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Ivica Smokovski

Managing Diabetes in Low Income

Countries
Providing Sustainable Diabetes Care with Limited
Resources
1st ed. 2021
Ivica Smokovski
Faculty of Medical Sciences, University Goce Delcev, Shtip, North
Macedonia
University Clinic of Endocrinology, Diabetes and Metabolic Disorders,
Skopje, North Macedonia

ISBN 978-3-030-51468-6 e-ISBN 978-3-030-51469-3

https://doi.org/10.1007/978-3-030-51469-3

© Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are reserved by the

Publisher, whether the whole or part of the material is concerned,
specifically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microfilms or in any other
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electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.

The use of general descriptive names, registered names, trademarks,

service marks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general
use.

The publisher, the authors and the editors are safe to assume that the
advice and information in this book are believed to be true and accurate
at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the
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This Springer imprint is published by the registered company Springer
Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham,
Switzerland
Preface
We are already feeling the first impact of diabetes tsunami, and it is
quite obvious that the coming waves are only going to get bigger. It is
felt in the most developed countries and healthcare systems, and even
they have a challenge managing the burden of diabetes, its
complications, and the pressure on resources. But the impact is felt
much stronger in the developing countries that already have difficulties
in coping with the current healthcare issues and are definitely not
prepared for the huge diabetes shock waves that are coming. And it is in
developing countries where almost 80% of the people with diabetes are
living, which only makes the problem even more complex.
The title of the book is Managing Diabetes in Low-Income Countries
—Providing Sustainable Diabetes Care with Limited Resources. However,
the term low-income countries, as used in the title and throughout the
book, goes beyond the standard World Bank criteria of categorizing the
countries. Please note while reading this book that low-income
countries refer to the lower resource, developing countries, including
both middle-income and low-income countries as defined by various
authorities.
The book consists of nine chapters including the burden of diabetes
prevalence, diabetes drivers, diabetes complications, available
treatments, monitoring of metabolic control, diabetes education, e-
Health solutions, nutrition, and diabetes prevention. The nine chapters
illustrate the situation in developing compared to developed countries
and propose initiatives for managing various diabetes challenges in a
setting with limited resources.
Since this book is written in the middle of one of the greatest
infectious pandemics humanity has ever faced, it is quite impressive to
witness the immediate response to contain, diagnose, and treat COVID-
19. It is spreading enormously fast, claiming lots of lives. It seems that
humanity is at its best when dealing with imminent, global, fast-
spreading danger. People have no problems changing their lifestyle they
have had for years, in order to protect themselves, their family, beloved
ones, and the whole humanity.
However, when we have to deal with another pandemic developing
more insidiously over years, such as diabetes, we are reluctant to do
even the slightest modification of our lifestyle. This results in a sad
situation where diabetes is taking its massive toll.
There are countries in Europe, considered one of the most
developed regions in the world, which are low-resource, developing,
and with a very high diabetes prevalence. Those countries are
struggling to balance between providing optimal diabetes care and not
driving their healthcare systems into bankruptcy.
An example of a developing European country with limited
resources is the Republic of North Macedonia, my home country that is
mentioned on several occasions throughout the book. I have been
honored to serve as a Medical Advisor for Diabetes Care to the Minister
of Health in the period 2012–2016, and member of the National
Diabetes Committee 2015–2017, so the examples presented in this
book are my personal experiences and involvements.
Many aspects presented in this book and referring to developing
countries could be equally relevant to the parts of population with
diabetes living in developed countries. On the other hand, a minor part
of diabetes population in developing countries has access to the highest
level of diabetes care. The inequality in access to diabetes care within
both developed and developing countries makes such categorization of
countries largely vague.
Despite the title, this book truly seeks to present the challenges and
potential solutions under circumstances with limited resources that
could be found in both developed and developing countries.
It seems that after the global lockdown COVID-19 has caused, the
struggle for providing sustainable diabetes care would become relevant
not only for the developing but also for the countries that are currently
considered as developed. The world would be different and there
would certainly be more issues contesting for the limited healthcare
resources.
It has been proven that even in a low-resource setting a lot could be
done to fight diabetes and its complications. I would be feeling very
fulfilled if this book has inspired you to take even a single initiative for
curbing one of the biggest pandemics modern humanity has ever faced,
diabetes.
And before you start reading, I would like to express immense
gratitude to my family and my mentors, friends, and great
endocrinologists, Prof Nanette Steinle and Prof Andrew Behnke
without whom this book would not have been possible.
Ivica Smokovski
Skopje, Republic of North Macedonia
April 2020
Abbreviations
ADA American Diabetes Association
AGP Ambulatory glucose profile
ASCVD Atherosclerotic cardiovascular disease
BG Blood glucose
BGM Blood glucose meter
BMI Body mass index
CDC Centers for Disease Control and Prevention
CGM Continuous glucose monitoring
CKD Chronic kidney disease
CVD Cardiovascular disease
DCCT Diabetes Control and Complications Trial
DKA Diabetic ketoacidosis
DPP Diabetes Prevention Program
DPP-4i Dipeptidyl peptidase-4 inhibitor
EDIC Epidemiology of Diabetes Interventions and Complications
EHCI European Healthcare Consumer Index
EHR Electronic healthcare record
FDA Food and Drug Administration
FPG Fasting plasma glucose
GDM Gestational diabetes mellitus
GDP Gross domestic product
GLP-1RA Glucagon-like peptide-1 receptor agonist
GMI Glucose Management Indicator
GNI Gross national income
GP General practitioner
GV Glycemic variability
HbA1c Glycated hemoglobin A1c
HDL High-density lipoprotein cholesterol
HHS Hyperglycemic hyperosmolar state
HIV/AIDS Human immunodeficiency virus/Acquired
immunodeficiency syndrome
ICU Intensive care unit
IDF International Diabetes Federation
IFG Impaired fasting glucose
IGT Impaired glucose tolerance
INR Indian rupee
isCGM intermittently scanned continuous glucose monitoring
ISO International Organization for Standardization
LDL Low-density lipoprotein cholesterol
LMICs Low- and middle-income countries
MARD Mean absolute relative difference
MKD Macedonian denar
MU Mega units
NAFLD Non-alcoholic fatty liver disease
NCD Noncommunicable disease
NeHS National e-Health System
NGSP National Glycohemoglobin Standardization Program
NHS National Health Service
OAD Oral antidiabetic drug
OGTT Oral glucose tolerance test
PG Plasma glucose
PPG Postprandial glycemia
PPPM Predictive, preventive, and personalized medicine
PVD Peripheral vascular disease
QoL Quality of life
SDEP Structured Diabetes Education Program
SGLT2i Sodium glucose cotransporter 2 inhibitor
SMBG Self-monitoring of blood glucose
TAR Time above range
TBR Time below range
TIR Time in range
UACR Urinary albumin creatinine ratio
UK United Kingdom
UKPDS UK Prospective Diabetes Study
UKPDS-PTM UK Prospective Diabetes Study Post-trial Monitoring
UHC Universal Health Coverage
US United States
USD United States Dollars
WHO World Health Organization
Contents
1 Burden of Diabetes Prevalence
References
2 Diabetes Drivers
References
3 Impact of Diabetes Complications
References
4 Cost-Effectiveness of Available Diabetes Treatments
References
5 Cost-Effectiveness of Monitoring Metabolic Control
References
6 Importance of Structured Diabetes Education
References
7 Benefits of Centralized e-Health System in Diabetes Care
References
8 Promise of Nutrition
References
9 Focus on Diabetes Prevention
References
Index
About the Author
Ivica Smokovski, MD, PhD
, is endocrinologist at the University Clinic of Endocrinology, Diabetes
and Metabolic Disorders, Skopje, and Ass. Professor at the Faculty of
Medical Sciences, University Goce Delcev, Shtip, Republic of North

Macedonia.

Prof Smokovski has extensive experience in diabetes care from

various positions: as a clinician at University Clinic, as a Medical
Advisor in pharmaceutical industry, and as a Medical Advisor for
Diabetes Care to the Minister of Health for 4 years (2012–2016).
He has been instrumental in instituting and serving as a member of
the first National Diabetes Committee, responsible for development of
National Diabetes Plan and National Diabetes Care Guidelines and
monitoring the implementation of policies and guidelines.
Prof Smokovski had a key role in the founding of National e-Health
System related to diabetes care, covering the total population of the
country across all healthcare levels. He has been involved in the
implementation of the diabetes care activities presented in this book.
Prof Smokovski has published the state-of-the-art article “Diabetes
care in the Republic of Macedonia:​Challenges and opportunities,” the
first comprehensive overview of the situation with diabetes in the
Republic of North Macedonia, estimated to have one of the highest
diabetes prevalence in Europe.
In addition, he has published the article “First stratified diabetes
prevalence data for Republic of Macedonia derived from the National e-
Health System,” the first analysis of diabetes data from the National e-
Health System.
Prof Smokovski is a National Representative of EPMA (European
Association for Predictive, Preventive and Personalized Medicine),
member of Presidency of the National Scientific Association of
Endocrinologists and Diabetologists, and President of the Scientific
Committee of National Diabetes Days.
He was responsible for the introduction of Neonatal Cardiac
Surgery, US-MK Exchange Physician Program, and Balanced Score Card
in public healthcare institutions of the country, and he served as a
President of the National Council of Residencies and Fellowships in the
period 2013–2016.
He was the first winner of the Prize for Best Published Article in the
Journal of Doctor’s Chamber of Macedonia in 2014 and a winner of the
Donnell D. Etzwiler International Scholar Award 2020.
Prof Smokovski is author of the Regional Project awarded two-years
grant (2019–2021) by the International Diabetes Federation, titled
“Estimation of Stratified Total Diabetes & Pre-Diabetes Prevalence in
Western Balkan Countries”.
He has been invited to lecture at numerous domestic and
international diabetes medical events.
© Springer Nature Switzerland AG 2021
I. Smokovski, Managing Diabetes in Low Income Countries
https://doi.org/10.1007/978-3-030-51469-3_1

1. Burden of Diabetes Prevalence

Ivica Smokovski1, 2
(1) Faculty of Medical Sciences, University Goce Delcev, Shtip, North
Macedonia
(2) University Clinic of Endocrinology, Diabetes and Metabolic
Disorders, Skopje, North Macedonia

Keywords Diabetes – Developing countries – Pandemic – Prevalence –

Burden – Complications – National – e-Health – Healthcare system –
Bankruptcy – Diagnosed – Undiagnosed – Total

It is now evident that we are living in a world of diabetes pandemic—

despite the scientifically sound estimates, worldwide diabetes
prevalence has been exceeding even the most pessimistic projections
from the past. If we go back in history, it was estimated in 2004 that
diabetes prevalence in 2030 would reach 366 million people [1]. What
actually happened was that the prevalence of 366 million people with
diabetes was already reached in 2011, 19 years earlier than initially
predicted [2]. According to the latest projections, there would be 578
million people with diabetes in 2030, almost 60% more of what was
estimated 15 years ago (Fig. 1.1) [1, 2].
Fig. 1.1 Estimated and actual number of people with diabetes, data adapted from [1,
2] (asterisk) Wild et al. (2014), (dagger) IDF Diabetes Atlas (2019)
Exponential rise of diabetes prevalence can also be observed from
the historical data in the past 20 years. The global estimate of the total
diabetes prevalence, including both diagnosed and undiagnosed cases
in the age group 20–79 years, was 151 million in 2000; rising to 194
million in 2003; 246 million in 2006; 285 million in 2009; 366 million
in 2011; 382 million in 2013; 415 million in 2015; and 425 million in
2017 [2].
According to the latest estimates from the International Diabetes
Federation (IDF) Diabetes Atlas, approximately 463 million people in
the age group 20–79 year were living with diabetes in 2019, equaling to
9.3% of the world’s population in this age group [2]. The total number
is predicted to rise to 578 million by 2030 (prevalence of 10.2%); and
700 million by 2045 (prevalence of 10.9%) [2].
The number of people with diabetes is extraordinary, and the
question is what places so many people in this category. Diabetes
mellitus is defined as Fasting Plasma Glucose (FPG) ≥7.0 mmol/L
(126 mg/dL); or 2-h Plasma Glucose (PG) ≥11.1 mmol/L (200 mg/dL)
during Oral Glucose Tolerance Test (OGTT, glucose load containing the
equivalent of 75 g anhydrous glucose dissolved in water); or HbA1c
≥6.5% (48 mmol/mol) in a laboratory using a method that is NGSP
certified and standardized to the DCCT assay; or if an individual
presents with classic symptoms of hyperglycemia and a random plasma
glucose ≥11.1 mmol/L (200 mg/dL) [3].
Diabetes mellitus is a heterogeneous entity and is classified into
type 1 diabetes (autoimmune beta-cell destruction resulting in absolute
insulin deficiency), type 2 diabetes (progressive loss of adequate beta-
cell insulin secretion due to insulin resistance), and gestational
diabetes mellitus (GDM, diabetes diagnosed during pregnancy) [3].
Other causes are less frequent, such as monogenic diabetes
syndromes (neonatal diabetes and maturity-onset diabetes of the
young), diseases of the exocrine pancreas (cystic fibrosis, pancreatic
cancer, pancreatitis, pancreatectomy), and drug- or chemical-induced
diabetes (glucocorticoid use, treatment of HIV/AIDS, or after organ
transplantation) [3].
Furthermore, the burden of diabetes is not only the magnitude of
people diagnosed with diabetes by any of the criteria above, but also
the huge number of people with diabetes who are not diagnosed. It is
estimated that 1 in 2 people with diabetes is undiagnosed; or, out of the
total 463 million in 2019, 232 million people with diabetes were
undiagnosed [2]. It means that for every person with known diabetes,
there is another one yet to be found, tested, diagnosed and adequately
treated. There are many people in the community who are not aware to
be living with diabetes. Unfortunately, many of those who have
diabetes, but are not diagnosed, initially present with diabetes
complications that are even more difficult and costly to treat.
The vast majority of people affected by diabetes are in their most
productive years. There were 351.7 million people with diabetes in
2019, or 75% of the total number, who were of working age from 20 to
64 years [2]. This number is expected to increase to 417.3 million by
2030, and 486.1 million by 2045 [2]. The magnitude of people with
diabetes in their working age has an immense impact on the economies
globally. The impact is felt much stronger if the economy is weaker, as
in the lower resource countries.
Diabetes is among the top ten causes of mortality in the adult
population worldwide [4]. Latest estimates for 2019 suggest that it has
caused 4.2 million deaths worldwide in the age group 20–79 years [2].
For this reason, it is often said that diabetes has killed more people
after World War II, than both World Wars combined. It is evident that
we are still counting the increasing number of casualties, with no signs
of flattening the curve in the near future. The fight against diabetes has
frequently been labeled by some prominent IDF leaders as the invisible
World War III that is affecting the whole humanity. If people with
diabetes are population of a separate country, it would be the third
largest country in the world, right after China and India, and much
bigger than the United States (US). Almost one percent of this country
would be dying annually.
The steep rise in diabetes prevalence discussed above has mainly
been attributed to the increased prevalence of type 2 diabetes [2]. Type
2 diabetes is estimated to account for more than 95% of all cases of
diabetes globally. Not only the absolute number, but also the proportion
of people with type 2 diabetes is increasing worldwide.
When facing pandemics of different nature, such as the recent
infectious COVID-19 pandemic, that are contagious, spreading fast and
globally, we see whole societies taking immediate action, building up
hospital and ICU capacities, governments discussing nationwide
strategies and solutions. The life of whole countries changes over night.
The question is why we are not seeing this sense of urgency when
facing the diabetes pandemic, claiming multiple times more lives than
the recent infectious pandemic with COVID-19?
The answer could be the insidious course of diabetes that lasts for
years before it is even diagnosed. We are not talking about days or
weeks of incubation, but often about years for diabetes to develop. And
when something is explosive in nature, as in infectious pandemics, we
don’t have difficulties modifying our lifestyle abruptly, adapting to the
new circumstances. We are afraid that the healthcare system will not
respond to the overwhelming number of infectious cases. However,
when something develops slowly over the course of years, people seem
to be reluctant to modify their lifestyle to delay it or prevent it. That
may explain why the challenge of flattening the curve of diabetes
prevalence is so burdensome.
When we talk about the burden of diabetes prevalence, we also have
to think of the diabetes related complications. It is well established that
people with diabetes have increased risk for coronary artery disease,
stroke, congestive heart failure, peripheral vascular disease,
retinopathy, nephropathy, and neuropathy, among the most common [2,
3]. Less recognized, however, equally important, are the increased
prevalence of depression, erectile dysfunction, or functional disability
[2, 3].
Cardiovascular diseases, leading cause of morbidity and mortality
worldwide, are two to four times more common in people with diabetes
compared to people with no diabetes [2, 3]. Diabetes remains the
leading cause of the new cases of blindness among adults, and the
leading cause of end-stage renal failure requiring dialysis [2]. The
enormous impact of diabetes related complications will be discussed in
more detail in the following chapters.
Diabetes has been a major healthcare issue for the lower resource,
developing countries. Developing countries include low-income
countries, with Gross National Income (GNI) per capita of USD 1,025 or
less, and middle-income countries, with GNI per capita between USD
1,025 and USD 12,375 in 2018 [5]. Developed, high-income countries
are those with GNI per capita of USD 12,376 or more in 2018 [5].
Developing countries are sometimes referred to as LMICs, or Low
and Middle Income Countries. It is estimated that only 15% of the
world population lives in developed countries and the remaining
majority lives in developing, lower resource countries.
The trend of rising prevalence of type 2 diabetes in both developed
and developing countries can be attributed to ageing, sedentary
lifestyle and increased calories intake, resulting in overweight, obesity
and insulin resistance. In 2019, 310.3 million people with diabetes
were living in urban areas (prevalence of 10.8%), compared to 152.6
million in rural areas (prevalence of 7.2%) [2]. Number of people with
diabetes in urban areas is expected to increase to 415.4 million
(prevalence of 11.9%) in 2030, and to 538.8 million (prevalence of
12.5%) in 2045, as a result of the global migration from rural to urban
areas [2]. The urbanization is more intensive in developing countries,
and could lead to even sharper increase in diabetes prevalence in those
countries.
Earlier diagnosis, treatment and reduction of premature
complications and mortality additionally contribute to the increased
diabetes prevalence, due to the better survival of people with diabetes
[2]. Diagnosing type 2 diabetes at an earlier age in recent years also
contributes to the increase of diabetes prevalence.
While the prevalence of diabetes becomes less steep in higher
resource parts of the world, it is expected to explode in the years to
come in the lower resource countries. It further aggravates the
situation with the already scarce healthcare resources in developing
countries, and poses additional challenges for the healthcare
authorities to prioritize and adequately allocate the limited resources.
Healthcare systems of developing countries have already been
struggling with the existing healthcare issues and have certainly not
been prepared to face the approaching diabetes tsunami. Most of these
countries have not been able to provide the currently recommended
standard diabetes treatment or glucose monitoring supplies to the
already diagnosed people with diabetes. The economic meltdown from
the recent global pandemic with COVID-19 would only aggravate the
financial situation in the healthcare systems of developing countries.
It is striking that in 2019, 79% of adults with diabetes, or 367.8
million (prevalence of 9.0%) were living in developing countries,
compared to 95.2 million (prevalence of 10.4%) in developed countries
(Fig. 1.2) [2]. Unstoppable diabetes tsunami is coming for the
developing countries which could easily be realized from the
projections for 2030 and 2045, if current trends are not changed.
Fig. 1.2 Diabetes prevalence in developed and developing countries, 2019–2045,
data adapted from [2]
In 2030, it is estimated that 82% of the total number of people with
diabetes will be coming from developing countries [2]. Estimated 470.1
million people with diabetes will be living in developing (prevalence of
10.0%), compared to 107.9 million in developed countries (prevalence
of 11.4%) (Fig. 1.2) [2].
In 2045, it is estimated that 84% of the total number of people with
diabetes will be coming from developing countries [2]. Estimated 587.6
million people with diabetes will be living in developing (prevalence of
10.8%), compared to 112.4 million in developed countries (prevalence
of 11.9%) (Fig. 1.2) [2].
Diabetes prevalence is projected to increase by 51% from 2019 to
2045 worldwide—from 463 million in 2019, to 700 million in 2045 [2].
This rise is largely due to the increase in low- to middle-income regions,
such as in Africa (except North Africa) by 143%, Middle East and North
Africa by 96%, South East Asia by 74%, and South and Central America
by 55% [2].
We should never forget how bad we have been in predicting
diabetes prevalence. No matter how tremendous those numbers may
appear, all historical projections have so far resulted in significant
underestimation of the diabetes prevalence. Therefore, we should only
consider future estimates as the most conservative ones.
The proportion of people with undiagnosed diabetes is also higher
in low-income (66.8%, 9.7 million) and middle-income (52.6%, 185.8
million), compared to high-income countries (38.3%, 36.4 million) [2].
Expected improvement of diagnostic rates in developing countries
would result in additional number of people with diagnosed diabetes
that the healthcare systems have to cope with.
Financial burden of diabetes and related complications has been
overwhelming for the healthcare systems across the world. It is
estimated that diabetes caused at least USD 760 billion of healthcare
expenditure in 2019, which is approximately 10% of the total spending
on adult healthcare [2]. This figure is projected to rise to USD 825
billion in 2030, and USD 845 billion in 2045 [2]. If indirect costs are
added, as explained in the following chapters, total diabetes related
costs become even higher.
 Diabetes pandemic is of such magnitude that it threatens even the
most developed healthcare systems in the world, such as the National
Health Service (NHS) in the United Kingdom (UK). Some experts
predict that due to the spiraling costs, diabetes alone could bankrupt
the NHS and should be declared as a ‘national crisis’. Mass media from
the UK have alarmed that the number of people with diabetes in the UK
has doubled in 20 years, due to the rise in prevalence of type 2 diabetes
[6]. Another frightening fact is that, although traditionally considered
as a diagnosis of the older population, type 2 diabetes is more often
diagnosed at an earlier age due to the growing prevalence of obesity in
children and adolescents [6].
The cost of diabetes treatment in the NHS has doubled in only a
decade, from 2008 to 2018 [6]. Furthermore, diabetes was responsible
for almost 26,000 cases of premature mortality annually in the UK [6].
Total diabetes related cost in the UK was estimated at USD 17 billion in
2019 [2].
If there is a risk of bankruptcy of the NHS due to diabetes, it could
certainly have a huge impact on the total UK and global economy. It is
well validated that diabetes is the largest contributor to healthcare
costs, not only in the UK, but also in the rest of Europe, exerting huge
pressure on the already stretched healthcare resources.
It is no surprise that diabetes is one of the costliest conditions in the
most developed country of the world, the US. The Center for Disease
Control and Prevention (CDC) Report from 2020 estimated that more
than 1 in 10 US adults—about 34.1 million—have either type 1 or type
2 diabetes, and 7.3 million of them are undiagnosed [7].
Total diabetes related health expenditure in the US in 2019 was
estimated at USD 294.6 billion, the largest amount spent on diabetes by
a single country [2]. It is three times more than the diabetes related
health expenditure of China, which occupies the second place and has
four times more people with diabetes than the US. It is estimated that
cost to the economy of diabetes related premature deaths in the US was
USD 19.9 billion annually, and a total of USD 90 billion was indirectly
lost due to diabetes [2, 8].
Above grave examples of the diabetes impact on the most developed
countries illustrate the potential it has to collapse the healthcare
systems of the developing, lower resource countries. An example of a
developing country struggling with one of the highest diabetes
prevalence in Europe is the Republic of North Macedonia, located in
South East Europe, with an estimated population of 2.06 million [9].
The increasing prevalence of type 2 diabetes in the past three decades
has been alarming and had a significant impact on the healthcare
system in the country.
The estimated total diabetes prevalence, of both diagnosed and
undiagnosed cases, in the Republic of North Macedonia was
approximately 80,000 people in 2004 [9]. Diabetes prevalence has
more than doubled in only 15 years, and the latest estimate of total
diabetes prevalence was 175,100 in 2019 [2].
Both diabetes national and age-adjusted prevalence in the Republic
of North Macedonia were higher compared to Europe as a region.
Diabetes national prevalence in adults 20–79 years in 2019 was
estimated at 11.2%, compared to 8.9% in Europe [2]. Diabetes age-
adjusted comparative prevalence (20–79 years) in 2019 was estimated
at 9.3%, compared to 6.3% in Europe [2].
It was estimated there were 2,300 people with type 1 diabetes in
the Republic of North Macedonia in 2015, or 2.7% of all diagnosed
cases [9]. The Republic of North Macedonia is considered a ‘cold spot’
for type 1 diabetes in Europe with a low incidence rate [9]. On the other
hand, the prevalence of type 2 diabetes in the country is strikingly high.
Basic diabetes data for the Republic of North Macedonia are presented
in Table 1.1 [2, 9, 10].

Table 1.1 Basic diabetes data for the Republic of North Macedonia, data adapted
from [2, 9, 10]

Total population 2,058,539

Diabetes national prevalence (20–79 years) (2019) 11.2%
Diabetes age-adjusted comparative prevalence (20– 9.3%
79 years) (2019)
Total number of people with diabetes (diagnosed and 175,100
undiagnosed) (2019)
People with diagnosed diabetes (2015) 84,568
People with diabetes on insulin treatment (2015) 37,011 (43.8% of diagnosed
cases)
Total population 2,058,539
People with type 1 diabetes (2015) 2,300 (2.7% of diagnosed
cases)
Women/men with diagnosed diabetes (% prevalence) 48,449 (4.6%)/36,119
(2015) (3.4%)
Urban/rural population with diagnosed diabetes (% 59,586 (3.6%)/24,982
prevalence) (2015) (5.6%)
Diabetes has been a huge healthcare and socio-economic burden for
the Republic of North Macedonia. National diabetes prevalence data
have been of utmost importance for the policy makers, healthcare
authorities, healthcare providers, and patient organizations.
Nevertheless, it is interesting that until recently, there were only
external estimates of the diabetes prevalence for the country. Those
estimates were based on extrapolations of diabetes prevalence from
other countries in the region, as there were no reliable data sources for
the national diabetes prevalence [10]. Using extrapolated data for
estimation of diabetes prevalence has been common for most of the
developing countries, lacking their own, good quality epidemiological
data [2].
It was also interesting that up to the latest, ninth edition of IDF
Diabetes Atlas, the same age-adjusted (20–79 years) comparative
prevalence of 10.1% was reported not only for the Republic of North
Macedonia, but also for the other countries from the region with no
own data, such as Albania, Bosnia and Herzegovina, Montenegro and
Serbia [10, 11].
Those estimates were based upon the extrapolation of diabetes
prevalence in geographically close countries with high quality data for
diabetes prevalence, such as Croatia, Cyprus, Greece, Slovenia and
Turkey [10, 11]. However, not all of those reference countries, although
geographically close, share similar dietary and lifestyle patterns with
the Republic of North Macedonia and the other countries with no own
data [10].
First step for the developing countries is to know their own
diabetes prevalence of diagnosed cases, as precisely as possible. In
other words, if we are talking about fighting a war against diabetes, we
have to know the strength of our enemy in every single country,
including the ones with limited resources. Additionally, it is not
sufficient only to know the total number of diagnosed cases, but also to
know the stratification of those cases by age, gender and place of living,
urban or rural. This information is of great value for explaining the
prevalence and helps for planning of future activities.
After determining the prevalence of diagnosed cases, it would be
beneficial to know the prevalence of undiagnosed cases through a
national epidemiological study. If the prevalence of diagnosed and
undiagnosed cases is known, the total diabetes prevalence could be
calculated, as well as the diagnostic rate for the country.
The next thing every developing country should consider is
mapping the network of diabetes care services provided across the
national healthcare system. In the case of the Republic of North
Macedonia, diabetes care services are provided across all three
healthcare levels, primary, secondary and tertiary. Around 1,600
primary care physicians are involved in the screening, diagnosing and
treating people with type 2 diabetes with oral antidiabetic medication.
In addition, there are 41 Diabetes Centers with around 120 specialists
(Endocrinologists, Diabetologists, Internists) which are functional units
at secondary level where further diabetes care is provided, including
prescription of insulin treatment and other novel injectable (e.g. GLP-
1RA) and non-injectable (e.g. DPP-4i, SGLT2i) diabetes medications.
Finally, there is one institution at tertiary level, the University Clinic of
Endocrinology, Diabetes and Metabolic Disorders in the capital of
Skopje. If not in possession of those basic metrics, any war against
diabetes is predestined to fail.
The first comprehensive, stratified diabetes prevalence data derived
from the National e-Health system in the Republic of North Macedonia
with a cut-off date 20-July-2015, were published in 2018 [10]. These
first actual data on the national diabetes prevalence discovered certain
differences compared to the previously reported extrapolations [10].
Diabetes prevalence data of diagnosed cases were stratified by age,
gender and place of living [10].
Latest, ninth edition of IDF Diabetes Atlas used the first stratified,
national data of diagnosed cases derived from the National e-Health
System (NeHS), for the estimates of total diabetes prevalence for the
Republic of North Macedonia in 2019 [2]. Those are the first results
without extrapolation of data from regional countries, and are
considered more accurate than the estimates from the previous
versions of the IDF Diabetes Atlas.
The Republic of North Macedonia was recognized in the latest IDF
Diabetes Atlas from 2019, as one out of only 12 countries worldwide
having a diabetes prevalence study conducted within the past 5 years
[2]. Hence, it is possible even for a developing country with limited
resources to report the national diabetes prevalence, at least of
diagnosed cases.
From the first stratified analysis of diabetes prevalence it was found
that genders were evenly distributed in the total population of the
Republic of North Macedonia, whereas the majority of the population
lives in urban municipalities (78.9%), mimicking the global distribution
of population [10].
The total number of diagnosed cases was 84,568; of those 36,119
men (42.7%) and 48,449 women (57.3%) (Table 1.1) [10]. Mean age of
all diagnosed diabetes cases was 62.6 ± 12.5 years. It was reported that
prevalence of diagnosed cases in the total population was 4.0% with
the highest prevalence in the age group 60–79 years, followed by
groups 80 years or older, 40–59 years, 20–39 years, and below 20 years
(Fig. 1.3) [10]. This is in accordance with the global estimates of
increasing diabetes prevalence towards older age groups [2].
Fig. 1.3 Diabetes prevalence of diagnosed cases in the Republic of North Macedonia,
total population and population 20–79 years [10]
The prevalence of diagnosed cases was higher in women compared
to men in the total population (4.6% vs 3.4%) (Fig. 1.3) [10]. This was a
surprising result in contrast to the global estimates of higher
prevalence in men (9.6%) than in women (9.0%) in 2019, but also in
the future projections (10.4% and 10.0% in 2030, and 11.1% and
10.8% in 2045, in men and women, respectively) [2].
From the study, the total number of diagnosed cases was higher in
urban (n = 59,586) compared to rural municipalities (n = 24,982);
however, the prevalence of diagnosed cases was higher in rural
compared to urban municipalities (5.6% vs 3.6%) across all age groups,
except for the age group below 20 years, where the majority of
diagnosed cases (99.1%) were from urban municipalities (Fig. 1.3)
[10]. This was also in contrast to the global trends of higher diabetes
prevalence in urban compared to rural areas [2, 10].
The process of urbanization has been very intensive in the Republic
of North Macedonia in the past 50 years with significant migration from
rural to urban municipalities. Higher diabetes prevalence of diagnosed
cases in rural municipalities contradicts the established views of higher
diabetes prevalence associated with urbanization [2, 10].
Diabetes prevalence of diagnosed cases in the population 20–
79 years was 5.0%, 4.4% in urban municipalities, and 7.5% in rural
municipalities. Diabetes prevalence of diagnosed cases in this age group
was 4.3% in men and 5.7% in women (Fig. 1.3) [10].
Since more than three quarters of the population currently live in
urban municipalities, a possible explanation could be that rural
municipalities, mainly inhibited by ethnic Albanian population, share
cultural, religious, dietary, and lifestyle habits more closely with the
Turkish population, having the highest diabetes prevalence in Europe,
as compared to the ethnic Macedonian population, mainly inhabiting
the urban municipalities [10].
In addition, higher prevalence in women compared to men,
especially in rural municipalities (7.0% vs 4.3%), could be explained by
the fact that men are more physically active, and more intensively
engaged in agriculture and farming. On the other side, women
traditionally stay at home, being responsible for maintaining the
households and less physically active while sharing the same dietary
pattern. This surprising finding of higher diabetes prevalence in rural
women only confirms the necessity of determining the stratified
diabetes prevalence in developing countries [10].
It was found that almost every third woman and every fifth man in
the age group 60–79 years in rural municipalities were diagnosed with
diabetes [10]. Possible reason for such a high prevalence could be the
limited access of rural population to Diabetes Centers which are located
exclusively in urban municipalities, where activities are directed also
towards diabetes prevention [10].
The Republic of North Macedonia could still be considered a ‘cold
spot’ for type 1 diabetes in Europe, as only 549 individuals (0.6% of all
diagnosed cases) were below the age of 20 years, with equal gender
distribution, and all but one individual coming from urban
municipalities. This finding further strengthens the importance of
environmental factors arising from urban municipalities in initiation of
autoimmunity in type 1 diabetes.
 Taking into account the estimated high diabetes prevalence and
exorbitant related costs, diabetes has been posing a serious threat, not
only to the national healthcare system, but to the society as a whole. As
an illustration, cost of insulin and related supplies, test strips, glucagon,
insulin pumps and ancillaries; not including the cost of oral antidiabetic
drugs, was 40% of the total cost of all non-hospital medications covered
by the Healthcare Insurance Fund and Government Programs in 2014
(Fig. 1.4) [9, 10].

Fig. 1.4 Cost of insulin and related supplies as a percentage of the total cost for non-
hospital reimbursed medications [10]. OAD Oral Antidiabetic Drugs, HCIF Healthcare
Insurance Fund

In order to manage the burden of diabetes prevalence, especially in

lower resource countries, numerous activities need to be undertaken.
Those activities have to be endorsed by the top policy decision makers
in order to be implemented.
Examples of activities undertaken at institutional level to address
the diabetes burden in the Republic of North Macedonia, include: (1)
adoption of National Diabetes Plan at the level of Ministry of Health,
strategic document describing the current situation and the proposed
activities on diabetes treatment, education, prevention; (2) addition of
diabetes as a specifically designated medical condition in the Law on
Healthcare; (3) adoption of international guidelines for diabetes care as
National Diabetes Care guidelines, published in the Official Journal of
the country where laws are published, to ensure adherence by all
stakeholders; (4) formation of a National Diabetes Committee, body for
monitoring of adherence to the National Diabetes Care guidelines; (5)
creation of NeHS to monitor the diagnosis and treatment of people with
diabetes [10, 12, 13].
These activities comply with the World Health Organization (WHO)
recommendations for establishing National Diabetes Plans and
providing Universal Healthcare Coverage (UHC) by 2030, as well as
reduction of premature death from non-communicable diseases
(NCDs), including diabetes, by 25% by 2025 [2, 14].
The findings from the national analysis in a small, severely affected,
lower resource country, such as the Republic of North Macedonia,
further strengthen the need that each developing country should be in
possession of its real-world, stratified, diabetes prevalence data,
instead of using extrapolations.
The analyses of the national, stratified diabetes prevalence were
performed with very limited financial resources, confirming it is
possible to generate numerous diabetes related reports in a setting of a
lower resource country, if the NeHS is in place.

What should be done to manage the burden of diabetes

prevalence in developing countries?
Each developing country should …
… know its numbers—as a minimum, the prevalence of diagnosed
cases, stratified by age, gender and place of living, urban or rural;
… consider epidemiological study to find the prevalence of
undiagnosed diabetes cases;
… map the diabetes care services across all healthcare levels;
… have a National Diabetes Plan, and consider designating
diabetes as a specific medical condition in the laws;
… adopt international guidelines as National Diabetes Care
guidelines, requiring adherence by all stakeholders;
… form a national body, National Diabetes Committee, overseeing
the adherence to the National Diabetes Care guidelines;
… implement a national, centralized, integrated electronic
healthcare system covering the total population across all
 healthcare levels.

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International Diabetes Federation; 2017.
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Ministry of Health. Law on the healthcare. Off J Repub Macedonia. 2015;10:12–
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Ministry of Health. Guideline on healthcare related to the treatment and control
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© Springer Nature Switzerland AG 2021
I. Smokovski, Managing Diabetes in Low Income Countries
https://doi.org/10.1007/978-3-030-51469-3_2

2. Diabetes Drivers
Ivica Smokovski1, 2
(1) Faculty of Medical Sciences, University Goce Delcev, Shtip, North
Macedonia
(2) University Clinic of Endocrinology, Diabetes and Metabolic
Disorders, Skopje, North Macedonia

Keywords Diabetes – Developing countries – Ageing – Obesity –

Prediabetes – Ethnicity – Gestational diabetes – Smoking – Psychosocial
– Stress – Prevention – Driver – Risk factor – Monitoring – EHR

Ageing population is one of the main drivers for the rise of diabetes
prevalence worldwide. People are living longer, thereby increasing their
chances to develop diabetes. In addition, people diagnosed with
diabetes are also living longer due to the improved treatment of
hyperglycemia and diabetes complications. As already mentioned, type
2 diabetes has recently been more often diagnosed at an earlier age,
increasing the overall type 2 diabetes prevalence through longer
survival.
There is a considerable difference if we compare developed and
developing countries in terms of life expectancy. Life expectancy at
birth in low-income countries is estimated at 62.7 years, 18.1 years
lower than in high-income countries, estimated at 80.8 years [1]. Most
of the people who die in high-income countries are of old age; however,
almost one third of mortality in low-income countries is in very young
children, under the age of 5 years [1].
The differences in life expectancy between women and men are
smaller in low-income countries compared to high-income countries
[1]. Currently, communicable diseases and maternal conditions
contribute most to differences in life expectancy between women and
men in low-income countries, whereas NCDs, including diabetes,
contribute most to the life expectancy differences in high-income
countries [1].
Life expectancy has been increasing globally over the years.
Although of shorter duration, life expectancy has also increased in the
developing countries and NCDs are expanding their share in
populations’ morbidity and mortality. If current trends of rise in obesity
and overweight continue, it is expected that very soon NCDs, including
diabetes, will become the main contributor to morbidity and mortality
even in the poorest, low-income countries.
According to the recommendations from American Diabetes
Association (ADA), screening for diabetes should begin at the age of
45 years at the latest, if no other risk factors are present [2]. Screening
should be considered earlier in overweight or obese adults who have
one or more additional risk factors for diabetes [2]. Those risk factors
include prediabetes, GDM, first-degree relative with diabetes, high-risk
race or ethnicity, history of cardiovascular disease (CVD), hypertension
(≥140/90 mmHg or treatment for hypertension), HDL <0.90 mmol/L
(35 mg/dL) or triglycerides >2.82 mmol/L (250 mg/dL), polycystic
ovary syndrome, physical inactivity, severe obesity, or acanthosis
nigricans [2]. If results are normal, testing for diabetes should be
repeated at least every 3 years [2]. These recommendations have been
widely adopted not only in developed, but also in developing countries.
Obesity is the most critical factor for developing insulin resistance
and inadequate insulin secretion, leading to the development of
prediabetes and diabetes. Prevalence of overweight and obesity is
continuously rising worldwide.
Overweight is defined as BMI between 25 kg/m2 and 30 kg/m2, and
obesity as BMI above 30 kg/m2. In Asian populations the cut off values
for overweight are lower, at 23 kg/m2. Obesity is the main reason not
only for the exponential rise of type 2 diabetes prevalence in adults, but
also for the growing prevalence of type 2 diabetes in children and
adolescents. Rising obesity prevalence in youth results in development
of diabetes at an earlier age compared to previous generations.
 Obesity and inadequate physical activity are important modifiable
risk factors for the development of type 2 diabetes. One of the main
goals of managing the burden of diabetes prevalence is to halt the rise
in overweight and obesity [2, 3].
Recently, the WHO reported that worldwide obesity has nearly
tripled since 1975 [4]. In 2016, more than 1.9 billion adults were
overweight (prevalence of 39%), and of these over 650 million were
obese (prevalence of 13%) [4]. Most of the world’s population currently
live in countries where overweight and obesity are associated with
higher mortality compared to underweight. It has also been reported
that over 340 million children and adolescents aged 5–19 were
overweight or obese in 2016 [4].
Furthermore, the WHO reported that the number of overweight or
obese infants and young children (aged 0–5 years) increased from 32
million globally in 1990 to 41 million in 2016 [5]. The vast majority of
overweight or obese young children live in developing countries, where
the increase has been more than 30% higher than of developed
countries [5]. Without intervention, obese infants and young children
will likely continue to be obese during childhood and adulthood [5].
Earlier studies reported high prevalence of childhood obesity (5–
19 years) in developing countries: 41.8% in Mexico, 22.1% in Brazil,
22.0% in India, and 19.3% in Argentina [6]. Important factors
contributing to the childhood obesity in developing countries included
high socioeconomic status, residence in urban municipalities, female
gender, unawareness about nutrition, marketing by global food
companies, increased academic stress, and poor facilities for physical
activity [6].
Recent reports have shown that almost 40% of adults and 18.5% of
young people in the US are obese, and that only one quarter of youth
meets the recommendations on physical activity [7]. It has been
reported that incidence of type 2 diabetes among those aged 10 to
19 years in the US, increased from 9 per 100,000 in 2002–2003 to 13.8
per 100,000 in 2014–2015 [7]. In recent years, considerable increase of
screen time has also been associated with reduced levels of physical
activity and increase in obesity.
In a US study of the impact of obesity on mortality, it has been
demonstrated that 1 in 5 fatal cases was associated with obesity, which
was three times above the previous estimations [8]. It is paradoxical
that convenient living, including increased calories intake and lower
levels of physical activity results in alarming rates of obesity and is
predicted to affect the life expectancy in the US. For the first time ever, it
may occur that children in the US would live shorter compared to their
parents, which is mainly due to the obesity related disorders.
Obesity rise is no longer exclusive for developed countries. It has
become one of the main healthcare concerns in developing countries as
well. Taking into account past and current BMI trends, it is anticipated
that obesity will continue to rise in developing countries. In the coming
years, the mean BMI in developed countries could be exceeded by
developing countries [9, 10]. Rather than focusing on obesity at the
individual level, activities need to be undertaken at the community and
national level [9, 10].
Initially, the daily increase in calories intake per person and the rise
of obesity were primarily related to parts of population with higher
socioeconomic status among developing countries [9, 10]. However,
recent trends demonstrate that rise in obesity is more prevalent in
parts of populations with lower socioeconomic status in developing
countries, which is in line with the similar observations in developed
countries [9, 10]. The availability and low cost of fast foods contribute
to those unfavorable trends.
Studies report that 70% of the fast-foods and almost half of the full-
service restaurant meals eaten in the US were of poor nutritional value
[9, 10]. Unfortunately, those dietary patterns are now replicated in
developing countries due to the lower costs per calories intake. It has
been reported that lower socioeconomic status, lower level of
education, lower physical activity, and lower cost per calorie, are
critical factors associated with the increase of BMI [9, 10].
It is tragic that in many countries, both developed and developing,
there are parents who are sometimes more worried about whether
they can afford their children or themselves any meal, and much less if
the meal is healthy or not. Such situations are, understandably, more
common in developing countries.
Rates of urbanization are increasing in the developing countries
resulting in a sedentary lifestyle associated with lower levels of
physical exercise and eating less healthy foods. With the wider
adoption of industrialization and technology, labor intensive activities
are decreasing in developing countries, contributing to the rise of
obesity and associated diabetes.
As the overweight and obesity are becoming more prevalent in
youth, ADA is recommending risk-based screening for type 2 diabetes
or prediabetes in children and adolescents who are overweight (equal
or greater than 85th percentile) or obese (equal or greater than 95th
percentile), and who have one or more additional risk factors, such as
maternal history of diabetes or GDM, family history of type 2 diabetes,
high-risk race or ethnicity, signs of insulin resistance or conditions
associated with insulin resistance (acanthosis nigricans, hypertension,
dyslipidemia, polycystic ovary syndrome) [2].
Additional parameters closely related to visceral obesity, despite the
widely used BMI, are waist circumference and waist-to-hip ratio.
Obesity has been closely related to hypertension and dyslipidemia,
major risk factors for CVDs. The rise in obesity is also associated with
the increase of diabetes related cases of cancer worldwide [3].
Increased calories intake per person per day has been a strong
driver for the increased diabetes prevalence in the Republic of North
Macedonia. The rising diabetes prevalence could be explained by the
similarity of the dietary pattern and lifestyle in the Republic of North
Macedonia with those of the population in Turkey, a country with the
highest diabetes prevalence in Europe [3, 11, 12]. This might be due to
the fact that the Ottoman Empire had occupied the territory of the
modern Republic of North Macedonia for more than five centuries until
the beginning of the twentieth century, exerting a huge influence on the
diet and lifestyle of the local population. Such a diet is mainly based on
non-integral wheat flour, bread, pastry, lots of sweets, high-fat meals,
and a lifestyle characterized by no, or inadequate physical activity [11,
12].
There has been a significant change in dietary patterns since the
early 1990s, when the Republic of North Macedonia gained its
independence from the former Yugoslavia. Total daily calories per
person per day increased by almost 50% in the country in less than
20 years, since the beginning of 1990 [11]. It was paralleled with the
rising rates of overweight (53% of the population) and obesity [11].
Prevalence of obesity in the population above 18 years has increased
from 17.7% in 2000, to 21.9% in 2016 (Fig. 2.1) [13].

Fig. 2.1 Prevalence of adult obesity in the Republic of North Macedonia, data
adapted from [13]
Given the importance of obesity as a diabetes driver, it would be
necessary to monitor the individual values of BMI in the Electronic
Healthcare Records (EHRs). By doing so, it would be possible to
monitor the prevalence of obesity at a national level. National e-Health
System is critical for recording metabolic parameters and monitoring
the prevalence of obesity in the country.
Ethnicities are well established to be associated with different
diabetes prevalence. One example is the ethnicities in the US, such as
African Americans, Hispano Americans, Native Americans, Asian
Americans, and Pacific Islanders, who have higher diabetes prevalence
than the Caucasians [14]. The rates of increase of type 2 diabetes in the
younger population have also been higher among racial and ethnic
minority groups compared to the Caucasians in the US [14].
 Globally, populations with highest diabetes age-adjusted,
comparative prevalence include Marshall Islands (30.5%), Kiribati
(22.5%), Sudan (22.1%), Tuvalu (22.1%), Mauritius (22.0%), New
Caledonia (21.8%), Pakistan (19.9%), French Polynesia (19.5%),
Solomon Islands (19.0%), Guam (18.7%) [3]. These top 10 countries in
terms of diabetes prevalence, except for the French and US colonies
(New Caledonia, French Polynesia, Guam), are middle- or low-income
countries.
There are multiple factors that contribute to the disparities among
different ethnicities, including biological and genetic factors,
socioeconomic status, and access to the healthcare system [14]. It is
common that most minority populations are of lower socioeconomic
status and have limited access to the healthcare system.
Ethnic differences could be illustrated by the facts that South Asians
have lower age at onset of type 2 diabetes, lower BMI threshold for type
2 diabetes, more rapid decline in beta cell function, low muscle mass,
increased abdominal obesity, and increased non-alcoholic fatty liver
disease (NAFLD) prevalence, compared to Caucasians [15].
Higher diabetes prevalence in rural compared to urban population
in the Republic of North Macedonia was also explained by the
differences in respective ethnic populations. Namely, rural
municipalities are mainly inhabited by ethnic Albanians who share
dietary and lifestyle habits more closely to the Turkish population
which has the highest diabetes prevalence in Europe, as compared to
the ethnic Macedonian population mainly inhabiting the urban
municipalities [12]. Therefore, developing countries should aim for
ethnic stratification of diabetes prevalence due to the possible
interethnic differences in diabetes pathophysiology.
Prediabetes, as a distinct medical condition, is another strong
driver for the development of diabetes. Prediabetes is defined as FPG
5.6 mmol/L (100 mg/dL) to 6.9 mmol/L (125 mg/dL), i.e. Impaired
Fasting Glucose (IFG); or 2-h PG during 75-g OGTT 7.8 mmol/L
(140 mg/dL) to 11.0 mmol/L (199 mg/dL), i.e. Impaired Glucose
Tolerance (IGT); or HbA1c 5.7–6.4% (39–47 mmol/mol) [2].
In addition to the steep rise of diabetes prevalence, there is a whole
contingent of people just about to be diagnosed with diabetes, namely
the people who are diagnosed with prediabetes. Management of
prediabetes is of utmost importance, since diabetes prevention
activities should primarily address the prediabetic population and
could result in a delay of progression to diabetes, or even reverting to
normoglycaemia.
It is estimated there were 374 million people with prediabetes
(prevalence of 7.5%) in 2019 worldwide, at a very high risk for
developing type 2 diabetes [3]. The estimated number of adults aged
20–79 years with prediabetes is predicted to rise to 454 million
(prevalence of 8.0%) by 2030, and 548 million (prevalence of 8.6%) by
2045 [3].
Similar to the situation with diabetes prevalence, the vast majority
of people with prediabetes come from developing countries. In 2019,
72.2% of adults with impaired glucose tolerance were living in low- and
middle-income countries [3].
It was estimated that 269.9 million adults (20–79 years) with
prediabetes were living in developing countries in 2019 (prevalence of
6.7%), compared to 104.1 million in developed countries (prevalence of
11.4%) (Fig. 2.2) [3]. The increase in prediabetes prevalence is
expected to be faster in lower income countries, compared to higher
income countries.
Fig. 2.2 Prediabetes prevalence in developed and developing countries, 2019–2045,
data adapted from [3]
In 2030, it is estimated that 75% of the total number of adults with
prediabetes will be coming from developing countries. Projections for
2030 is that 340.0 million people with prediabetes will be living in
developing (prevalence of 7.2%), compared to 114.0 million in
developed countries (prevalence of 12.1%) (Fig. 2.2) [3].
In 2045, it is estimated that 79% of the total number of adults with
prediabetes will be coming from low- and middle-income countries. It
is projected that 430.2 million adults with prediabetes will be living in
developing (prevalence of 7.9%), compared to 117.8 million in
developed countries (prevalence of 12.5%) (Fig. 2.2) [3].
Prevalence of prediabetes is higher in the Republic of North
Macedonia as a developing European country, compared to Europe as a
region. Number of people in the age group 20–79 years with
prediabetes in the Republic of North Macedonia was estimated at
120,700 in 2019, with age-adjusted comparative prevalence of
prediabetes in this age group of 7.1%. It was considerably above the
age-adjusted comparative prevalence of prediabetes in Europe,
estimated at 4.4% [3].
For all the people with prediabetes, testing for diabetes should be
conducted at least on a yearly basis [2]. It has been demonstrated from
the Diabetes Prevention Program (DPP) studies that lifestyle
interventions resulting in weight reduction were effective in delaying
type 2 diabetes [16–31]. These studies suggest what needs to be done
to delay or prevent prediabetes, if such lifestyle interventions are
implemented in the normoglycaemic population.
It has to be emphasized that DPPs are complex and are not aimed
only at high-risk, prediabetic population. Instead, those programs also
include school teachers teaching pupils on nutrition and physical
activity. In many cases, overweight and obese school teachers are
trained to modify their lifestyle first, in order to convey the benefits of
modified lifestyle to their pupils. Situation is similar with healthcare
providers who need to be trained to improve their lifestyle before they
could have an impact on the lifestyle of the people they are caring for.
People with prediabetes have to be monitored closely and should
have the diagnosis of prediabetes recorded in their EHRs. In that way,
the progression of prediabetes to diabetes could be followed at
individual, but also at a national level. Activities to prevent diabetes
should be addressing individuals with prediabetes and need to be
regularly evaluated if effective.
Gestational diabetes is another critical risk factor for the
development of type 2 diabetes. Screening for GDM is performed at 24–
28 weeks of gestation in pregnant women not previously diagnosed
with diabetes. Most commonly used criteria for diagnosis of GDM are
meeting or exceeding any of the following PG values after OGTT: FPG
5.1 mmol/L (92 mg/dL), or 1 h-PG 10.0 mmol/L (180 mg/dL), or 2 h-
PG 8.5 mmol/L (153 mg/dL) [2].
An estimated 15.8% (20.4 million) of live births were affected by
hyperglycemia in pregnancy in 2019, and of those 83.6% were due to
GDM [3]. The vast majority (86.8%) of cases of GDM come from low-
and middle-income countries, where access to antenatal, perinatal and
postnatal care has often been limited (Fig. 2.3) [3].
Fig. 2.3 Proportion of gestational diabetes in developed and developing countries,
data adapted from [3]
Prevalence of GDM increases rapidly with age, which is in reverse
relation to the number of pregnancies that rapidly decreases with the
age. As a result of the higher fertility rates in younger women, the
absolute number of cases of GDM is higher in women under the age of
30 years [2, 3].
Gestational diabetes is associated with increased risk of type 2
diabetes in women later in their life. Women diagnosed with GDM have
almost seven times higher risk of developing type 2 diabetes during
their lifetime, compared to women with normoglycaemic pregnancy
[32]. It has been reported that women with GDM have almost twice
higher risk of developing CVD compared to women without GDM [33].
Gestational diabetes could result in an increased risk of childhood
overweight and obesity, increased insulin resistance and higher risk of
prediabetes in the offspring [34]. Consequently, the offspring of a
mother with GDM is at a higher risk of developing type 2 diabetes [34].
Women who were diagnosed with GDM should have lifelong testing for
diabetes, at least every 3 years. Gestational diabetes has to be recorded
in the individual EHRs, and to be followed at subsequent visits after
delivery, to reassess the risk for developing type 2 diabetes.
Smoking is another very important risk factor for diabetes,
especially in developing countries. This is important as in 2014, the US
Surgeon General’s Report identified for the first time that cigarette
smoking not only raises the risk of vascular and other complications of
diabetes, but it is a direct causative factor for type 2 diabetes [11, 35,
36]. The risk of developing diabetes is 30–40% higher for active
smokers than non-smokers [35, 36].
The WHO estimates that tobacco is the largest cause of preventable
mortality in the world. In 2015, it was estimated there were more than
933 million smokers worldwide. Smoking is responsible for almost six
million deaths each year, or the loss of 140 million years of healthy life.
Nearly 80% of the smokers, most of them males, are coming from the
developing countries, a greater burden than malaria and HIV combined
[37, 38].
Smoking is responsible for 5–6% of all morbidity globally and its
share is rising over time [37, 38]. Tobacco use is increasing in
developing countries and if no action is taken, the number of annual
tobacco deaths is projected to rise to more than eight million by 2030,
amounting to the loss of more than 200 million years of healthy life [37,
38].
Studies have confirmed that insulin is less effective in people with
type 2 diabetes exposed to high levels of nicotine [11, 35]. Hence, those
who smoke need larger doses of insulin to control their glycaemia.
Furthermore, smokers who have diabetes are more likely to develop
macro- and microvascular diabetes complications. Unfortunately, the
Republic of North Macedonia is one of the top 10 countries of the world
in smoking prevalence, which may also be the reason for the very high
diabetes prevalence in the country [11].
As smoking is a major risk factor for CVD and diabetes, it is critical
to know the smoking status of each individual. For that purpose,
smoking status has to be recorded with the other metabolic parameters
in individual EHRs, and should be monitored at subsequent visits.
Monitoring of smoking prevalence at a national level would guide the
authorities on the further steps to be taken, and to evaluate if previous
anti-smoking policies were effective.
Psychosocial stress could also be considered as a strong, still not
adequately recognized driver for the development of diabetes. Although
suggested that emotional stress might result in diabetes almost four
centuries ago, it has just recently been reported that the majority of the
effects of psychosocial stress on diabetes risk are not mediated through
the traditional risk factors, such as hypertension, physical inactivity,
smoking, inadequate diet, and obesity [39, 40]. Studies suggest that not
only chronic stress, but also general emotional stress, anxiety, sleeping
problems, anger, and hostility are associated with an increased risk for
the development of type 2 diabetes [39, 40].
Population in developing countries is exposed to psychosocial stress
to a higher extent compared to the developed countries, due to the
higher levels of poverty, unemployment, unstable housing and limited
food access in some cases. We can again take the Republic of North
Macedonia as an example, with a sharp growth in prevalence of type 2
diabetes, especially after 1990 [11]. The strong contributor might have
been the societal transition from a centrally planned economy
guaranteeing jobs and income before 1990, to a market economy with
job and income insecurity afterwards [11]. The, so called, ‘transitional
economy’, has led to an unprecedented rise in unemployment and
associated psychosocial stress, especially among the middle-aged
population, which has largely contributed to the increase of diabetes
prevalence in the country [11].
Medications, such as glucocorticoids, some HIV medications, and
antipsychotics [2, 41], are known to increase the risk of diabetes and
should be considered when deciding if the individuals who are treated
should be screened for diabetes. Cystic fibrosis and post-
transplantation use of immunosuppressive medication are other rare
factors for the development of diabetes [2].
The assessment of risk factors or use of a risk assessment tool is
recommended to guide healthcare providers on whether to perform a
screening test for diabetes. One of such risk assessment tools that could
be used in developing countries is the ADA diabetes risk test [2]. This
diabetes risk test is based on age, gender, history of GDM, family history
of diabetes, history of hypertension, physical activity and weight.
 Another risk score test used for type 2 diabetes is the FINDRISC
(Finnish Diabetes Screening Risk) externally validated in numerous
populations with acceptable sensitivity and specificity. Diabetes risk
with FINDRISC test is calculated based on the gender, age, BMI, use of
blood pressure medications, history of high blood glucose, level of
physical activity, daily consumption of vegetables, fruits or berries, and
family history of diabetes [42].
The use of diabetes risk test might be of help to the providers to
identify higher risk individuals for further investigations. Diabetes risk
could also be recorded in the EHRs for further monitoring. If the NeHS
is in place, the monitoring of diabetes drivers should be done at each
physician’s visit and could easily be implemented in a setting with
limited resources.

What should be done to manage the diabetes drivers in

developing countries?
Each developing country should …
… set a national targets for curbing obesity, critical driver for
diabetes prevalence;
… target prediabetic population with dietary changes and
increased physical activity;
… screen every pregnant women for GDM due to considerably
higher risk for type 2 diabetes for the mother and the offspring;
… have comprehensive national policies for drastically reducing
smoking prevalence;
… enable that NeHS is used for monitoring of the diabetes drivers.

References
1. World Health Organization. World health statistics overview 2019: monitoring
health for the SDGs, sustainable development goals. Geneva: World Health
Organization; 2019.
2.
American Diabetes Association. Standards of medical care in diabetes 2020.
Diabetes Care. 2020;43(1):s1–212.
Another random document with
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dictate important policies, and particularly to lay out the secretary’s
work. The other trustees resented her assumption of superior
authority. Both factions took Betty into their confidence. One insisted
on giving her lunch; the other asked her to dinner. Mr. Morton
telegraphed for impossible details. Mrs. Post had hit upon this
busiest day of the year for cleaning Betty’s room. Feeling very young
and inadequate, and very, very sleepy, Betty escaped as soon as
possible from the trustees’ dinner, put a “Do not disturb” sign on her
door and went to bed.
The pale morning sun was creeping faintly in at her window, though
she was sure she hadn’t been asleep ten minutes, when somebody
knocked on her door. Somebody had to keep on knocking for an
embarrassing interval before Betty woke up enough to realize what
was happening, and to open the door. Connie stood outside. She
was attired in a scarlet silk kimono, the gift of her generous but
thoughtless roommate. For Connie’s washed-out hair had a decided
suspicion of red in its dull tints, and her complexion was the sort that
went with red hair and should never go with a scarlet kimono. In the
dim light of the corridor her sallow, anxious little face looked
frightened and quite ghostly.
“Did I wake you up, Miss Wales?” she demanded stupidly. “It’s four
o’clock in the morning. I saw your ‘Don’t disturb’ sign, but I suppose
it was meant for last night. Besides I—you see, Miss Wales, Marie
has disappeared.”
Betty stifled a tremendous yawn and tried to consider Connie’s news
with becoming seriousness.
“I’m afraid I don’t understand,” she said at last. “You mean she isn’t
in your room? Are you sure she isn’t in some one’s else?”
Connie nodded. “Yes—she—I’m quite sure, Miss Wales. She’s
disappeared.”
“When?” asked Betty, who was wide awake now.
“I don’t know, Miss Wales. About ten was when I really saw her last.
She had a chafing-dish party last night. I was studying with Matilda
Jones. I kept expecting Marie to come for me, as she usually does
just before they disperse, to have some of the refreshments. When
the ten-minute bell rang, I went to our room. She was there, but she
went right out for something. When she came back it was after ten,
so she undressed in the dark. At least I supposed she undressed.
When I woke up just now she was gone.”
“Oh, well,” said Betty pleasantly, “she’s somewhere in the house, of
course. She ought to be in her room in bed, but——”
“Her saddle and that big felt hat she wears when she rides, and her
corduroy suit have disappeared too, Miss Wales.”
Betty started. “They have? Then she’s probably gone on some early-
morning riding-party. Oh, dear, those crazy girls! What won’t they
think of next?”
“I don’t believe it’s a regular riding-party, Miss Wales. From things
Marie has been saying lately, I think it’s an elopement.”
Betty’s eyes grew round, and her voice quivered with anxiety.
“Please tell me all that you know about it, Miss Payson, as quickly as
you can. There may be no time to lose.” Betty closed the door softly
and began hurriedly to put on her clothes, while she listened to
Connie’s story.
“Well,” began Connie eagerly, “she’s been writing letters lately—oh,
quantities of them! She always writes a good many, but lately she’s
spent most of her time at it. And she’s cut classes a good deal. She’s
never done that before. And a few days ago she gave me six of her
dresses—two perfectly new ones. She said she shouldn’t want so
many clothes much longer. Then day before yesterday a man came
to call. I heard the girls say it was the same one she was with the
night of the prom. She was very much excited that evening, and it
wasn’t about the play, because when I spoke about that to her she
didn’t know what I meant at first, and then she said, ‘Oh, the play!’ as
if it wasn’t of any consequence to her. Yesterday morning when I
came into our room after a class she was rolling a lot of things up in
her rain-coat. I asked her what in the world she was doing, and she
—she kissed me”—Connie blushed at the intimate confession—“and
said she was just seeing how much you could tie on to a saddle,
because some one had asked her to find out. And now”—Connie’s
lips and voice quivered—“and now she’s gone. That’s all I know,
Miss Wales. I think she’s eloped on horseback with that man from
her home in Montana.”
“But that would be so perfectly absurd!” Betty was dressed by this
time. She twisted her hair into a hasty knot, and put on a droopy hat
to hide the snarls. “Have you ever heard Marie speak of riding to any
of the little towns around here, Miss Payson? Was she especially
fond of any little village near here?”
Connie considered for a minute. “She likes the ride to Gay’s Mills,
because it’s all the way through the woods. And she’s been over
there twice lately. She went riding day before yesterday,—we all
thought it was queer for her to go riding on the day of the play—and I
think from something she said that she lost the girl she started out
with, and maybe met some one else.”
“What girl did she start with?”
Connie mentioned the name of the sophomore who, being
proverbially unlucky with horses, had fallen off on the famous
Mountain Day ride.
“I see,” said Betty curtly. She was perfectly sure that, unless
Montana Marie had meant to lose her, she would never have gone
riding with that particular girl. “Please telephone Grant’s garage,”
Betty ordered swiftly. “Tell them to send up a car at once, and a man
who knows the country roads. Say it’s for me. If they object to the
early start tell them it’s a matter of vital importance. If that’s not
enough, hold the wire and call me. I shall be in Mrs. Post’s room. I
hate to bother her, but I can’t very well go alone.”
“Couldn’t you take me?” asked Connie eagerly.
Betty considered. “Why—yes—yes, that might be quite as well. Then
you go and get ready, while I do the telephoning.”
Twenty minutes later Connie and Betty were flying along the road to
Gay’s Mills. It was a slender chance, but in the absence of other
clues it must serve. Connie confided to Betty that she had never
been in an automobile before.
“It doesn’t matter,” Betty told her absently. “Oh, I beg your pardon. I
don’t believe I quite understood what you said.”
Connie lapsed into rather frightened silence, and Betty was left free
to consider the situation. “Undertaking” Montana Marie O’Toole
looked, this morning, like a pretty serious business. If she really had
eloped, what would Mrs. O’Toole say? And what would President
Wallace think? Not much use getting her through mid-years for an
ending like this. But somehow Betty couldn’t believe that her
freshman would be so foolish. She almost ordered the chauffeur to
drive back to the campus; she was sure they would find that Georgia
was missing too, and the other riding people. Then suddenly she
remembered the maid and the groom, as she had thought them,
talking by the Morton House door, and Montana Marie’s belated
arrival at Mrs. Post’s treat. Was an elopement perhaps the kind of
thing that you didn’t rehearse? Betty’s heart sank. Perhaps she
ought to have called Mrs. Post and divided responsibilities. Perhaps
she ought even to have aroused Prexy. Certainly she ought to have
had a better reason than Connie’s vague surmises for choosing the
Gay’s Mills road. The Gay’s Mills road turned sharply just then, and
Betty saw two horseback riders trotting decorously to meet her—
Montana Marie in her Western riding things, including the forbidden
magenta handkerchief, and a man whom Connie identified briefly
with an excited ungrammatical little squeak.
“It’s him!”
 CHAPTER XIX
LIVING UP TO HARDING

“Sh!” Betty warned her hastily, because of the chauffeur, and leaning
forward she ordered him to stop. “I want to speak to those people,”
she explained briefly.
Just then Montana Marie, who had the sun in her eyes, recognized
Betty, and triumphantly announced the discovery to her companion
in her shrillest tones. “It’s Miss Wales come after us. What did I tell
you?”
Then she slipped off her horse, and with the reins thrown over her
arm came to meet Betty, while the man from Montana, looking very
glum and very foolish, prepared to stay where he was.
But, “Come on, Fred, and meet Miss Wales,” Montana Marie
commanded imperiously, and he dismounted in turn and followed
Marie.
“You needn’t have come after us,” Marie began smilingly. “We were
just going back of ourselves. I happened to think that you wouldn’t
like it.”
“Then you haven’t——” began Betty eagerly.
“Haven’t eloped?” finished Marie easily. “Oh, no, not yet. We weren’t
half-way to Gay’s Mills when I happened to think how you’d feel. And
ever since we’ve been standing in the road, up there at the top of the
hill, arguing about it, haven’t we, Fred?”
The boy—he looked younger than Marie—nodded sullenly. “Not
arguing exactly,” he amended. “You just kept saying over and over
that you wouldn’t go on.”
“Until I’d seen Miss Wales,” amended Marie calmly. Then she looked
at the car, and, apparently noticing Connie for the first time, called
out cheerfully, “Hello, roomie! Too bad I waked you out of your early-
morning nap with that squeaky door.”
“Good-morning,” Connie quavered back in a frightened voice.
“We ought to get rid of her and of that chauffeur,” declared Marie
competently. “Why not all go home now, and then I can come to see
you this morning, Miss Wales, whenever you say.”
This was such an amazing proposition from the chief eloper, that
Betty stared at it for a moment.
“You can trust us to follow right along, Miss Wales,” said the man
from Montana quietly. “Or better still, Marie can go back with you,
and I’ll lead her horse home. I guess that’s the best way, Marie.”
Betty took a sudden liking to the man from Montana. There was
something very straightforward and businesslike about him, and his
sulks were only natural under the circumstances.
“All right,” agreed Marie, having considered the proposal for a
moment. “Only give me my saddle-pack. It might jog loose without
your noticing, and it has my silver toilette things in it, and all my
pictures of you, Fred.”
So Montana Marie O’Toole, bearing the precious possessions which,
for reasons known only to herself, she had chosen to bring with her
on her elopement, placidly took her seat in the tonneau, between
Connie and Betty; and all the way home she chatted composedly,
instructing Connie in the lore of automobiling—quite as if an early-
morning elopement (that did not come off) was a part of her daily
routine.
“Don’t you tell anybody about Fred and me,” she ordered Connie,
when they were back at the Morton. “And say, take my rain-coat and
empty it out, before the girls get a chance to see it and wonder what
it means. I’m going to talk to Miss Wales.”
But once alone with Betty, she broke down and cried, dabbling at the
tears with her magenta handkerchief.
“Maybe you think I don’t want to marry Fred,” she wailed. “Maybe
you think I didn’t get Ma interested in American colleges on purpose
so Fred and I could be nearer together. It takes two weeks for letters
from the Bar 4 ranch to get to Paris. Think of the things that can
happen on a ranch in two weeks. From Bar 4 to Harding is only four
days. Of course a college in Montana would have been still better,
but Ma would have seen through that. Oh, dear, what shall I do, Miss
Wales?”
“Send your friend about his business, go home in June, tell your
mother about your engagement,—if you are engaged,—and have a
pretty wedding in your own home, when you and your family decide
that it is best for you to be married.” Betty was trying hard to act the
part of sensible, middle-aged adviser to heedless youth, though she
felt extremely unequal to the rôle.
“That sounds lovely,” wailed Montana Marie, “but the trouble is, you
don’t know Ma.”
“I know she’s very fond of you,” began Betty.
“But she’s a lot fonder of a ridiculous idea she’s got into her head of
having me marry a duke, or a prince, or some other horrid little
foreigner. That’s what she’s designed me for, ever since I was born
and Pa struck it rich on the same day. She’s always thought it was a
sort of providence. And my being in love with Fred doesn’t make the
least particle of difference to her.” Marie sobbed again forlornly. “I
’most wish we had gone right on and got married this morning.”
“Oh, no, you don’t,” Betty assured her earnestly. “Think how
ashamed I should have felt, and how all the college would have been
talked about and laughed at on your account.”
Marie brightened visibly. “I thought of that myself. That’s exactly why
I wouldn’t go on. Out in Montana lots of girls just ride off and get
married on the spur of the minute. But it’s different here, isn’t it? I felt
that it was, after we’d started. And it’s different with me. After you’ve
been to school in Paris, and to college for nearly a year, and have
traveled a lot, you can’t do the way you could if you’ve lived your
whole life in a mining camp. I thought when I put on my Western togs
that I’d get into the spirit of the occasion, but I didn’t. I felt silly.”
“Was it your idea?” asked Betty curiously.
“Oh, yes,” acknowledged Montana Marie, “it was every bit my idea.
Don’t you blame it on Fred. His only reason for coming East was to
make sure that nobody had cut him out. You see he didn’t
understand about the businesslike nature of the Prom. Man Supply
Company. Miss Wales——”
“Yes.”
“Do you suppose you could possibly persuade Ma to let us be
married?”
“If you’ll send Fred home and finish your year’s work here properly,
I’ll try.”
Montana Marie considered. “All right. I can promise that much
without any trouble. I told Fred that I’d rather elope out West than
here, if we had to do it at all. Ma wants to take me to Europe again
for the summer, but I shall just put my foot down that I’ve got to see
my father first. Then if you haven’t persuaded her by that time——
Oh, Miss Wales——”
“Yes,” encouraged Betty smilingly.
“If Georgia Ames sent Ma an invitation to commencement, I think
she’d come. That would give you a chance to talk to her, and talking
is better than writing any day.”
Betty agreed that it was.
“And you must talk to Fred before he goes, so you can see what a
nice boy he is. Ma ought to see that what we need in our family isn’t
a silly title nor more money, but brains and good sense and nice
manners. Fred has all those.”
Betty promised to talk to Fred later in the morning, and Marie
prepared to depart. After she had opened the door she came back to
ask a final question.
“Miss Wales, when you promised to undertake me last summer, you
didn’t guess why I wanted to come to Harding College so badly, now
did you?”
“Why, no,” said Betty. “I thought you were coming for what you could
get out of it,—the fun and the experience and the education.”
“Whereas,” Marie took her up, “I was coming to be nearer to Fred,
and to have a chance to marry him. But I did get the fun and the
experience and the education too. So you haven’t wasted your time,
Miss Wales.” Montana Marie held up her flower-like face for a kiss.
Up in her own room Montana Marie changed into a linen dress,
discoursing meanwhile to Connie on the merits of a college
education. “Concentration is all right. That is going to come in handy
whatever we do later. But the best thing about a college education is
the way you have to live up to it. So many people are nice to you and
help you along. You can’t make them sorry they did it. All my life
people are going to find out that I was at Harding for a year—well, at
least a year,” put in Marie hastily. “And after the royal way I’ve been
treated here, I’ve got to live up to Harding. I wish I’d thought of that
sooner, but I was certainly lucky to think of it when I did.”
Later she expatiated upon the same thesis to Betty and the man
from Montana, whom she had conducted to Betty’s office for the
promised interview.
“Maybe,” said the boy with a whimsical smile, “maybe I’m not up to
Harding standards, Marie. This year at college has changed you—I
can see that. Maybe I’m not——”
“Nonsense!” cut in Marie, and slammed the door after herself. The
next minute she stuck her head in to say, “If you’re not up to them,
you’ll have to improve, that’s all. Because you and I——” she backed
out and shut the door—softly this time.
That night Straight Dutton trilled outside Betty’s window. “Come out
for a speck of a stroll,” she begged. “It’s lovely lilac-scented
moonlight out here, and I’ve got a jist to tell you. It’s about your
freshman.”
Wondering anxiously if Montana Marie’s attempt at an elopement
could have been discovered, Betty hurried out to meet Straight.
“I’ve discovered why she came to Harding,” Straight began with
gratifying promptness. “And it’s just as queer and ridiculous as you’d
expect her reason for doing a good sensible thing to be.”
“Yes?” queried Betty, her heart sinking lower with Straight’s every
word. If Straight knew, all the college knew. Even if the newspapers
didn’t get hold of it, it was bad enough; and if they did——
“How did you find out, Straight?” she asked desperately.
“She told me.” Straight was too much amused by the absurdity of the
reason to notice Betty’s perturbation. “She didn’t mean to tell, but I
got it out of her.”
Betty met this disclosure in annoyed silence.
“Want to guess?” asked Straight gaily. “But you never could. She
came to learn American slang, so she can fascinate the French
nobility with it. She says they all adore American slang. She says I
have taught her more than any other one person, and so when she’s
married to a count or a duke or an earl—what’s a French earl, Betty?
—she’s going to ask me to the wedding to show her undying
gratitude. Isn’t that absurd? And yet she means every word of it.”
“Oh, Straight, dear!” Betty laughed at her merrily. “What perfect
nonsense! Even Montana Marie isn’t so absurd as that. She was
paying you up for the weird tales of Harding customs that you told
her last fall.”
“Oh, I don’t think so,” said Straight positively. “She’s forgotten all
about those weird tales. Well, if this isn’t her real reason, I’ll bet the
real one is just as comical. Montana Marie O’Toole never struggled
into Harding College just to learn a little Latin and less Greek.”
“Maybe not,” agreed Betty solemnly. “Very likely you’re right,
Straight.”
“When I flap my invitation to the duke’s wedding in your face,”
declared Straight solemnly, “then you’ll see that I am. Fluff and
Georgia and Timmy and I are compiling her a dictionary of slang for
our parting present.”
“Be sure you dedicate it ‘To the Champion Bluffer,’” advised Betty,
her eyes dancing at the thought of Straight’s probably speedy
disillusion. “And now I must really go in, Straight. I have dozens of
things to do.”
“Wait a minute,” Straight begged, desperate in her turn. “Betty
Wales, twins are twins. If Georgia and Fluff are going to be in a
wonderful new tea-shop in New York, what’s to become of me? Can’t
there be a place for me too? Fluffy won’t do anything unless I’m
there to keep her cheerful and help her decide things. Can’t there be
a place for me too? I know I’m not clever like Fluffy, nor pretty. My—
hair—doesn’t—curl. But twins are twins, Betty Wales.”
Betty patted her shoulder comfortingly. “I’ll think. If Emily Davis goes
back to teaching, perhaps Georgia could be here, and you and Fluff
—or you two could be here. Well, I’ll think, Straight. I ought to have
thought sooner. I wish I had a twin to keep me cheerful and help me
decide things. I need one this minute worse than Fluffy ever did in
her life. Now I must go.”
Straight stared after her wonderingly. “She needs a twin! Good
gracious! If she was twins, I guess there isn’t anything in the world
she couldn’t do. And yet for all she’s such a winner, she knows what
it means to be just a plain straight-haired twin like me. She’ll manage
about fixing a place for me. And she shan’t ever be sorry she did.
Now I can go to the last meeting of the Why-Get-Up-to-Breakfast
Club and be the life of the party.”
Meanwhile Betty Wales, quite appalled by the day’s complications,
was getting them off her mind by writing to Jim. “Here are a few of
the things I have on hand just now,” she wrote. “Stopping
elopements, deciding on the eligibility of strange suitors, persuading
eccentric mothers to let their daughters marry, fitting two twins into
the position that one twin will fill. So of course I can’t come to New
York again until after commencement, and you must persuade Mr.
Morton that it doesn’t matter a bit. Which is as nice a job as most of
mine.”
 CHAPTER XX
CLIMAXES

“Ma’s coming, all right!” Montana Marie told Betty gleefully, a week or
so after the elopement that didn’t come off. “I told her it might be her
last chance at a Harding commencement, and she thinks that means
that I’m to be in gay Paree with her again next winter, so she’s in a
very good humor. I hope it’s ripping hot weather for commencement.
Hot weather wilts Ma right down, and makes her easier to manage.”
A few days later Marie had another announcement to make. “Pa is
coming East too. Georgia addressed her invitation to Mr. and Mrs.
James J., just out of politeness. Now she is wild on the question of
tickets for things. If Pa really comes here, her sister Constance will
have to go on standing room to the senior play and the Ivy concert.
For my part I’m crazy to see Pa, but I don’t imagine he’ll care much
about these commencement doings. His real reason for coming East
is to hire an architect in New York—I don’t know what he’s going to
build, but I wrote right back and told him about your friend Mr.
Watson.” Marie giggled amiably. “That address that Mrs. Hinsdale
gave me is forever coming in handy.”
Betty wished, quite unreasonably, that Marie’s memory for addresses
was shorter, or her interest in Jim’s career less personal. Whatever
Mr. O’Toole meant to build, it would probably be built in Montana;
and Montana is a very, very long way from Harding. It was much
nicer having Jim in New York.
Meanwhile Betty was far too busy to spend much thought on the
O’Toole family’s affairs; when Mrs. O’Toole actually appeared on the
scene, it would be time enough for bothering with her. 19—’s third
year reunion was equally imminent and much more interesting. Of
course the members who lived in Harding were depended upon to
attend to all such details as boarding places and class supper, to
plan for informal “stunt-meetings,” and to arrange a reunion costume
that should go far ahead of that worn by any other returning class.
Besides all this, the B. C. A.’s had decided to give a party for 19—.
Madeline had glibly agreed to plan it, and had got as far as confiding
to all her friends that this time she had really thought of something
extra-specially lovely, when the Coach and Six took her to New York,
and Agatha Dwight’s interest in the fairy play kept her there. At first
the B. C. A.’s waited hopefully for her return. Then they held a
solemn conclave to discuss their dilemma. But the only plans they
could evolve seemed so prosaically commonplace beside Madeline’s
most casual inspirations that they continued to wait, this time with
the calmness born of despair. For the B. C. A. invitations had been
sent out broadcast to all 19—ers, and though 19— could have an
absurdly good time over “just any old thing,” it wasn’t “just any old
thing” that they would expect of the B. C. A.’s. Finally Betty wrote to
Roberta Lewis, who would be passing through New York on her way
up to Harding. “Capture Madeline,” she ordered summarily. “Bring
her up here if you can, but anyway make her tell you about the B. C.
A. party. Don’t come away without her plans for it, on penalty of
being put out of the Merry Hearts—almost.”
Luckily for Roberta, Madeline was easily captured. She was sulking
in solitary state in her studio apartment, because, though Agatha
Dwight liked the fairy play tremendously, no manager could be found
to put it on.
“They say, ‘Stick to your old line,’” grumbled Madeline. “As if the one
play I’ve written—about a modern woman—was a line. They say,
‘New York doesn’t care for fairies.’ As if every sensible person wasn’t
born caring for fairies—the really-truly mystic sprites like mine. Oh, I
suppose the thing’s not good enough! Anyway I won’t grumble about
it any more. I’ll plan a B. C. A. party that will make dear old 19—
laugh itself sick. Not a fairy party—a—a germ party, Roberta. You
shall be the Ph. D. Germ—in an Oxford gown with a stunning scarlet
hood. I shouldn’t wonder if Miss Ferris will lend you hers. Then
there’ll be the Love Germ, and the Wedding Bells Germ, the Club
Germ, the Society Germ, and the Germ of a Career. And little Betty
Wales shall be the college girl that they all viciously attack. It shall be
a play with a moral,—one of nice old Mary’s nice little morals. And
the moral shall be: ‘It isn’t the Germ you like that gets you; it’s the
Germ you can’t live without.’ Could you imagine life without a Ph.D.,
Roberta? If you could, then the modern microbes are still fighting
their hardest for you, and the Love Germ will get you yet if you don’t
watch out. But Betty is the ideal object for the attack of the modern
microbes, because she’s a little of everything, except possibly clubs.
Whereas, the Society microbe wouldn’t look at you, Roberta. It would
run away at your approach.”
“Will you come up to Harding to-morrow?” asked Roberta anxiously,
ignoring the aspersion upon her ability to be a society butterfly.
“This afternoon if you like,” Madeline returned, as calmly as if she
hadn’t been implored by every mail for two weeks past to come up
and help with the reunion arrangements.
The B.C.A. party turned out a Merry Hearts’ party. Roberta Lewis
made a beautiful Ph. D. microbe, with her hair “scrunched back”
under a mortar board, big spectacles, and a manner copied from an
astronomy instructor who was universally known in Harding circles
as Miss Prunes and Prisms. Roberta hadn’t acted since the senior
play, she said, but she was in splendid form nevertheless. So was
K., who, as the Pedagogic Microbe, delivered a speech founded on
her personal experiences that brought down the house.
“You must each make up her own part,” Madeline told the cast, when
they met for the first (and only) rehearsal. “I haven’t had time to write
out the speeches. Babbie, you ought to know how to lobby for the
society act. You liked it pretty well that first winter you were out of
college. Eleanor, you’re in love; well, explain the sensation. Babe,
you don’t act as if marriage was a failure; speak up for it. Nita, you’re
not a really energetic club-woman, I’m happy to say, so here are
some few ideas to help you out. I shall speak of a career from bitter
experience. Betty, all you have to do is to look thoughtful while we
talk, and scared while we fight for you. At the end, when we decide
to give you your choice, you are to explain that, since the world is too
full of a number of things,—namely modern microbes,—the thing to
do is to shut your eyes and decide which one you can’t live without.
And until you’ve decided, you propose to enjoy life all around. See?
I’ll write out your speech, if I can get time, because it ought to be
exactly right, to get the best effect. Fire away now, Roberta.”
The rehearsal proceeded amid wild confusion. Madeline coolly
advised the cast to improve their lines, reminded them encouragingly
that the costumes would help out wonderfully, and departed, to
compose a new ploshkin song, while the supper committee, to whom
she had promised it weeks before, waited patiently on her door-steps
to seize and carry it to the printer.
The B. C. A. party was sandwiched in between a thunder-shower
and the Glee Club’s commencement concert. The stage was an elm-
shaded bank, the audience room as much of the adjacent back-
campus as would hold 19—, and a few stray specimens of its
fiancés, its husbands, and its babies. The “show” was cheered to the
echo, and the “eats” which followed, carefully selected from the Tally-
ho’s latest and most popular specialties, were voted as good as the
show.
“Of course,” the supper committee chanted, besieging Madeline
while she ate, “of course we want it repeated with the class supper
stunts.”
Madeline waved them away with a spoonful of strawberry ice.
“Talk to the cast. This is one piece of idiocy that I’m not responsible
for. Oh, I helped plan it, and I wrote the moral. That’s positively all I
did. Congratulate K. and Roberta, not me. And have it again for class
supper if you really want it. Couldn’t we run in the class animals for a
sort of chorus—‘Beware the Love Germ, 19—ers,’ and so on.
Ploshkins and Red Lions, and Jabberwocks and Ritherums would
make a lovely Moralizing Chorus. Yes, I’ll write it, but I won’t make
wings for any more animals. I’ve decided that I’m too old and too
distinguished to make any more animals’ wings.”
19—’s class supper was at the Tally-ho—of course. T. Reed had
brought little T. to the reunion, and little T. had brought his big
ploshkin mascot to the supper. The undistinguished Mary Jones and
her plain, frizzle-haired little girl were there with the class loving-cup.
All the old cliques and crowds were there, sitting as they used to sit,
but fused, by the esprit de corps that no class had quite so strongly
as 19—, into a big, splendid, happy whole. Eleanor was toast-
mistress again. It was once toast-mistress, toast-mistress forever,
with 19—. Jean Eastman had a speech called “Over the Wide, Wide
World,” all about wintering in Egypt and buying rugs in Persia and
yachting in the strange South Seas. T. Reed had one on “Such is
Life,” all about raising babies and mushrooms and woolly lambs on a
ranch in Arizona. Nita’s was called, on the menu-card, “Keep your
eye on the Ball,” and it was a funny muddle of all the finest things
that 19—ers had done by everlasting keeping at it. Roberta’s degree
was one of the fine things, and Christy’s fellowship; and Madeline’s
play was the grand climax, only Madeline spoiled the rhetorical effect
by calling out, “Nita, you know I always do things by not keeping at
them. I hereby refuse to point your moral and adorn your tale.”
In the midst of Nita’s speech Betty Wales disappeared. The few girls
who saw her go thought that she was modestly trying to escape
hearing her praises sounded by Nita, as one of the people 19— was
proudest of. Helen Adams, who had noticed Nora come in and speak
to Betty, thought that some domestic crisis demanded her attention,
and hoped she wouldn’t have to stay in the kitchen very long. For
Helen had a speech herself by and by, and she had planned to get
through it by looking right into Betty’s intent, encouraging little face.
But Betty didn’t get back in time for Helen’s toast nor for the two that
came after it. The stunt-doers were gathering in Flying Hoof’s stall to
put on their costumes, and the rest of the girls were pushing back
their chairs to face the platform that Thomas the door-boy had built
in front of the fireplace, when Betty Wales got back. She looked as if
the domestic crisis had been of a strenuous sort, but at last happily
terminated. Her face was flushed, and her hair curled in little damp
rings on her forehead. But her expression was as serene as
possible, her eyes sparkled with fun, and her dimples just wouldn’t
stay in, though she tried to be duly serious over having lost half the
toasts—and half the supper too.
“But the stunts haven’t begun, have they? Does ours come first? Did
any engaged girls run around the table that we don’t know about
already? Little Alice Waite! Oh, how nice! Don’t begin our stunt just
yet. I want to speak to Madeline a minute. Oh, well, never mind, if
they’re all waiting.”
So the “College Girl and the Modern Microbes, with a Moralizing
Chorus of Class Beasts,” went at once on the boards. Betty Wales
was no actress; not even her warmest admirers had ever imagined
that she possessed histrionic ability, and it was only to satisfy a whim
of Madeline’s that she had taken what she laughingly dubbed “a
regular stick part” in the Germ play. But at the class supper
performance she surprised everybody by her vivacity. She informed
the Ph. D. Germ that she’d better take a course in doing her hair
becomingly. She mocked the Pedagogic Germ with the hated epithet
“Schoolma’am! schoolma’am!” She caught the Love Germ by an
insecure white wing, and assured it that nobody fell in love with girls
who were just pinned together. All through the contest of the Germs
for her she kept interjecting remarks in a disconcertingly unexpected
fashion. And at last the time came for the moral. Betty hesitated just
a minute, and then began her one regular speech. She began it just
as usual, and she went on just as usual until she came almost to the
end: “So the thing to do is to shut your eyes and decide which one
you can’t do without.” At this point she shut her eyes for an
impressive moment. Then she opened them, and, with a half-
frightened, half-merry look at Madeline, she walked up to the Love
Germ and the Wedding Bells Germ, and dragged them, one on each
side of her, to the front of the platform.
 “I’VE SHUT MY EYES AND I’VE CHOSEN”
“And so I’ve shut my eyes and I’ve chosen, and—please everybody
congratulate me quick! Eleanor Watson first, please, Eleanor dear.”
Betty Wales ran down from the platform, still dragging the winning
Germs after her, and followed by a riotous mob of other Germs and
Class Animals, which was speedily joined by another mob of all the
finest class of 19—.
There were no more stunts that night. When the supper committee
stopped trying to get a chance to congratulate Betty and hear how it
all happened, why, by that time it was much too late for stunts. It was
time—and long past time—for the class march to the other suppers,
to return serenades and congratulations, and then to visit “Every
Loved Spot on the Whole Blessed Campus,” as the new ploshkin
song put it, and to sing the ploshkin song and the other reunion
favorites until everybody was hoarse enough and tired enough to be
ready to stop reunioning—and that meant extra-specially hoarse and
extra-specially tired; and time in plenty was needed for its
accomplishment.
When it was all over, nobody knew anything about Betty’s
engagement, except that it was to Jim Watson.
“I was out of the room when they ran around the table,” she had
explained over and over. “So I just spoiled Madeline’s lovely moral to
tell you. But she says she doesn’t mind, and I wanted you all to
know, while we’re here together, how blissfully happy I am.”
“After the rest are out of the way the Merry Hearts will meet in the
Peter Pan Annex, top story.” So the word went round, when 19—
was finally ready to disperse. “The fifteeners went to bed ages ago,
so it’s empty. We don’t want to go to bed.”
“I should say not,” each Merry Heart acknowledged the news of the
rendezvous. “We want to hear all about Betty Wales.”
“Yes, Jim came up to-night unexpectedly. Where is he now? In bed, I
certainly hope,” said Betty Wales. “Ye-es, he’d asked me before, but
he never asked me—hard enough. And then Madeline’s rule—
whether or not you can live without a person—or a thing—is ever so
much easier to apply when you’re maybe going to lose the person
for a long, long time.”
“And were you going to lose Jimmie for a long time?” inquired
Eleanor, who didn’t know any more than the rest how the great
desire of her heart—second only to her plans for her own and Dick’s
happiness—had suddenly become a reality.
Betty nodded proudly. “He’s got a splendid big commission. It’s to
build a town—a whole nice little new town—factories, schools,
houses, everything, at a mine and a water power that Mr. O’Toole
owns. First he’s got to go to Germany to work up some plans for it. It
will all take several years. And I saw that I couldn’t get along without
——”
“Stop! That’s a very dangerous moral,” cut in Madeline hastily. “Don’t
keep repeating it around here, or somebody else may be infected
with the Love Germ.”
“Very well,” agreed Betty gaily, “then I won’t say over the dangerous
moral. But—the town he has to build is thirty miles from a railroad
that hasn’t been built. I mean—the town isn’t there yet either. And it
will be on a railroad by and by, but it isn’t now. Wouldn’t it be losing
Jim pretty hard to have him away off there without me?”
“How about the Coach and Six?” demanded Madeline severely.
Betty went on smiling her happy little smile. “I’ll have to start it off
somehow before I go. Mr. Morton will understand. He likes Jim. Oh,
and when I’m gone there will be a place for Straight. So the twins are
settled, and that’s one thing off my mind.”
“Who’ll undertake Montana Marie O’Toole?” demanded Madeline
inexorably. “She isn’t a thing that you can start off and then leave to
go on by herself in proper style.”
Betty laughed. “I don’t know about that. It’s Mr. O’Toole who has
commissioned Jim, on Marie’s recommendation, to build the town.
So she’s really responsible about Jim and me. I’m going to tell her
to-morrow that, since she can plan things so well for other people,
it’s time she managed her own affairs better. That is, of course I shall