below. If these inputs are managed and
processed adequately great value can be created for public health and therefore the World
Health Organisation is interested in collaborating with UN Pulse and other data analytics
initiatives on such matters.
Diagram 2: Overall Goals of Big Data Analytics in Healthcare20
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Responsible Handling of Data
A key issue is involving the right stakeholders to ensure that the data collected is handled
responsibly. Health data is arguably one of the most vulnerable types of data available and so it has
to be handled with great care. Healthcare professionals such as doctors need to be involved in such
large scale operations to ensure that data is handled appropriately. Public health bodies such as
national and international organisations have to discuss issues such as regulation, safety and
ownership of data. There are multiple levels concerning this issue. First and foremost it includes
everyone’s individual rights as a human being and not being discriminated because of data
available on one’s health. The consent given from individual’s requiring healthcare data has to be
made very clear and sharing data should be regulated and handled with the utmost sensitivity. Data
security is another issue. Institutions of all kind have to ensure that their hardware and software
including encryption techniques are updated in such a way as to minimize security breaches. Data
has to be anonymized and stored in different locations to ensure that theft, whether physical or
not, is inefficient. Furthermore data should not be stored for a definite amount of time. The United
Nations has a role to play in educating its member states on these matters and ensuring that
governments are aware of their responsibilities regarding health informatics.
Piecing it all Together
The above illustrate the potentials and challenges of utilizing big data and social media to make
studies on small as well as large groups of people with an impacting and useful outcome for the
individual’s health and well-‐being. The key lies in combining these approaches to ensure progress is
made in improving public health -‐ that is to use mobile services and public-‐private partnerships to
gather, analyse and process information on crowd involvement in order to address regional,
national as well as global health challenges. So far there is no resolution on the topic that puts
together the individual pieces and collaborations outlined above. The World Health Organisation
can help improve awareness and educate people by streamlining its policies to get projects started
in individual countries. It also has a role to play as an educator to help ensure projects are
sustainable and take into account the needs of its member states and people by focusing on
regulations and minimizing fears of privacy and safety. Currently there are societal movements
towards empowering individuals as well as data transparency. If these are matched with patient
needs, new doors in public health will be opened.
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Questions to be considered: Which social media applications does your country use? Are there any barriers to using them?
What is the mobile phone penetrance, smartphone penetrance, internet user penetrance in your
country?
Which providers/companies/NGOs/governments/partnerships is your country collaborating with to
improve such penetration?
What research and which projects and companies have been working on mobile health in your
country or region?
What experiences does your country have with public-‐private partnerships to work on healthcare?
What are the data privacy rules and regulations of your country or region you are operating in,
especially with respect to healthcare? This can be seen quite easily if you look at news and
government views of your country regarding facebook/google/twitter.
What incentives are there for entrepreneurs to start a healthcare company or mobile company in
your country and what is missing or what makes the incentives good and useful for other
countries?
What applications can you think of that could use an app or data from an app to improve
healthcare? There are two options here: using data already generated by users or getting users to
generate further relevant data. Brainstorm about how one could use the data and services available
from e.g. facebook, google, amazon, linkedin, quora, twitter, snapchat, whatsapp, pinterest,
Instagram to improve healthcare.
We especially encourage you to take a look at the UN Pulse Initiative as well as the reports
prepared by the United Nations focusing on the Data Revolution to aid with your understanding of
the concepts. A sample WHO resolution on a healthcare topic – Hepatitis-‐ can also be found in the
bibliography below.
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1 (WHO 1948) 2 (WHO 2014) 3 (WHO 2015) 4 (WHO 2014) 5 (Cavazza 2013) 6(Economist 2010) 7 United Nations 2015) 8( Internetlivestats 2015) 9 (eMarketer 2014) 10 (United Nations 2015) 11 (Facebook 2014) 12 (Facebook 2015) 13 (PWC 2012) 14 (Lohse B 2013) 15 (Tsuya A, et. al. 2014) 16 (D. I. Kramera, et al 2014) 17 (Chris Parr -‐ TES Global LTD, 2014) 18 (New York Times, 2013) 19 (Gates Foundation, 2015) 20 (SIAM 2013)
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Bibliography-‐ Topic A
Adam D. I. Kramera, Jamie E. Guillory, and Jeffrey T. Hancock, (2014) Experimental evidence of massive-‐scale emotional contagion through social networks. Proceedings of the National Academy of Sciences 111 (24) 8788–8790, doi: 10.1073/pnas.1320040111
Barbara Lohse, (January–February 2013) Facebook Is an Effective Strategy to Recruit Low-‐income Women to Online Nutrition Education. Journal of Nutrition Education and Behavior, 45 (1), 69-‐76
Bill and Melinda Gates Foundation (2014), Foundation Fact Sheet, available on http://www.gatesfoundation.org/Who-‐We-‐Are/General-‐Information/Foundation-‐Factsheet accessed 9.1.2015
Cavazza Frederic (2013), Social Media Landscape, available on http://www.fredcavazza.net/2013/04/17/social-‐media-‐landscape-‐2013/ accessed on 9.1.2015
Chris Parr for Times Higher Education-‐ TES Global LTD, (2014) The 10 most popular academic papers of 2014 Available from http://www.timeshighereducation.co.uk/news/the-‐10-‐most-‐popular-‐academic-‐papers-‐of-‐2014/2017470.article accessed on 05.01.2014
eMarketer (2014), Smartphone Users Worldwide Will Total 1.75 Billion in 2014, available from http://www.emarketer.com/Article/Smartphone-‐Users-‐Worldwide-‐Will-‐Total-‐175-‐Billion-‐2014/1010536 accessed on 9.1.2015
Facebook, (2014) Quarterly Earnings Slides Q3 2014, Available from http://files.shareholder.com/downloads/AMDA-‐NJ5DZ/3793703010x0x789303/06DECC7B-‐0588-‐4A52-‐A8DD-‐3A591AB02395/FBQ314EarningsSlides20141027.pdf, accessed on 06.01.2015
Facebook, (2015) Page-‐ Hypothyroid Mom, Available from https://www.facebook.com/HypothyroidMom?fref=ts, accessed on 06.01.2015
Global Pulse (2014), Using mobile phone data and airtime credit purchases to estimate food security, available from http://www.unglobalpulse.org/mobile-‐CDRs-‐food-‐security accessed 9.1.2015
Global Pulse (2014), Social Media for Remote Monitoring and Detection of HIV in Brazil, available from http://www.unglobalpulse.org/social-‐media-‐HIV accessed on 9.1.2015
Independent Expert Advisory Group on a Data Revolution for Sustainable Development (2014), A World that Counts-‐ mobilising the data revolution for sustainable development, Available from http://www.undatarevolution.org/wp-‐content/uploads/2014/12/A-‐World-‐That-‐Counts2.pdf accessed on 9.1.2015 Internet Live Stats (2015), Internet Users, available from http://www.internetlivestats.com/internet-‐
users/ accessed on 9.1.2015
Kaplan Andreas M., Haenlein Michael (2010). Users of the world, unite! The challenges and opportunities of social media. Business Horizons 53 (1). p. 61. doi:10.1016/j.bushor.2009.09.003.
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World Health Organisation (1946), Preamble to the Constitution of the World Health Organisation as adopted by the International Health Conference, New York, 19-‐22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organisation, no. 2, p. 100) and entered into force on 7 April 1948.
PricewaterhouseCoopers Private Limited, (2012) Touching lives through mobile health-‐ Assessment of the global market opportunity, Available from http://www.pwc.in/assets/pdfs/telecom/gsma-‐pwc_mhealth_report.pdf, accessed on 04.01.2014
Society for Industrial and Applied Mathematics (2013), Big Data Analytics for Healthcare available from http://www.siam.org/meetings/sdm13/sun.pdf accessed 9.1.2015
The New York Times (2013), Searching Big Data for ‘Digital Smoke Signals’ available on http://www.nytimes.com/2013/08/08/technology/development-‐groups-‐tap-‐big-‐data-‐to-‐direct-‐humanitarian-‐aid.html?pagewanted=2&_r=1 accessed 9.1.2015
Tsuya A, Sugawara Y, Tanaka A, et al. (2014) Do cancer patients tweet? Examining the twitter use of cancer patients in Japan, J Med Internet Res. 16(5):e137. 10.2196/jmir.3298
United Nations (2013), UN Pulse Annual Report, available from http://www.unglobalpulse.org/2013-‐Annual-‐Report accessed 9.1.2015
United Nations (2014), About the Independent Expert Advisory Group, available from Grouphttp://www.undatarevolution.org/about-‐ieag/, accessed 9.1.2015
United Nations Global Pulse, About, available from http://www.unglobalpulse.org/about-‐new accessed 9.1.2015
World Health Assembly Resolution 67.6 (24 May 2014) Hepatitis, available from http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R6-‐en.pdf
World Health Organisation (2014), Change@WHO. Available on http://www.who.int/about/who_reform/change_at_who/issue5/Change_at_WHO_Newsletter_May_2014_en.pdf?ua=1 accessed on 9.1.2015
World Health Organisation (2015), About WHO. Available on: http://www.who.int/about/en/ Accessed on 8.1.2015
World Health Organisation, (2005) Constitution of the World Health Organisation, available on http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-‐en.pdf?ua=1&ua=1 accessed on 8.1.2015
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Topic B: Reducing impact of diabetes on world health by 2030
Glucose is a key molecule to life. It provides vast amounts of energy our bodies need to
survive and perform everyday actions. We get glucose by breaking down the food we eat, and
sometimes when we eat a bit more food than we need, our bodies face an excess of energy.
Usually glucose would be used as a short term source of energy, however as our bodies won’t
always use all the energy it decides to store the glucose in the form of tissue fats, this form of
energy can allow glucose to be stored in the body for long periods of time. High glucose levels in
blood is toxic to the body and glucose needs to be kept at a constant level, if its lower than this
level, the body uses the stored energy to increase glucose levels back to the norm (Table 1 shows
the criteria normal and elevated levels of glucose). Insulin is key as it tells the body to store the
excess glucose as fats. Insulin fails at its job when it cannot maintain blood glucose levels, glucose
levels will increase, eventually resulting in diabetes. Figure 1 shows how insulin works.
Figure 1: Mechanism of action for insulin. Insulin will bind to the insulin receptor which opens the glucose channel allowing glucose to enter the cell
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“Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or
when the body cannot effectively use the insulin it produces. This leads to an increased
concentration of glucose in the blood (hyperglycaemia).” – WHO definition of diabetes21
From 1500 BCE, people have been suffering
from a disease which has been described as ‘too
great emptying of the urine’. It was until 2000
years later that Indian physicians were able to
distinguish between the two types of diabetes,
type 1 was associated with the youth while the
latter was associated with obesity, type 2 diabetes
has the greatest impact on the world. Close to 350
million23 people worldwide are thought to have
diabetes and this number is only going to increase,
with the WHO estimating diabetes to be 7th leading
cause of death by 2030, 3.8 million people die from
diabetes every year, this is comparable to HIV/AIDS
in its reach. For some populations there is a
genetic factor that influences susceptibility of
diabetes, these factors are difficult to avoid.
Type 1 diabetes is a form of diabetes where the immune system destroys the beta cells in
the pancreas which produce the insulin necessary for the breakdown of glucose, basically the body
cannot produce enough insulin. Blood and urine glucose levels increase as a result. Symptoms
include more frequent urination, increased thirst, increased hunger and weight loss. This type of
diabetes accounts for 5%24 of all the cases of diabetes and is most commonly diagnosed amongst
the youth population, the highest rates for type 1 diabetes is found in the United States and
Northern Europe. The usually diagnosis is when patients have diabetic ketoacidosis (dry skin, rapid
deep breathing, drowsiness, abdominal pain, vomiting and other symptoms).
Type 2 diabetes is a form of diabetes whereby cells develop a resistance to insulin.
Symptoms include increased thirst, frequent urination, and constant hunger amongst others. 90%
Condition 2 hour glucose Fasting
glucose
Unit mmol/l(mg/dl) mmol/l(mg/dl)
Normal <7.8 (<140) <6.1 (<110)
Impaired
fasting
glycaemia
<7.8 (<140) ≥ 6.1(≥110) &
<7.0(<126)
Impaired
glucose
tolerance
≥7.8 (≥140) <7.0 (<126)
Diabetes
mellitus ≥11.1 (≥200) ≥7.0 (≥126)
Table 1: The various levels of blood glucose. 2 hour glucose is
usually measured after eating a meal22
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of all cases of diabetes involve this type, a lack of insulin production is common as the disease
progresses. Lifestyle factors greatly influence those who are affected, with the primary cause being
obesity. Key WHO recommendations include; having a healthy diet, regular exercise, maintaining
normal body weight and avoiding tobacco which are factors that can prevent or delay the onset of
type 2 diabetes. Although a manageable disease with plenty of treatments available, 80% of deaths
come from low and middle income countries which show a key component to its control is from
access to healthcare.
Gestational diabetes is a temporary form of diabetes which affect pregnant women as they
develop high blood sugar levels. Various pregnancy-‐related factors cause a failure in the ability of
insulin receptors to act. This affects up to 10% of pregnancies, and is an easily manageable disease
with a controlled diet being one of the first steps to tackle this. Diagnosis comes from primarily
from pre-‐natal screening and countries with good health infrastructure can detect this disease
before it is able to properly harm expectant mothers. Babies who were born to mothers with
gestational diabetes have a higher lifetime risk of developing obesity and type 2 diabetes.
Impaired Glucose tolerance is a precursor to type 2 diabetes. This is a condition whereby
blood glucose levels are higher than the norm but below the level required for diagnosis of
diabetes, a conservative estimate is that 50 million people have this condition as many cases are
not diagnosed. These people are targets to prevent the onset of diabetes, and recommendations to
this group include healthier eating and greater exercise, such is the effect of the recommendation
that type 2 diabetes in many cases have been prevented.
Economic costs of Diabetes
Diabetes in the modern world is a manageable disease, and for many countries, people with
diabetes remain part of the workforce until retirement. Thus this disease does not fully withdraw a
person’s economic activity, however there are costs to the economy. A systematic review carried
out suggests that two thirds of the overall costs of diabetes were a direct result of treatment, whilst
one third was indirect costs which among other factors include losses in productivity for those who
work despite having diabetes25. Between 2005 and 2014, WHO estimates suggest that more than
$1trillion was lost in national income as a result of diabetes’ treatments and economic losses, as
the problems surrounding diabetes worsen that figure is expected to triple by 2030, and these are
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highly conservative estimates26. Healthcare providers will have to face the increased costs of
treating more diabetic patients and treatment of their complications. It is the developing countries
that will have to face the biggest share of the costs due to the increasing diabetic populations, this
coupled with the fact that spending on diabetes treatment and preventative measures in
developing countries is low means that there will be significant costs which may spiral out of
control.
For all employers an increasingly diabetic work force is a worry due to the productivity
losses, patients may need more temporary leave of the workplace to manage the disease, thus
employers need to play a part in improving the conditions of the workplace. Some companies
participate in workplace wellness programmes27, where the aim is to get employees more active
and aware of their health. Some initiatives include clinical screening (blood pressure, cholesterol)
and access to corporate membership rates at fitness centres. Having access to these programmes
allow for employees to lead healthier lifestyles and this can have a further impact on society as
families feel of the employees follow the lead in being healthier. Although these employer-‐led
initiatives are costly in the short term, it is generally seen to save money and potentially increase
profits in the long term
Complications that arise from Diabetes
Further complications
can arise later on in life as a
result of diabetes. Diabetics
need to get examinations on
their eyes once a year as they
are at high risk of getting
diabetic retinopathy. Figure 228
shows that when there is an
increase in glucose levels, the
percent of people with retinopathy increases.
Typically those that are in the 8th decile and above would be diabetic. Having poor eyesight has
more knock-‐on consequences as it can impair driving ability which makes that person less mobile
Figure 2: Prevalence of retinopathy by Decile of fasting glucose
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and have a negative impact on the persons’ wellbeing. The graph is a significant for a greater truth,
whilst spending on research of non-‐communicable diseases such as diabetes is really low, there are
greater costs than previously thought, spending also needs to be directed towards complications
that can arise from diabetes.
Other such complications that need to addressed include kidney disease of which diabetics
have an increased risk29. Diabetes is a leading cause of chronic kidney disease, and damage to
kidneys can develop which lead to their efficiency reducing or complete failure. This increases the
strain on kidney transplant waiting lists, there is already a shortage of organ donors and the further
projected increase in diabetes is likely to lead to a greater strain on kidney transplant waiting lists.
As with retinopathy, these complications can be managed, a combination of regular checkups
coupled with maintaining normal blood glucose and pressure can reduce the risk of these
complications arising.
Further costs of diabetes complications come from cardiovascular disease30. This is the most
common cause of death and disability amongst people who have diabetes. Cardiovascular disease
is one of the leading causes of death worldwide, and diabetics can suffer from heart attacks to
strokes. When these complications arise it further puts a strain on public resources as well as the
individual, the individual would be away from work for long periods of time and it would take
months before they are economically active again, for employers this means having to find a
temporary replacement which can be difficult if a particular job has a specified set of skills, finally
for health services it means having to care and rehabilitate a patient for a long period of time, the
opportunity cost lies in the fact that other patients can be treated, and strokes in particular occupy
a lot of resources.
Blood pressure control can be particularly useful as a prevention method for all vascular
diseases, ACE inhibitors and diuretics come in the form of generic drugs and can be very cheap for
developing countries where blood pressure control is sub standard, improving access to these
drugs can bring the greatest savings to developing nations.
Similar problems arise in particular with nerve damage where the extremeties are at risk, if
these problems escalate it can potentially lead to foot amputations. Risk of amputation amongst
diabetics is 25 times31 greater than those without diabetes, large amounts of care is needed if
amputations take place, regular foot care can mean a reduced risk of amputation.
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Health expenditure on Diabetes
In countries with a lower income, national health infrastructure is usually not as advanced,
and unlike the developed world where most governments have some form of provision of national
healthcare, it is up to the individual to bear a vast amount of costs to deal with diabetes. Total
expenditure of diabetes amongst the developing world is 20%; these are the countries that have
the most cases of diabetes and are not spending enough to treat it. For individuals in countries like
India they need to spend on average 25% of their income on private care for diabetes, this figure
increases for central and southern America where an average of 50% of income is spent on
diabetes care32. Despite individuals spending a high proportion of their income on diabetes care,
health outcomes are significantly lacking when compared to the developed world where out of
pocket expenses are minimal. Families will face increased economic stress as they cannot afford to
purchase other goods, such is the situation that many families have to forgo education for their
children due to high out of pocket expenses. For the many in the developed world, the relative cost
of care would seem a lot less, people in the developing world cannot afford the cheap and generic
drugs that are readily available, these drugs can prevent renal failure, heart attacks, strokes and
Figure 3: Mean diabetes-‐related health expenditure per person with diabetes (20-‐79 years of age), data from 2013
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amputations, yet the individual does not have the small amount of money required to purchase
these drugs.
Spending in USD is highlighted in figure 333, a huge disparity in spending between developed
and developing countries is seen. In India, less than $100 is spent per person, and this figure
reaches $400 per person in China, regardless of rapid economic growth in these countries,
resources for diabetics is vastly lacking. The disparity is further highlighted when in Burundi only $6
is spent per person nationally compared to USA where this figure exceeds $10,000 per person. In
lower income countries, children with diabetes may have to sacrifice their education to get funds
for their or a relatives’ treatment. This has an adverse effect on the child’s future outcomes, they
won’t be able to earn a higher income
later on in life due to a lack of
education, which means they stay in
the poverty trap. As their offspring are
more susceptible to diabetes then the
process continues, it becomes difficult
to break this cycle.
By 2025, 80% of all cases will
come low/middle income countries
which shows that this is not a disease for the rich. Diabetes does not discriminate on gender and
affects men and women equally. The older a person gets, the greater the expenditure on diabetes
later on in life will be. As highlighted in figure 434, spending is highest in the age range of 60-‐69.
Many developing countries have large youth populations, and as economies grow, the demand and
availability for fast food will increase, this will increase obesity rates, and as the youth population
get older, more spending will be needed as their dependencies on healthcare increase.
Problems with diagnosis
IDF estimates suggest that half of all people with diabetes are undiagnosed, they are totally
unaware they have a disease. There are great disparities between each region, but no country has
perfected the diagnosis of diabetes, amongst developed countries up to 30% are undiagnosed, this
number increases vastly when taking into account developing countries. Undiagnosed diabetes
Figure 4: Health expenditure due to diabetes by age in $
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does not discriminate on income, many people with higher incomes are still undiagnosed, and a
fact still true considering the greater amount of money spent on diabetes by high income countries,
a truly global solution needs to be reached to tackle this problem. The IDF has created an
informative poster which can be accessed at this link: http://www.idf.org/sites/default/files/Atlas-‐
poster-‐2014_EN.pdf. The poster breaks down by region the total cases of diabetes and the amount
which are undiagnosed, the western pacific region, Asian and African regions have rates of 50%
undiagnosed. The up to date poster provides a country breakdown of diabetes related statistics on
the second page. People can go several years without knowing they have diabetes, the symptoms
may not show up but glucose levels will silently increase, and sometimes when diagnosis is too late
some complications such as heart disease may arise, this is problematic as the people who gain
these complications could have otherwise prevented them. People can very easily be diagnosed
with diabetes, simple ‘tick tests’ which list risk factors are readily available, this can be a cost-‐
effective option for diagnosis, but is not definitive as it will only identify risks.
Depression
People with diabetes have an increased susceptibility to depression35, although there is not
much evidence to support the direct link between glycaemic control and depression, many studies
have outlined the increased risks of depression with those who have diabetes. Type 1 and type 2
diabetes have rates of depression two and three times higher respectively when compared to those
without diabetes, whilst women in general are more likely to experience depression with and
without diabetes. The diabetic youth population is also more susceptible to developing depression.
A number of social factors come into play, such as the constant reminders for taking medication,
having to monitor more aspects of their life, having to restrain from certain social activities due to
the detrimental effect on their health. A greater argument about the provision of mental health
services arises when dealing with issues such as depression, these services are heavily underfunded
and understaffed. Solutions need to involve greater doctor patient contact and better pastoral care
among other things. The fact that diabetes is increasing amongst children is worrying. In Japan,
prevalence of diabetes among high school children has doubled, promoting healthier lifestyle
earlier such as better diets and more exercise can help prevention.
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Obesity
Another important link with diabetes is the increasing rates of obesity worldwide, a side
effect due in part to countries developing which result in incomes rising, improving access to fast
and unhealthy food, and a combination of time constraints preventing people from cooking
healthily and poor education surrounding healthy eating all contribute to the obesity rise. Obesity is
an increasingly global problem, as the youth populations become more inactive and eat more
unhealthy foods every country will have to face this issue. In England, 90% of adults (16-‐54 years)
with type 2 diabetes are classed as overweight or obese, and those who are obese have a
prevalence rate of diabetes which is five times greater than those with a healthy weight36. A report
by public health England made reference to an increased risk of type 2 diabetes for those with
higher obese BMI, when compared to those in the lower obese BMI bands, as there is an increasing
trend of severe obesity, the strain on public services will increase as a result and more people will
develop type 2 diabetes.
A controversial treatment that could be used to buck this trend is gastric band surgery37. In
the early stages of development in terms of its effect on diabetes, it has proven to be a very
effective weight loss method, this highly interventionist approach has in the past only been used on
patients as a last resort, however a consultation by NICE suggests that opening this form of surgery
to newly diagnosed diabetics with a BMI of 30 could save billions in the long term. Considering 10%
of the NHS budget is spent on dealing with diabetes, the savings implications could be huge. If
further trials prove this method of intervention is viable, hundreds of thousands of people in the UK
could be eligible. From a different perspective, some people would rather avoid spending
thousands of pounds, and rather the individual put up most of the costs, this ideological debate
about how national health organisations should allocate funds needs to be had. Costly procedures
like these can only be done on large scale in countries of high income, they are very limited for low
income countries.
Access and administration of Insulin
First being developed and used in 1922, insulin in many ways has been a success story,
where in so many diseases (Ebola) there is little to no treatment, insulin has had the ability to be
mass produced. Many types of insulin are available on the market and due to the huge demand
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there is opportunity for profit, due to this factor there is continued research and development into
insulin, and prices are being pushed downwards, compared to other treatments insulin is
reasonably price. Having cost effective treatments has the ability to save money in the long run, the
impact of these savings can be best felt in lower income countries.
Many countries have strong protectionist policies and thus tax imports, amongst the
imports being taxed include insulin, which drive up the prices in the countries and make them
unaffordable for individuals. Zambia has a programme for insulin management, diabetics in Zambia
who receive insulin can live an average of 11 years longer, and this is compared to Mali and
Mozambique where a person can die within a year. These countries have broadly similar economic
and social outlooks, but the insulin programme offers vastly differing health outcomes.
Improving access to insulin is important, but problems lie in the administration, diabetics
need to monitor their blood glucose levels, these pieces of equipment have been lowering in prices
in recent years but are out of the access of many patients. Monitoring glucose levels is key to
insulin self-‐administration, the individual needs to make sure the correct amount of insulin is
inserted into the body otherwise further complications (hypoglycaemia or hyperglycaemia) can
arise. Insulin is administered on a sliding scale depending on blood glucose levels and the timings
need to be monitored as well for effective treatment. Other methods of insulin administration such
as nasal inhalation are being developed but it seems for the next few years progress on
administration will remain stagnant.
Negotiating lower drug prices
Higher income countries have the means to sustain drug payments, however lower income
countries do not have as greater access to these drugs. Many European countries such as Spain and
the UK employ powerful negotiating tactics which reduce the price of drugs, if these collective
bargaining tactics can be used with lower-‐income countries it could potentially lead to drug prices
which are lower than market rate. Many of these countries have poor health infrastructure and do
not have the means to negotiate on a national level for these essential drugs, and such negotiations
could only be possible if lower income countries could afford the payments and could establish a
base to negotiate.
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Cost-‐effectiveness study
The cost-‐effectiveness of preventative treatments was assessed in the Indian Diabetes
Prevention Programme. The subjects are those who have impaired glucose tolerance, and the
effectiveness of lifestyle modification and metformin supplements were tested. It was concluded
that these treatments were cost-‐effective. The cost of administering lifestyle modifications and
metformin was $270 over a three year period, the cost effectiveness from the prevention of a case
of diabetes was $1,35938. As the period was three years, this study was short term and more
studies would be need to assess the long-‐term cost-‐effectiveness.
Changes to lifestyle
Lifestyle modification include maintaining good nutrition which includes having a diet
tailored towards diabetics, generally recommendations suggest that the diet should be high in
soluble dietary fibre, low in saturated fats and low in sugar. Each institution has differing
recommendations, and there is no universal set of recommendations which can provide the ideal
example of the ‘perfect’ diabetic diet, harmonising these guidelines can help individuals with their
dietary choices. It’s clear that a good diet is necessary, but there is no clear definition of what is a
good diet, each country has its own cuisine so diets vary. A debate needs to be had on what the
guidelines should be, whether they should include what a diabetic diet consists of, or more
specifically amounts of carbohydrates, fats and sugars a diabetic should consume. Sometimes
diabetics over correct and get cases of hypoglycaemia (low blood sugar), if this happens quick
treatment needs to be administered and the treatment is simple as consuming a sugary drink.
Diabetes UK has said that some people would stand to gain by moving towards a vegan diet as this
would eliminate many saturated fats, and contain high amounts of fibre, as with diets it does not
have much evidence to support such as big lifestyle change, measured need to address the deficit
in evidence surround a healthy diabetic diet.
Other lifestyle modifications which can be included could be taking stairs instead of
escalators, walking or cycling for short distances, these are very manageable changes and cost next
to nothing to implement. The UK’s NHS recommends two and a half hours of moderate exercise
every week39, this becomes an easier goal to achieve when people realise that mundane activities
such as mowing the lawn count as exercise, however the other goal which includes doing vigorous
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exercise such as playing sports two more times a week is a lot more difficult to pursue due to time
constraints. This information can be conveyed via educational programmes, but it is more
harrowing to know that 80% of all type 2 diabetes is preventable and changes to lifestyle can
contribute to this prevention.
Underfunding of research towards cures
Although a lot of money is spent on treatments, a greater focus is needed on cures, diabetes
is a disease which can be eliminated but for the most part of its history focus has been on
management. A problem comes from a lack of funding, overall of all official overseas development
aid only a meagre $2.9 million went to fund all non-‐communicable diseases (the source of this
money is from the 0.7% GDP commitments to developmental aid from many developed nations),
and on average only 2.5% of loans made for health purposes from the world bank went towards
chronic diseases, these figures appeal to a greater truth on the huge underfunding of diabetes, the
world bank recognises the costly problems from diabetes but the hypocrisy lies in the amount of
loans made to treat all chronic diseases. Less than 20% of the global spend on diabetes is spent in
low income countries where 80% of diabetics live, with all things considered a small amount of
money will go a long way for these countries. Potential avenues for cure include regenerating
pancreatic tissue to produce insulin, this is controversial for many people because it includes the
use of embryonic stem cells, stem cell laws around the world are restrictive, and the efficacy of
these laws need to be justified if they are preventing future cures.
Health expenditure
The culmination of all the costs, and consequences of diabetes leads to the greater
argument over the provision of health services worldwide. Most OECD countries have some form of
provision of universal healthcare, where by services are easily accessible and to a high standard.
Figure 540 shows the expenditure of healthcare for each country as a percent of GDP, the trend
seems to be that developing countries have slightly higher expenditure, thus an obvious
recommendation would be for lower income countries to commit to a higher GDP spend on
healthcare. The greater truth for many low income countries is the health infrastructure is not
developed to the extent needed to cope with the basic needs of the population, and they have a
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huge reliance on charities. Many of these countries need to develop a national strategy to tackle
various diseases and using their limited funds to follow this strategy. If maternal care poor, it
becomes difficult to manage gestational diabetes, and mothers will experience more complications
as a result. In countries like the UK a general practitioner system is used, most countries do not
have the means to do this due to a shortage of doctors, short term solutions already implemented
include allowing doctors to offer care via telephone, this allows doctors to contact areas which are
rural and hard to reach, it’s a more cost effective option than the GP system. However it does not
address the long term shortage of medical staff and specialist in areas such as diabetes, greater
training and education programmes are needed to expand the pool of doctors and nurses
worldwide. Only with national health infrastructure can diseases like diabetes effectively be
managed and its impact be reduced.
Figure 5: Map of each countries health expenditure as a % of GDP
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As the millennium development goals expire this year, a lot has been done to try and
achieve those goals, it may be wise to create post-‐2015 commitments to reduce the impact of
diabetes. Many predictions have diabetes and its consequences worsening by 2030, much needs to
be done to negate the impact. Figure 641 shows a list of targets related to diabetes agreed upon by
the NCD Alliance, these are some of the targets the WHO needs to consider.
WHO and the International Diabetes Federation
The WHO has an active working relationship with the International Diabetes Federation (IDF); they
exchange ideas and author joint publications. The IDF specialises in the treatment, prevention,
cure, and raising awareness of diabetes, whilst the WHO’s main objective is to advise on all health
related matters. WHO cannot dictate what the IDF does as it is separate organisation and resolution
writing must reflect this, it can advise and suggest roles for the IDF.
Figure 6: Set of targets developed by NCD Alliance
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The IDF is a global alliance of national diabetes associations from 170 countries and
territories. They participate in multiple campaigns to ‘promote diabetes care, prevention and a cure
worldwide’42. The IDF and WHO have an official relationship whereby they can exchange advice,
and dual author publications. As the IDF is a specialised body in diabetes, it is better able to provide
health care advice and evidence to the WHO, they can use this advice and liaise with health
ministers on creating effective health care policies.
Their main UN-‐related achievement to date is the establishment of ‘World Diabetes Day’
which is their primary awareness campaign. More direct examples of their work include the ‘Life for
a child programme’ which helps 12,000 children in developing countries access diabetes care.
The WHO deals with diabetes under the broader umbrella of the ‘Chronic diseases and health
promotion’ department. The department has objectives which advocate for health promotion,
chronic disease prevention, and promoting healthcare amongst the poor and disadvantaged
population. Although their advocacy for chronic diseases is strong, they provide practical
information about the risk factors which is available for all. This is done by the WHO Global
InfoBase. The WHO Diabetes Programme seeks to prevent diabetes where possible, a key core
function is to develop standards and norms for the diagnosis and treatment of diabetes for the
international community. The WHO carries out population-‐based studies which provide countries
with key statistics to help develop their health policies.
UN resolutions
In May of 1989, the Forty-‐second World Health Assembly recognised diabetes as a ‘chronic,
debilitating and costly disease’ which presented a significant burden on public health services, and
recognised how the problem was growing amongst developing countries 43 . The main aim
surrounding this resolution was to detail the problems of diabetes by gathering statistics, and to
invite countries to share information on dealing with diabetes. Clause 2.2 of this resolution seemed
to have the most impact by fostering ‘relations with the International Diabetes Federation and
other similar bodies’ as the WHO and IDF have collaborated extensively over multiple reports and
campaigns on diabetes. Further examples of this collaboration come from the resolution passed by
the general assembly on December 2006 which established ‘World Diabetes Day’ as a United
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Nations Day observed on the 14th November44. A joint campaign by the WHO and IDF which lead to
this day giving diabetes a greater awareness, and this being the first resolution by the general
assembly to recognise the issue of diabetes and the need to tackle it.
These resolutions have achieved the goal of getting diabetes recognised on the world stage,
however they are far beyond what is needed to truly tackle this disease. More specific solutions are
needed to address the ever growing problems resulting from diabetes, and stronger national
commitments are required, by 2030, these problems will have ballooned, and a post MDG
commitment to reduce diabetes needs to be considered to reduce the impact of diabetes on world
health.
Country questions to be considered
We ask you to come prepared regarding healthcare and the diabetes situation of your country in
comparison to other countries. This would encompass finding out about e.g.:
• Healthcare expenditure + Diabetes statistics
• Healthcare system and diabetes management; is the system Public/private; how is it
funded? How and why is diabetes care underfunded and what is being done against that?
Are there any policy papers of my country or regional organisation (EU, ECOWAS, etc.?)
• Which international partners are we collaborating with? E.g. World Bank, IDF, other
countries, development organisations, pharmaceutical companies?
• Are there any national organisations aiming to improve diabetes care? How can their
knowledge be used to help other countries? What scientific know-‐how do we have or need
from others?
• Accessibility-‐ physical as well as financial-‐ of diabetes treatments? What is the
socioeconomic situation of my country?
• Is mobile health being used in conjunction with diabetes care? Are there incentives for
startups in healthcare in your country? (mobile healthcare in conjunction with diabetes is
becoming an important topic as smartphone penetration is high across the entire world)
• What stakeholders exist in my country? What is my country’s relationship to other
countries, towards the pharmaceutical industry, patents or development aid programmes?
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Is my country a net giver or net receiver? Are there any resolution outcomes which would
especially benefit or harm us?
• How are trade tariffs and trade affecting my country and prices of diabetes treatment? E.g.
are pharmaceuticals mainly exported or imported into my country? Effect of World Trade
Organisation and patenting.
• With which countries does my situation compare/differ and how will that affect my
country’s position in debate?
• How do we make a resolution that leads to SMART goals being developed to help tackle
diabetes by 2030 i.e. goals that are specific, measurable, accepted, realistic and timely?
We encourage you to research in the resources detailed in the bibliography as well as for instance
the WHO, the OECD, the World Bank, the Gates Foundation, the pubmed library, your country’s
ministry of health site or ask on quora.com etc.
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21 (World health organisation n.d.) 22 (World health organisation 2006) 23 (Danaei G 2011) 24 (American Diabetes Association n.d.) 25 (Charmaine S. Ng 2014) 26 (International Diabetes Federation n.d.) 27 (Marquez 2013) 28 (World health organisation 2006) 29 (Nam Han Cho 2013) 30 (Nam Han Cho 2013) 31 (International Working Group on the Diabetic Foot 1999) 32 (International Diabetes Federation n.d.) 33 (Nam Han Cho 2013) 34 (Nam Han Cho 2013) 35 (Tapash Roy 2012) 36 (Public Health England 2014) 37 (Boseley 2014) 38 (Ramachandran 2007) 39 (National health service 2013) 40 (World development indicators n.d.) 41 (Nam Han Cho 2013) 42 (International Diabetes Federation n.d.) 43 (World Health Assembly 1989) 44 (General Assembly 2006) Bibliography-‐ Topic B
American Diabetes Association. n.d. Type 1 Diabetes. Accessed January 1, 2015. http://www.diabetes.org/diabetes-‐basics/type-‐1/.
Boseley, Sarah. 2014. NHS anti-‐obesity plans could lead to sharp rise in gastric band surgery. http://www.theguardian.com/society/2014/jul/11/nhs-‐anti-‐obesity-‐gastric-‐bands-‐diabetes.
Charmaine S. Ng, Joyce Y.C. Lee, Matthias PHS Toh, Yu Ko. 2014. “Cost-‐of-‐illness studies of diabetes mellitus: A systematic review.” Diabetes Research and Clinical Practice 105 (2): 151-‐163.
Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ et al. 2011. “National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-‐years and 2.7 million participants.” Lancet 378 (9785): 31-‐40. http://www.thelancet.com/journals/lancet/article/PIIS0140-‐6736(11)60679-‐X/fulltext.
General Assembly. 2006. “61/225. World Diabetes Day.” http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/61/225&Lang=E.
International Diabetes Federation. n.d. International Diabetes Federation. http://www.idf.org/who-‐we-‐are.
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International Diabetes Federation. n.d. “United Nations Resolution 61/225: World Diabetes Day.”
http://www.idf.org/sites/default/files/UN%20Resolution%20on%20World%20Diabetes%20Day%20of%20Dec%202006.pdf.
International Working Group on the Diabetic Foot. 1999. “International consensus and practical guidelines on the management and the prevention of the diabetic foot.” International Working Group on the Diabetic Foot. http://onlinelibrary.wiley.com/doi/10.1002/1520-‐7560(200009/10)16:1%2B%3C::AID-‐DMRR113%3E3.0.CO;2-‐S/full.
Marquez, Patricio V. 2013. Healthier Workplaces = Healthy Profits. 22 January. http://blogs.worldbank.org/health/healthier-‐workplaces-‐healthy-‐profits.
Nam Han Cho, David Whiting et al. 2013. IDF Diabetes Atlas, Sixth edition. International Diabetes Federation. http://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf.
National Health Service. 2013. Physical activity guidelines for adults. http://www.nhs.uk/Livewell/fitness/Pages/physical-‐activity-‐guidelines-‐for-‐adults.aspx.
Public Health England. 2014. “Adult obesity and type 2 diabetes.” https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_obesity_and_type_2_diabetes_.pdf.
Ramachandran, Ambady et al. 2007. “Cost-‐Effectiveness of the interventions in the primary prevention of diabetes among Asian Indians.” Diabetes Care 30: 2548-‐2552.
Tapash Roy, Cathy E. Lloyd. 2012. “Epidemiology of depression and diabetes: A systematic review.” Journal of Affective Disorders 142: S8-‐S21. http://www.jad-‐journal.com/article/S0165-‐0327(12)70004-‐6/abstract.
World development indicators. n.d. “Health expenditure, total (% of GDP).” World bank web site. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries/1W?order=wbapi_data_value_2012%20wbapi_data_value%20wbapi_data_value-‐last&sort=desc&display=map.
World Health Assembly. 1989. “WHA42.36 Prevention and control of diabetes mellitus.” Geneva. http://www.who.int/diabetes/publications/en/wha_resol42.36.pdf.
World Health Organisation. 2006. Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation. Geneva: World Health organisation. http://whqlibdoc.who.int/publications/2006/9241594934_eng.pdf?ua=1.
—. n.d. World Health Organisation. Accessed 1 1, 2015. http://www.who.int/mediacentre/factsheets/fs312/en/.