Diabetes Voice by International Diabetes Federation

Global perspectives on diabetes

Volume 59 â&#x20AC;&#x201C; March 2014

The double burden of diabetes and disaster

13 DiabetesVoice

Contents

Diabetes Views

News in Brief

International Diabetes Federation Promoting diabetes care, prevention and a cure worldwide Diabetes Voice is published quarterly and is freely available online at www.diabetesvoice.org.

g l o b a l c a m pa i g n Taking big steps: a look back at World Diabetes Day 2013

Diabetes care in Rwanda: against all odds

Merry Rivas González and Lorenzo Piemonte

Crispin Gishoma

Report on the World Diabetes Congress 2013 Melbourne

Anne-Marie Felton

The Melbourne Declaration on Diabetes

Adrian Sanders

h e a lt h d e l i v e r y Testing the limits: the double burden of diabetes and disaster

Elizabeth Snouffer, Talia Raab, Juvy Holasca, Stéphane Besançon, Assa Traoré Sidibé, Bah Traoré, Djibo Amadou, Paulette Djeugoue, Anne-Laure Coulon, Serge Halimi and Carolyn Robertson

clinical care Diabetes treatment and cancer: five years after ‘breaking news’

Debate: long-term safety of insulin in type 2 diabetes

Andrew Renehan

Sarah Holden, Craig Currie and Steve Bain

The Asian diabetes phenotypes: challenges and opportunities

Juliana CN Chan, Roseanne Yeung, and Andrea Luk

Addressing the challenge of GDM in the developing world: perspectives from rural western Kenya

IDF Diabetes Atlas reveals high burden of hyperglycaemia in pregnancy

Sonak D. Pastakia, Beryl Ajwang’ Onyango, Mercy Nabwire Ouma, Astrid Christoffersen-Deb and Carolyne Cherop

Ute Linnenkamp

Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) 2014: fact, frustration and future needs 56

This publication is also available in French and Spanish. Editor-in-Chief: Rhys Williams Managing Editor: Olivier Jacqmain, diabetesvoice@idf.org Editor: Elizabeth Snouffer Editorial Assistant: Agnese Abolina Advisory group: Pablo Aschner (Colombia), Ruth Colagiuri (Australia), Maha Taysir Barakat (United Arab Emirates), Viswanathan Mohan (India), João Valente Nabais (Portugal), Kaushik Ramaiya (Tanzania), Carolyn Robertson (USA). Layout and printing: Ex Nihilo, Belgium, www.exnihilo.be All correspondence and advertising enquiries should be addressed to the Managing Editor: International Diabetes Federation, Chaussée de La Hulpe 166, 1170 Brussels, Belgium Phone: +32-2-538 55 11 – Fax: +32-2-538 51 14 © International Diabetes Federation, 2014 – All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permission of the International Diabetes Federation (IDF). Requests to reproduce or translate IDF publications should be addressed to the IDF Communications Unit, Chaussée de La Hulpe 166, B-1170 Brussels, by fax +32-2-5385114, or by e-mail at communications@idf.org. The information in this magazine is for information purposes only. IDF makes no representations or warranties about the accuracy and reliability of any content in the magazine. Any opinions expressed are those of their authors, and do not necessarily represent the views of IDF. IDF shall not be liable for any loss or damage in connection with your use of this magazine. Through this magazine, you may link to third-party websites, which are not under IDF’s control. The inclusion of such links does not imply a recommendation or an endorsement by IDF of any material, information, products and services advertised on third-party websites, and IDF disclaims any liability with regard to your access of such linked websites and use of any products or services advertised there. While some information in Diabetes Voice is about medical issues, it is not medical advice and should not be construed as such.

David Hadden and David McCance

ISSN: 1437-4064

DIABETES IN SOCIETY

Cover photo : © Ed Kashi On the Cover: 13-year-old Reem at Al Za'atri refugee camp for Syrians, near Mafraq, Jordan on Nov. 25, 2013.

New IDF Guideline for managing type 2 diabetes in older people 58

Trisha Dunning, Alan Sinclair and Stephen Colagiuri

Diabetes voices: the power of learning for life

V OICEBO X

March 2014 • Volume 59 • Issue 1

62 66

DiabetesVoice

Diabetes views

Worldwide wake-up call

Diabetes is the unresolved development issue of the 21st century

The newly released 6th edition of IDF Diabetes Atlas reports that the number of people living with diabetes rose cataclysmically to 382 million in 2013. Our evidence shows that diabetes prevalence will skyrocket by 2035. By that time, nearly 600 million people will live with diabetes, and approximately 470 million will have impaired glucose tolerance. Put another way – 1 in every 8 people worldwide, 1 billion people, will live with or be at risk of diabetes. For the 21st century diabetes is a wake-up call. These astounding statistics do nothing to represent the all-to-often preventable death of one man, woman or child from all forms of diabetes. Statistics have a way of becoming faceless revelations, the scope of which unjustly diminishes the significance of millions of lost lives, as well as the plight of poverty and suffering attributable to diabetes. Diabetes in all its destructive forms is not only a health crisis. It is an unresolved development issue for low- to middle-income countries worldwide. There is no economic advantage or political usefulness in ignoring the diabetes pandemic, but statistical evidence asserts our world is doing just that. The International Diabetes Federation (IDF) and its Member Associations battle against the steady rise of diabetes. We have a formidable arsenal of tools – preventive strategies, life-saving therapies, and the dedicated activity of a global consortium of advocates, experts, researchers and medical professionals. Despite this we are losing the fight to protect both people at risk and those without care, but also economic growth and stability for developing countries.

Our greatest challenge to fostering government action will be providing political leaders and policy makers with strong evidence for taking on and achieving the UN NCD targets. This is an integral part of IDF’s Global Advocacy objective. It is with great admiration that we can celebrate a sign of progress just on the heels of World Congress in Melbourne. The Melbourne Declaration on Diabetes was officially launched on 2 December 2013. It was agreed and signed by 50 parliamentarians. They are committed to ensuring diabetes is high on the political agenda in every country, encouraging prevention, early diagnosis, management and access to adequate care, treatment and medicines. I would like to pay tribute to Guy Barnett who worked hard to bring the parliamentary forum together in Melbourne. My gratitude goes out to Hon. Judi Moylan, who has generously accepted being IDF’s Global Coordinator of our Global Network of Parliamentary Champions for Diabetes along with British MP Adrian Sanders as President. Simon Busutti MP, of Malta and Dr. Rachel Nyamai MP, from Kenya will serve as Vice-Presidents. With their leadership, and the commitment from other parliamentarians worldwide, IDF’s mission will achieve greater gains. Our challenge is global, and now with a global response at the highest level we must succeed in garnering appropriate attention, support and funding to quell the rise in diabetes worldwide.

In 2011, history was made with the adoption of the UN Political Declaration on Non-communicable Diseases (NCDs) which included diabetes. In November of 2012, UN member states agreed on the first-ever comprehensive Global Monitoring Framework for the Prevention and Control of NCDs including a set of voluntary global targets and indicators to stop the rise in chronic killers like diabetes and obesity. In 2013, foundations of the global NCD architecture to accelerate progress were adopted. The approved set of nine global targets and 25 indicators are milestone achievements. They send a strong message that all countries must be committed to a reduction in premature deaths from NCDs, by 25% by 2025. Advancing voluntary global targets at a time when political agendas are rich with a variety of competing interests can instigate opposition.

DiabetesVoice

Michael Hirst President, International Diabetes Federation

March 2014 • Volume 59 • Issue 1

Diabetes views

Several kinds of battle

Several different battles are illustrated by the contents of this Issue of Diabetes Voice. The first of these is the battle individuals face to maintain any kind of diabetes self-care in the wake of cataclysmic natural disasters – hurricanes, typhoons, inundations, earthquakes, forest fires or whatever form these disasters may take.

People who don’t succumb from the disaster itself face a serious battle to survive with reasonable health in its aftermath. In addition to the shelter, clean water and food that they and everyone around them require, people living with diabetes urgently need more specialist support to keep them alive and well – the kind of support organisations such as SEMPER (Stanford Emergency Medicine Program for Emergency Response), Insulin for Life, Sweet Alert and other similarly altruistic organisations can provide. These are at the leading edge of the swift humanitarian responses that are needed to ensure that those who have diabetes can claw their way back to a reasonable existence. The particular example of this in these pages is that of Typhoon Haiyan in the Philippines which, in November last year, shocked us all with its extreme, brutal violence. Though several months have now passed since that occurred, the need for assistance goes on and will continue for some considerable time. The second battle is that which individuals face when battles of a more obvious kind are raging all around them – in war zones such as Syria and previously in Mali. If, as has been said, ‘the first casualty of war is truth’ then its second casualty, not far behind, is order. Social order is a prerequisite for delivering essentials for the care of any long-term condition and without that social order all is chaos. In the case of diabetes these essentials may be insulin and the means by which to administer it, oral hypoglycaemic and other oral agents or the kit and equipment needed for the monitoring of blood glucose. Like me, I’m sure your heart will bleed when you read our article on conditions in the heat of the battle in Syria. The third type of battle is the hidden, silent battle which takes place at the molecular and cellular levels in those in whom a cancer is developing. The relationship between diabetes and cancer (a ‘double whammy’ if ever there was one) is featured in several contributions to this Issue. Andrew Renehan reports on a number of aspects of this relationship including the question of whether insulin treatment in people with type 2 diabetes increases the long-term risk of developing cancer. This, and the analogous question for cardiovascular disease, is also addressed in our two contributions to the ‘debate’ section. This particular question of the long-term safety of insulin is important enough for us to seek contributions from a cancer expert (Renehan), a diabetes expert (Bain) and pharmacoepidemiologists (Holden and Currie). The question is complex. Interpreting the evidence is not easy and not all the evidence we need is available. My own current view on this important matter is that the question of whether long-term insulin treatment in type 2 diabetes increases significantly the risk of cancer or cardiovascular disease is, at present, ‘unproven’. However, the answer to the deeper, related (and more

March 2014 • Volume 59 • Issue 1

important) question of whether the benefit of insulin treatment in type 2 diabetes – better blood glucose control leading to reduced microvascular complications and so on – is likely to outweigh any increased risk of cardiovascular disease or cancer in the long-term is ‘yes, it is’. It’s not so long ago that healthcare professionals would not utter the word ‘cancer’ to a patient. More open use of the term and a greater optimism in the face of it have, there’s no doubt, been the result of improvements in treatment. Where people living with cancer have access to specialist help from cancer teams with surgery, chemotherapy, radiotherapy and other interventions available to them, the chances of a successful ultimate outcome are often quite good. As with diabetes, however, many millions are denied access to the services they need and the outcome is not at all what it should be. World Cancer Day this year fell on 4th February. The ‘Four Cancer Myths’ that were focussed upon for ‘debunking’ were: ‘we don’t need to talk about cancer’; ‘cancer … there are no signs or symptoms’; ‘there is nothing I can do about cancer’ and ‘I don’t have the right to cancer care’. How similar they are to myths about diabetes. Among many other features to look out for in this Issue are: the indepth examination of diabetes in Asia by Juliana Chan and colleagues; observations on World Diabetes Day and the World Diabetes Congress in Melbourne; important new information about hyperglycaemia of pregnancy and diabetes in older people while our ‘Diabetes Voices’ slot this time focuses on diabetes educators and the debt which their patients owe to them. Read on and continue, please, to send us your observations on Diabetes Voice to diabetesvoice@idf.org!

Rhys Williams is Emeritus Professor of Clinical Epidemiology at Swansea University, UK, and Editor-in-Chief of Diabetes Voice.

DiabetesVoice

News in brief

IDF welcomes new

Member Associations In the 22nd IDF General Assembly, 18 new Member Associations were approved reaching a total of 231 worldwide. The International Diabetes Federation (IDF) welcomes its new Member Associations into the IDF family.

Following are the new Full Members by IDF Region: Africa ■ Diabetes Association of Botswana in Gaborone, Botswana ■ Association des Diabétiques du Congo (ADIC) in Goma, Democratic Republic of Congo

Europe ■ International Diabetes Association of Ukraine in Kiev, Ukraine ■ Federación de Diabéticos Españoles (FEDE) in Madrid, Spain ■ Panhellenic Federation of People with Diabetes (PFOPWD) in Athens, Greece ■ Diabeticky Dorast – DIADOR in Bratislava, Slovakia ■ Tashkent Charity Public Association of the Disabled and People with DM ‘UMID' in Tashkent, Uzbekistan Middle East and North Africa (MENA) ■ Arabic Association for the Study of Diabetes & Metabolism (AASD) in Cairo, Egypt ■ Upper Egypt Diabetes Association (UEDA) in Fayoum, Egypt ■C hronic Care Center in Baabda, Lebanon

South and Central America (SACA) ■ Asociación para El Cuidado de la Diabetes en Argentina (CUI.D.AR) in Buenos Aires, Argentina ■ Asociación Día Vida Pro Diabéticos in Curridabat, Costa Rica ■ Fundación Aprendiendo a Vivir con Diabetes (FUVIDA) in Guayaquil, Ecuador ■ Fundación Los Fresnos ‘Casa de la Diabetes’ in Cuenca, Ecuador ■ F undación Santandereana de Diabetes y Obesidad (FUSANDE) in Bucaramanga, Colombia South East Asia (SEA) ■ Research Society for the Study of Diabetes in India (RSSDI) in Delhi, India ■ Eminence in Dhaka, Bangladesh Western Pacific (WP) ■ Diabetes Committee of Hospitals Association of Korea (DCoHAK) in Pyongyang, North Korea

View the list of Full Members on www.idf.org/membership/ meet-our-members

DiabetesVoice

March 2014 • Volume 59 • Issue 1

News in brief

Meet the new CEO of IDF -

Petra Wilson

Last November the International Diabetes Federation (IDF) welcomed Dr. Petra Wilson as its new CEO. We asked Petra about her hopes for IDF and how her past experiences can help break down barriers and serve people with diabetes.

What attracted you to IDF? ‘I have been involved in public health for over 20 years and it is clear to me that diabetes is one of the largest challenges we face in relation to the social and economic wellbeing of people around the world. On a personal note, I feel it is now time to do something which I feel passionate about and which can have a direct and tangible impact on people with the disease.’ How do you see your background as helping to advance the cause of IDF? ‘At Cisco, I was involved in the European Health and Care Business Solutions team, working alongside the World Health Organization (WHO) and national and regional governments on policies to use communications technologies driving safer and more efficient healthcare delivery systems. At IDF I think it is vital that we start looking at how we can really bring the power of eHealth and mHealth to the diabetes community. This will help break down geographic and social barriers in care and benefit

March 2014 • Volume 59 • Issue 1

people with diabetes and their healthcare team. I don’t think any diabetes organisation has fully harnessed the power of communications technology yet.’ How can this technology enhance the lives of people with diabetes? ‘I believe in bringing a “warm hands to cool technology” approach. My idea is not to replace the warmth of the human touch but to extend and embellish healthcare professional reach into developing countries by embracing the benefits of great new technologies. If we can harness this technology we can track how people are dealing with their diabetes and give healthcare professionals vital information on how to deal with any existing or potential management challenges. For example sensor technology which picks up on a person’s hypo- or hyper-glycaemic episodes can be used to track trends which can benefit management of their diabetes in the future and help prevent the onset of complications.’

How do you hope to widen IDF’s footprint? ‘I am seeking to broaden IDF’s reach around the world and to expand our evidence base by approaching new partners both inside and outside of the diabetes world. It is imperative to partner with a variety of sectors to understand the disease better and to help educate where necessary. IDF is also building partnerships to combat and understand diabetes complications such as cardiovascular disease and diabetic retinopathy. These partnerships will in turn strengthen IDF’s position when it comes to negotiating diabetes targets and political action plans with national governments and with unilateral organisations such as WHO.’

DiabetesVoice

News in brief

Currently,

in Diabetes Research and Clinical Practice

DRCP is the official journal of IDF. The following articles have appeared recently or are about to appear in that journal. Access information can be found in the QR code. DIAGNOSTIC CRITERIA AND CLASSIFICATION OF HYPERGLYCAEMIA FIRST DETECTED IN PREGNANCY Article in Press: Available online An update of the 1999 WHO diagnostic criteria which takes into consideration new evidence from the HAPO study; proposes a new classification for hyperglycaemia first detected in pregnancy; removes 1999 ambiguity with regard to fasting plasma glucose values and clarifies ambiguities in the IADPSG’s criteria related to ranges of plasma glucose values for distinguishing diabetes in pregnancy and GDM. THE EFFECTIVENESS AND SAFETY OF BEGINNING INSULIN ASPART TOGETHER WITH BASAL INSULIN IN PEOPLE WITH TYPE 2 DIABETES IN NON-WESTERN NATIONS: RESULTS FROM THE A1CHIEVE OBSERVATIONAL STUDY Home PD, Latif ZA, González-Gálvez G, et al. Diabetes Res Clin Pract 2013; 101: 326-32.

on the

Bookshelf

MANAGING THE DIABETIC FOOT By Michael E. Edmonds (author), Alethea V.M. Foster (author) 248 pages, English, Wiley-Blackwell; 3rd edition (March 3, 2014) Written by the BMA award-winning author team of Mike Edmonds and Alethea Foster, Managing the Diabetic Foot is a practical, handy and accessible guide for the clinical management of severe foot disease associated with diabetes. Featuring over 150 clinical photos, numerous hints and tips to aid rapid-reference, it provides the latest national and international guidelines.

HYPOGLYCAEMIA IN CLINICAL DIABETES By Brian M. Frier (Editor), Simon Heller (Editor) and

‘A1chieve was a 24-week non-interventional study evaluating insulin analogues in 66,726 people with type 2 diabetes in routine clinical care in 28 non-Western countries. … The data support the use of basal plus prandial insulin regimens in routine clinical practice in people with type 2 diabetes with inadequate control.’

Rory McCrimmon (Editor)

INSULIN DETEMIR IN THE MANAGEMENT OF TYPE 2 DIABETES IN NON-WESTERN COUNTRIES: SAFETY AND EFFECTIVENESS DATA FROM THE A1CHIEVE OBSERVATIONAL STUDY Zilov A, El Naggar N, Sha S, et al. Diabetes Res Clin Pract 2013; 101: 317-25.

optimal clinical management in order to achieve good glycaemic control.

392 pages, English, Wiley-Blackwell; 3rd Edition (Jan 21, 2014) A comprehensive guide to hypoglycaemia, written by a team of experts, with reference to ADA and EASD guidelines throughout. Topics covered include the physiology of hypoglycaemia, clinical features, potential morbidity and

‘This subgroup analysis of the A1chieve study examined data from 15,545 people who started treatment with insulin detemir ± oral glucose-lowering drugs in routine clinical care. … People with type 2 diabetes in poor glycaemic control starting treatment with insulin detemir reported significant improvements in glycaemic control with improved treatment tolerability … after 24 weeks.’

DiabetesVoice

Particular attention is paid to the way hypoglycaemia is managed in different groups, such as the elderly, in children, or during pregnancy.

CONTRÔLER SON DIABÈTE ET MENER UNE VIE ACTIVE: 500 RÉPONSES AUX QUESTIONS FONDAMENTALES By Claude Colas (Author), Charles Fox (Author), Anne Kilvert (Author) 320 pages, French, Editions du Dauphin (31 October 2013) Written in French by three experienced diabetologists for people with type 2 diabetes. This complete guide provides answers to hundreds of questions a person living with type 2 diabetes may have on causes, symptoms, treatments, and management of diabetes.

March 2014 • Volume 59 • Issue 1

News in brief

New IDF alliance prioritizes sight

A former driver Gilbray Alum was diagnosed with type 2 diabetes and developed cataract blindness which prevented him from completing many tasks and passing on skills and knowledge. Photo: Kabir Dhanji.

The International Diabetes Federation (IDF) has signed a ten year partnership with The Fred Hollows Foundation, Australia’s leading eye charity, to tackle diabetic retinopathy – the fastest growing form of preventable blindness worldwide. The alliance was announced in Melbourne 2013 just before the launch of the World Diabetes Congress. The new alliance will work to prioritize eye care as part of general healthcare for people living with diabetes and develop new global guidelines on treatment. By investing in low cost treatment and a skilled workforce, the partnership hopes to enhance care in all aspects of screening for and management of the condition. The partnership will also collaborate on rolling out diabetes programmes, including mass screenings, in a range of developing countries.

March 2014 • Volume 59 • Issue 1

By 2035, around 592 million people are expected to have diabetes. Of this number, 177 million are expected to be at risk of diabetic retinopathy at any one time – the majority of whom will be in lowand middle-income countries – without access to an annual eye examination. ‘If we detect diabetic retinopathy early enough, we can intercede and we can stop people from going blind,’ says the Foundation’s CEO, Brian Doolan. ‘The Foundation can’t do this alone.’ Diabetic retinopathy presents no early symptoms and usually occurs between 10 to 20 years after the onset of diabetes. Unfortunately retinopathy develops faster when diabetes is undiagnosed and untreated. The Fred Hollows Foundation is

an independent, not-for-profit Australian based international development agency that works in 19 countries to eliminate avoidable blindness and improve Indigenous Australians’ health. It draws its inspiration from the life and work of Professor Fred Hollows (1929-1993), an internationally acclaimed eye surgeon and activist for social justice.

Allied Hospital, Faisalabad, Pakistan Photo: Sam Phelps

DiabetesVoice

the global campaign

Taking big steps:

at World Diabetes Merry Rivas González and Lorenzo Piemonte

World Diabetes Day (WDD) 2013 marked the fifth and final year of the 2009-2013 campaign on ‘Diabetes education and prevention’. The campaign’s outreach priority was to help local communities understand that diabetes is a global health threat with serious and far-reaching consequences by engaging them with important messages related to education and prevention. The WDD campaign also organised a range of activities to strengthen recognition about diabetes through ‘Take a Step for Diabetes’. One simple message was clear; a multitude of small and simple actions can achieve meaningful outcomes for people with diabetes and those at risk. The global diabetes community was encouraged to rally around the slogan ‘Diabetes: protect our future’ with the following four key messages (see Box).

and healthy lifestyles; improve the lives of people with diabetes; and help reduce a person’s individual risk of developing type 2 diabetes. Participants were provided with a selection of different activities to choose from ranging from 30 minutes of physical activity a day to large-scale awareness events involving hundreds of people. An online platform was created to collect all steps and a target of 371 million was set in support of the number of people living with diabetes in 2012. The campaign ran from May to December 2013 and

A new initiative, ‘Take a Step for Diabetes’, was developed to engage IDF Member Associations and the wider diabetes community by encouraging symbolic donations of steps accrued through a variety of individual or group activities. These included actions to promote diabetes awareness

2. 1 in 2 people with diabetes don't know they have it: Are You at Risk?

DiabetesVoice

1. World's most populated countries: 1. China 2. India 3. DIABETES 4. USA 5. Brazil

3. Diabetes, know the complications: Amputation, Blindness, Heart Attack, and Kidney Disease 4. People with diabetes are just like you and me: Don't Discriminate

was a huge success, with the 371 million steps achieved well in advance of the established deadline. Over 650 individuals and groups registered and submitted steps on the platform, dedicating much time and effort to showcasing their activities to the world in support of the diabetes cause. In recognition of these efforts, IDF sent an open letter to United Nations Secretary General Ban Ki-Moon on behalf of all participants in the ‘Take a Step for Diabetes’ campaign, reaffirming the importance of maintaining the global diabetes commitments made during the 2011 United Nations High Level Meeting on Noncommunicable Diseases (NCDs) for the global health agenda. 14 November 2013 also saw the release of the sixth edition of the IDF Diabetes Atlas, containing the latest estimates on the global and regional prevalence of the diabetes pandemic. The new edition estimates that 382 million people have diabetes, with dramatic increases seen all over the world. WDD is part of the global

March 2014 • Volume 59 • Issue 1

the global campaign

a look back Day 2013

March 2014 • Volume 59 • Issue 1

DiabetesVoice 11

the global campaign

response and the opportunity for millions of people to come together and produce a powerful and united voice calling on the world to act on diabetes to protect our future. The 2013 campaign also saw the Pin a Personality initiative gain momentum and firmly establish itself as a popular way of raising diabetes awareness. Launched in 2012 to increase mainstream recognition of the blue circle as the global symbol of diabetes, the campaign has helped over 1,000 worldwide public personalities keen to learn more about diabetes through the blue circle pin. Over 10,000 pins were distributed for this initiative in 2013 and used to spread diabetes awareness among national and international leaders and personalities associated with, among others, the arts, science entertainment, media, religion, politics and sport. All ‘pinned’ personalities are featured on the IDF website.

From Abu Dhabi to Zanzibar the world went blue for diabetes in November. From Abu Dhabi to Zanzibar the world went blue for diabetes in November. The signature activity in many countries continued to be the Blue Monument Challenge. Over 60 countries brought diabetes to light in 2013 with some old favourites such as the Sydney Opera House, the Little Mermaid in Copenhagen and several new lightings in countries like Spain, Indonesia and Saudi Arabia. The Hispanic community Throughout the world, diabetes organisations, health professionals and concerned individuals united around

DiabetesVoice

the blue circle and organised a multitude of awareness activities throughout November. The Hispanic diabetes community was particularly active and enthusiastically supported the campaign by organising large-scale events such as screenings, fairs, walks and runs. Some highlights included: ■ In Argentina, the diabetes community supported an online campaign initiated by several local organisations requesting the amendment of the National Law for the Protection of People with Diabetes (Ley Para la Protección a Diabéticos) and demanding essential medicines for those living with the disease. The campaign was a great success with major progress achieved.

■ In Nicaragua, IDF Member Association Asociación de Padres de Niños y Jóvenes Diabéticos (APNJDN) addressed Members of Parliament and requested new legislation for people with diabetes, in particular, a national diabetes programme that promotes diabetes education and prevention incorporating IDF´s International Charter of Rights and Responsibilities of People with Diabetes. ■ I n Paraguay, IDF Member Association Fundación Paraguaya de Diabetes (FUPADI) had a special audience with the President Horacio Cartes and members of the National Government, including the Minister of Health, who were presented with the blue circle pin.

■ In Brazil, the three IDF Member Associations organised activities in over 1,000 towns and cities throughout the country. In Rio de Janeiro the iconic Sugarloaf Mountain was proclaimed ‘sugar-free’ (Pão sem Açúcar) on 14 November, and the famous Maracana football stadium was lit up in blue for the first time along with many Brazilian monuments and buildings for WDD.

■ In Uruguay, IDF Member Association Asociación de Diabéticos del Uruguay (ADU) conducted over 15,000 diabetes screenings and distributed more than 300,000 leaflets and posters on WDD promoting the importance of physical activity and improved blood glucose control. Several fundraising activities were also organised to raise money for camps for children with diabetes.

■ In Mexico, local and national governments adopted new regulations to tackle diabetes. In the Federal District of Mexico City, a new Law for the Prevention, Treatment and Control of Diabetes (Ley Para la Prevención, Tratamiento y Control de la Diabetes) was adopted in September and, days before WDD, the President of Mexico Enrique Peña Nieto presented the new National Strategy against Diabetes and Obesity (La Estrategia Nacional para la Prevención y Control de la Obesidad y Diabetes). Prominent monuments in the capital were lit in blue and hundreds of people gathered around the famous Angel de la Independencia to form a human blue circle.

The commitment and enthusiasm displayed in the events and activities that took place throughout the world in November 2013 highlight unity in our community, bringing renewed hope to those who live with diabetes today and for the prevention and cure of diabetes tomorrow.

Merry Rivas González and Lorenzo Piemonte Merry Rivas González is IDF Project Coordinator for World Diabetes Day. Lorenzo Piemonte is IDF Communications Coordinator.

March 2014 • Volume 59 • Issue 1

the global campaign

Diabetes care in Rwanda: against all odds Crispin Gishoma

Rwanda is a small developing country of 26,338 square kilometres, landlocked in central Africa, with an approximate population of 12 million inhabitants. The majority of people are subsistence farmers. Rwanda is home to one of the most appalling crimes of the 20th century, and it will take generations of Rwandese to heal from the devastation and loss. In the ‘1994 Tutsi Genocide’, more than a

million people were innocently killed, thousands exiled, or jailed and many widows and orphans left behind once the killing stopped. Public services for the population were crushed and the healthcare system was paralysed with very few professionally trained doctors remaining in the country. Healthcare facilities and centres were destroyed and access to medicine was nearly non-existent.

While Rwandan institutions were overwhelmed by multiple emergencies, the health sector spent most of its remaining resources on infectious diseases, including HIV. Diabetes care in Rwanda suffered during the conflict and people with diabetes struggled to survive. Diabetes was overlooked, and people were in danger. Diabetes care policies did not exist, and seriousness of the condition was played down by doctors and ignored by the general public.

Diabetes was overlooked, and people were in danger.

Rwanda Diabetes Association (RDA) headquarters

March 2014 • Volume 59 • Issue 1

To tackle these challenges, Rwanda Diabetes Association (RDA) was created in 1997 with the aim of improving the well being of all people with diabetes in Rwanda, and to join the global effort to advocate better diabetes care and prevention. For 16 years, RDA has been given support by the Rwanda Ministry

DiabetesVoice 13

the global campaign

of Health, the International Diabetes Federation (IDF), Insulin for Life, Life for a Child Programme, World Diabetes Foundation, Insulin Zum Leben, Team Type 1, Marjorie’s Fund and the University of Pittsburgh, USA. It is only through the support of these organisations and programmes that people with diabetes in Rwanda have access within its clinics and government hospitals to information by trained healthcare professionals on diabetes self-management. Advocacy for diabetes in Rwanda has also progressed for better diabetes treatment, improved communication with diabetes care stakeholders, and access for indigenous people. Diabetes care and training In a country where diabetes awareness is low or perceived as ‘a rich man’s disease’, RDA prioritised national media communications to increase awareness, early diagnosis and prevention. One of the objectives was to train and even correct journalists and healthcare authorities about diabetes information. Now after three years, journalists have been awarded for their work in helping to inform the population about diabetes. In addition, RDA has a magazine which is also used as another platform to disseminate diabetes awareness messages. However, diabetes awareness is meaningless without available care and treatment. RDA has opened clinics in Kigali and Gisenyi (northwest Rwanda) with an average of 20,000 patient visits per year. Main activities within these clinics are consultation, treatment, education, training, counselling, and providing diabetes medical supplies. Since 2005, RDA’s efforts have facilitated training on diabetes management for more than 800 healthcare professionals. One indicator of the results of this training is a marked difference in the number of people who

DiabetesVoice

Laureates at the end of the diabetes training

have been diagnosed since that time. In addition to the permanent diabetes care and training in Kigali and Gisenyi, RDA works closely with 32 hospitals throughout the country where a team of nurses and diabetes educators conducts quarterly visits. These visits include diabetes training and awareness sessions with people who have either type 1 or type 2 diabetes.

we know that youth with diabetes were usually dying either before diagnosis or as a result of poor diabetes management. Since 2003, the ‘Care for Youth with Diabetes Programme’ of RDA in partnerships with the IDF Life for a Child Programme, Pittsburgh University, and Team Type 1 provides care, education,

Youth with diabetes were usually dying either before diagnosis or as a result of poor diabetes management. Care for Youth with Diabetes Programme One of the great achievements of RDA is caring for youth with type 1 diabetes. In a small country like Rwanda where diabetes was nearly unknown, it was unthinkable to the general public that diabetes could be a danger for youth. The survival of children diagnosed with type 1 diabetes depends on access to insulin. Based on nine years of experience,

The official magazine of RDA

March 2014 • Volume 59 • Issue 1

the global campaign

Diabetes screening on World Diabetes Day 2013, Kigali, Rwanda

Fight Against Obesity initiative and World Diabetes Day, Kigali, Rwanda

insulin and other supplies for children and young adults up to 25 years who live with type 1 diabetes. Education for Diabetes Conversation MapTM The Education for Diabetes Conversation MapTM tools have been a success for diabetes education in Rwanda. Based on IDF recommendations, the Conversation MapTM is effective for diabetes education and RDA has used these tools to improve self-management skills and to protect people from complications related to diabetes. One of our clinic patients told us, ‘I would have been dead without RDA’s help and my knowledge about diabetes saved me. Before I was desperate and

March 2014 • Volume 59 • Issue 1

had accidents but since I was educated with the Map tools, I manage my diabetes better and I feel confident, healthier and I am able to work’.

RDA emphasizes the importance of exercise and a healthy diet to prevent type 2 diabetes and cardiovascular diseases. Fight Against Obesity initiative and World Diabetes Day Diabetes advocacy is an important priority for RDA. Using event opportunities, together with over-weight people living in Kigali who are often afraid to show up in public, RDA launched the ‘Fight Against Obesity’ initiative by encouraging over-weight people to

exercise in order to prevent diabetes. This also provides a platform to advocate against discrimination of people living with diabetes or the obese. RDA emphasizes the importance of exercise and a healthy diet to prevent type 2 diabetes and cardiovascular diseases. Since it was created, RDA has had an average of two public events quarterly (sports, screenings, diabetes education, media events, and more) but World Diabetes Day (WDD) celebrated every 14th November is the most popular event. In Rwanda, the WDD campaign is the most important event to advocate for diabetes and involves many different, concerned people. Local associations, health oriented NGOs, the government, WHO and many other organisations join together with the RDA to raise up the voices of people living with diabetes. Diabetes Camp The very first diabetes camp for youth in Rwanda was held in the Mwulire

DiabetesVoice 15

the global campaign

Diabetes Education Centre. The objective of this camp was to resolve problems that many young people living with diabetes face after diagnosis. Most problems are characterized by a lack of knowledge about self-management vis-à-vis diabetes, loneliness, and lack of confidence in their future because many drop out of school early due to diabetes stigmatization. The slogan of our first camp in Rwanda was ‘Live better with diabetes’. Diabetes Education Centre The Diabetes Education Centre in Mwulire, set up in 2010, is the only education centre in Rwanda. It was created in order to assist youth with diabetes and help them overcome challenges. RDA realized that most youth with type 1 diabetes had no future when they passed the age of 25 and lost access to the programme that covers 100% of the necessary treatments, medicine and regular education. Their knowledge about diabetes self-management was low and they lacked vocational training or stopped their studies because of diabetes complications or poor family means. Many of the children with type 1 diabetes are very poor and cannot even afford the recommended diet.

Many of the children with type 1 diabetes are very poor and cannot even afford the recommended diet. The RDA education centre provides diabetes education, including life style behaviour education as well as vocational training to enable youth with diabetes (15-25 years) to be successfully independent after the programme. Training sessions include diabetes care, beauty salon workshops, tailoring, baking and agriculture. There are 15-20

DiabetesVoice

Campers learning about growing vegetables

Diabetes Educations Centre in Mwulire, Rwanda

youth trained at a time, for a period of six months. The programme is free of charge for all children. There have been 97 young people trained so far. Despite the efforts of Rwanda Diabetes Association, there is much more to do against an increase in the number of people who are diagnosed and an increase in people at risk for diabetes. Factors that adversely affect the lives of people with diabetes in Rwanda include poverty, discrimination, food insecurity, lack of

diabetes education and lack of organized and consistent care. Everyone has a right to efficient medical care regardless of social economic background.

Crispin Gishoma Crispin Gishoma is Director of Rwanda Diabetes Association.

March 2014 • Volume 59 • Issue 1

the global campaign

Report on the World Diabetes Congress 2013 Melbourne Anne-Marie Felton

The city of Melbourne provided the platform for the World Diabetes Congress 2013 enabling the International Diabetes Federation (IDF) to speak to the city and the world, ‘Urbi et Orbi’, on the challenges facing mankind in the light of the global epidemic of diabetes. The Congress represented a kaleidoscope of excellence through its scientific programme and numerous satellite symposia bringing together key participants: people with diabetes, professionals, professional societies, politicians and policy makers. The scale of the event was enormous and has been recognised as the largest medical conference ever held in Australia. A total of 10,300 participants attended the Congress which offered over 275 hours of scientific sessions delivered by 400 world-class experts. The dilemma for many attendees was making decisions between competing interests. However most of the keynote presentations are currently available to view on the IDF website as webcasts. All of the abstracts and oral presentations are also available. The political significance of the Congress has gathered momentum with the formation of the Global Parliamentary Champions for Diabetes Forum, led by Mr. Adrian Sanders MP, as its President. This significant forum will now hold the centre ground for political advocacy for diabetes at a global level. It has had a long period of gestation and the commitment of Sir Michael Hirst, IDF President, and Guy Barnett, former Australian Senator, has nurtured and ensured its delivery. It is noteworthy that so many politicians including representatives from the EU, notably Commissioner Tonio Borg and

March 2014 • Volume 59 • Issue 1

DiabetesVoice 17

the global campaign

his cabinet colleagues, and First Lady of South Africa, Bongi Ngema, actively contributed to forum discussions and have made formal commitments to sustaining its success. I have no doubt that the Global Parliamentary Champions for Diabetes Forum will become an integral part of IDF’s global mission of political advocacy. The eloquence of Sir Michael Hirst was evident in his opening address and his keynote lecture during the Congress. I had the great honour and pleasure of chairing the Opening Ceremony and, without exaggeration, one could hear a pin drop between the moment his address ended and the standing ovation began, illustrating the appreciation by all for his charismatic leadership and profound commitment to diabetes. Youth was very evident throughout the Congress, not only in the Opening Ceremony but also in the IDF Young Leaders in Diabetes Programme. These Young Leaders are the future of national diabetes organisations and IDF. The leadership programme developed by IDF through the initiative of its Chair, Debbie Jones, will continue to be a beacon of hope and pertinence to ensure the future of IDF.

IDF President Sir Michael Hirst (right) presents former cricketer Wasim Akram (left) with an award for his work in regard to diabetes around the world

DiabetesVoice

The scientific programme provided three and a half days of multi-streamed content. There were seven Streams in total including two new ones: Diabetes Research in the 20th Century: a Historical Perspective and Diabetes in Indigenous Peoples. The IDF Award Lectures for these two Streams were given respectively by Jesse Roth (USA) and Alex Brown (Australia). The other six IDF Award lecturers were: Michael Brownlee (USA) (Basic Science); Stephen O’Rahilly (UK) (Clinical Science); Jean-Philippe Assal (Switzerland) (Education and Integrated Care); Jean-Claude Mbanya (Cameroon) (Global Challenges in Health); Wasim Akram (Pakistan) (Living with Diabetes) and Nick Wareham (UK) (Public Health and Epidemiology). The latest and sixth edition of the IDF Diabetes Atlas was presented in December, which has become the gold standard resource for referencing the worldwide diabetes crisis, and utilised by all multi-stakeholders working with IDF to stop the pandemic.

Young Leaders in Diabetes Programme

March 2014 • Volume 59 • Issue 1

the global campaign

In summing up, the 2013 World Diabetes Congress built on the experience and success of previous congresses. There was a sense of marked inclusivity and everyone present felt truly inspired. The Congress undoubtedly offered a unique opportunity for both first-time participants and consummate diabetes experts to network. The experience provided a renewed commitment to diabetes and the chance to be inspired by youth and accomplished experts.

Morning run with Sir Michael Hirst (President, IDF), The Hon David Davis MLC (Minister for Health and Minister for Ageing, Victoria) and Bas van de Goor (Olympic gold medal-winning volleyball player and person with type 1 diabetes)

I would like to take this opportunity to thank everyone for participating in the 2013 World Diabetes Congress and to those who will engage the Congress webcasts. In addition, a personal thank you to the Organising Committee and the Congress Team in the IDF Executive Office, the Chair of the Programme Committee, Paul Zimmet, and the Chair of the National Advisory Committee, Trisha Dunning. Also a special thank you to the IDF Media and Communications team who ensured that key messages were delivered globally. Last but certainly not least, a special thank you to the Diabetes Australia Victoria and Diabetes Australia for their generosity of support and commitment to all aspects of this Congress. I have the privilege of chairing the Organising Committee for the upcoming World Diabetes Congress, 2015. I look forward to seeing you there.

Aboriginal Australian performance at the WDC 2013 Opening Ceremony

Anne-Marie Felton Anne-Marie Felton is a Vice-President of IDF, and the Co-Founder and current Chair of the Federation of European Nurses in Diabetes (FEND).

March 2014 â&#x20AC;˘ Volume 59 â&#x20AC;˘ Issue 1

DiabetesVoice 19

the global campaign

The Melbourne Declaration on Diabetes Adrian Sanders

At the 2013 World Diabetes Congress in Melbourne, Australia, a declaration on diabetes was agreed and signed by invited parliamentarians representing 50 countries. The Melbourne Declaration on Diabetes was agreed at the first-ever Global Parliamentary Champions for Diabetes Forum on the 2nd December 2013.

United Kingdom All-Party Parliamentary Group for Diabetes (APPG Diabetes) and Chairman of the European Policy Action Network for Diabetes (ExPAND). I have also lived with type 1 diabetes for a quarter of a century.

The priority of the group will be to build a coalition of diabetes advocates for action to tackle the pandemic at the local, regional, national and trans-national level raising urgent diabetes awareness in parliaments and assemblies across

The Declaration calls for urgent action to address the diabetes pandemic and our dedicated signatories pledge to work across parliaments to help prevent the incidence of diabetes, ensure early diagnosis and improve the treatment of people with the condition. The Global Parliamentary Champions for Diabetes Forum elected two VicePresidents, Dr. Rachael Nyamai MP (Kenya) and Simon Busuttil MP (Malta) and myself as the first President. My qualifications for this prestigious position include my work as Chairman of the

DiabetesVoice

The First Lady of South Africa signing the Melbourne Declaration on Diabetes

March 2014 â&#x20AC;˘ Volume 59 â&#x20AC;˘ Issue 1

the global campaign

the globe. This new grouping will fill a missing gap, and I am determined we will do much more. There is a great deal of cross-national communication among

medical professionals, pharmaceutical companies, health ministers and patient groups but nothing for parliamentarians who can set the agenda, influence

Objectives for 'Parliamentarians for Diabetes’ global network 1. Exchange policy views and practical initiatives of relevance and to hear from experts on opportunities for action and progress in the prevention and management of diabetes. To always strive for ‘best practice’, and advocate for people with diabetes, their families and carers, and those at risk and to become a powerful force internationally to respond in a coordinated and focussed way to the diabetes pandemic and to promote the diabetes cause. 2. Provide parliamentarians with the opportunity to attend meetings organised by the IDF and their Member Associations, aiming to improve health outcomes for people with diabetes, stop discrimination towards people with diabetes and prevent development of type 2 diabetes. A special focus should be the different regions of the globe to ensure practical solutions are offered. 3. Establish a platform for the dialogue between IDF Member Associations and other stakeholders to exchange information and discuss special areas of common interest. These will include prevention, workforce, costs of diabetes, access to medicines, and effective strategies to combat and manage the pandemic. To report back to ministers, parliamentarians and other key decision-makers in our home countries and to seek commitments to deliver on the targets set at the 66 WHA in 2013. The global network will support the sharing of resources such as research, legislative initiatives, prevention campaigns and joint initiatives relevant to the various regions of the globe.

March 2014 • Volume 59 • Issue 1

4. Encourage all governments to acknowledge that diabetes is a national health priority that requires a comprehensive action plan leading to action. 5. Respond to and participate in relevant debate and discussion on and related to the World Health Assembly, World Health Organization, United Nations and other appropriate organisations or government bodies and specifically to ensure the inclusion of diabetes and NCDs in the post-2015 development framework noting this framework should be aligned with the goals and targets on diabetes agreed at the WHA. Diabetes intersects all major dimensions of global development, including poverty reduction, gender inequality, education, environmental sustainability and infectious diseases. 6. Confer honour and express gratitude to those Members of Parliament supporting the diabetes cause, wherever they may be and to use our best endeavours to recruit other Members of Parliament for this purpose. 7. Create opportunities for networking and building relationships between Members of Parliament, other key decision-makers, the IDF and its Member Associations and others. To hold meetings in various regions of the globe as agreed, and to meet again as a Global Forum at the next World Diabetes Congress in 2015. 8. Appoint a global co-ordinator with appropriate administrative and management support to assist the global network to achieve the above objectives.

budgets and vote for policies. As the first global network of parliamentarians for a specific medical condition, we will create a platform to raise the profile of diabetes within governments across the world. Through the communication of ideas and best practice and the encouragement of action within parliaments around the world we can move towards that tipping point where the allocation of resources and effort to prevent, diagnose and treat diabetes is no longer questioned. The urgency required cannot be overstated given the rising tide of diabetes across all continents and countries rich and poor. Already the scale of the challenge threatens the healthcare budgets of most countries and the economies of many. It is a great honour to be tasked with leading this group and I am grateful for the support and guidance of IDF through its President Sir Michael Hirst, his Co-Chair behind the initiative, former Australian Senator, Guy Barnett, and the global coordinator for the forum, the Hon. Judi Moylan. This formidable team will become a positive force governments will not be able to ignore.

Adrian Sanders Adrian Sanders is the Member of Parliament for Torbay in Devon, UK. To read the Melbourne Declaration on Diabetes, please visit: www.idf.org/sites/default/files/ Melbourne_Declaration.pdf

DiabetesVoice 21

Health Delivery

Testing the limits: burden of diabetes How do we measure a diabetes crisis? Living with dia-

Now imagine a double burden such as the isolation

betes, particularly type 1 diabetes, in the developed

and deprivation in war or natural disaster: these

world often exposes the limitations of life-saving

are regions without electricity, clean food and wa-

therapies and medications: testing blood glucose

ter, medical care and essential diabetes supplies.

five to ten times per day, injecting insulin anywhere

Consider the ten-year old boy living with type 1

from six to ten times daily, wearing medical devices

diabetes who, buying time in a refugee camp, is

subcutaneously and dealing with hyperglycaemia

finally administered a blood glucose test by an aid

and the threat of complications against tight blood

worker. The result of the test is alarming; perhaps

glucose control and the risk of severe, sometimes

well over 40 mmol/L (720 mg/dL), partially because

fatal, hypoglycaemia. In the best circumstances, dia-

he had his first bowl of food for the first time in a

betes therapies are difficult, but people can survive.

week. How long will he survive without insulin?

Hierarchy of needs ignores diabetes Elizabeth Snouffer

Dr. Julieta Gabiola has been visiting the Philippines on an annual basis for chronic disease research projects for the last ten years, but her visit midNovember 2013 was different. ‘Every morning at 6 am, we would hit the road, choose a new location to build a pop-up clinic and get to work setting up a triage station, a pharmacy, small

DiabetesVoice

surgical unit and three-four tables for doctor and nurse teams, and then the people would begin to line-up. After a 15 hour day – we would start all over again the next morning,’ says Gabiola, an Assistant Professor of Medicine at Stanford University. Earlier in November 2013, the CEO of Stanford University School of Medicine

contacted Dr. Gabiola to join Stanford Emergency Medical Emergency Response (SEMPER), a trained medical response team deployed to cover disaster zones and humanitarian relief efforts around the world. Two weeks after the Philippines was hit by the force of the Haiyan/Yolanda Typhoon, Gabiola joined SEMPER and flew to Tacloban City – the area hit hardest by

March 2014 • Volume 59 • Issue 1

health delivery

The double and disaster Testing the limits of diabetes in a world where early

helping people without diabetes supplies survive

death from the condition is preventable is intol-

the aftermath of Typhoon Haiyan in the Philippines;

erable and unjust, but still occurs today in many

an insulin distribution team and advocacy leader

regions worldwide. Thankfully, aid sometimes ar-

who are taking risks to get insulin to those most

rives, saving lives in a climate where international

in need in Syria; and a team of specialists saving

aid operations often dictate ‘diabetes is not in the

the lives of thousands who live with diabetes in the

framework and not an emergency’.

Republic of Mali.

Our special report focuses on three regions and the voices of those closest to diabetes in environmental or political crisis: doctors and aid workers

the typhoon. ‘By the time we arrived, primary care for chronic conditions was what was needed most for the survivors’. The SEMPER team left Tacloban City and went to work outside of the city in small rural municipalities, called barrios or barangays, which had been crushed with just as much devastation as Tacloban, but had not yet gotten the same emergency relief.

People live in a state of uncontrolled blood sugars. ‘I saw many people with type 2 diabetes who had no insulin,’ says Dr. Gabiola, pointing out one important factor that many people in developed

March 2014 • Volume 59 • Issue 1

nations may not understand, ‘Even before the typhoon, people with diabetes in these communities did not have access to medicine and they would have already run out of insulin long before the typhoon had arrived. They live in a state of uncontrolled blood sugars.’ According to the doctor, the real problem cases were not just people who didn’t have insulin, but those with complications: people who needed kidney dialysis but have no access to

DiabetesVoice 23

Health Delivery

care; those with peripheral neuropathy; and many walking wounded with lacerations and ulcers that needed immediate attention. ‘The fact is that these people have a choice to make – they can buy a diabetes pill for 50 pesos (about USD 1.20) or they can buy a ½ kilo of rice, vegetables and fish for that same amount and feed their family. It’s not hard to understand their choices. It’s a hierarchy of needs.’

Oral medications are in short supply for treating type 2 diabetes. When asked what the future holds for people living with diabetes who can’t afford medication, Dr. Gabiola is painfully candid, ‘They’ll never be OK because they can’t afford the medication necessary for survival. We gave many people a month supply of medicine before we left the Tacloban region, but we know they will stretch it out for six months, injecting insulin or taking a pill once a week. The only thing we can depend on is that next team of relief will be right behind us doing the same thing.’ According to Dr. Richard Elwyn V. Fernando, President of the Philippines Diabetes Association, the Visayas region – where Tacloban City is located – is facing two challenges: ‘The first challenge relates to the fact that we have thousands of vials of insulin, but getting out to the people in the barrios is difficult because the roadways are so poor.’ People with diabetes must travel to Tacloban City to retrieve their insulin but some are reluctant to do so because they are prioritising home rebuilding for their families. The second challenge facing diabetes care according to the healthcare professionals in the government hospitals is related to type 2 diabetes.

DiabetesVoice

‘Only about 15 to 20% of the people with type 2 diabetes are insulin dependent, and we’re getting reports that oral medications are in very low supply,’ says Fernando. Oral medications for hypertension and heart disease are also in shortage. While there isn’t much good news, people suffering from kidney failure have been very fortunate to receive dialysis. A few kilometres outside of Tacloban City, volunteers for the Philippine Society of Nephrology set up a free clinic two weeks after Typhoon Haiyan for patients in need. ‘People from all over the Tacloban area and the outer barrios can travel twice a week to receive this free service, which has saved many lives,’ explains Fernando. A month after Typhoon Haiyan in December 2013, Dr. Marian Denopol, an internist at the Vicente Sotto Memorial Medical Centre in Cebu City, Philippines, was visited by a father and his three children who were all diagnosed with type 1 diabetes years before. ‘I had worked with the family in Cebu before they moved to Tacloban. When they returned to see me the father told me, “We needed to save ourselves so of course everything including diabetes supplies like insulin, our diabetes diaries and meters were swept away.”’ The children’s blood glucose levels when they came to see Dr. Denopol at the hospital were all above 500 mg/dL (28 mmol/L). ‘I gave them insulin and a meter which had been donated from Insulin for Life (IFL) and instructions for how to manage going forward.’ All the medical professionals in Cebu, including some of the staff from the Vicente Sotto Hospital, went to both the Northern parts of Cebu and the islands including Tacloban to help out. Dr. Denopol gave the emergency teams diabetes supplies including insulin, test strips and syringes primarily donated by IFL. When

Insulin is being provided to one of the patients at Tacloban, Philippines

the teams came home, the feedback she received was that all the diabetes patients were disoriented and many people had uncontrolled blood glucose levels. Back home in Cebu, things aren’t much better. Dr. Denopol has a patient population of about 3,000 people living with type 2 diabetes from low-income communities. Their poor diabetes health status reflects the challenges people with diabetes in developing nations face: ‘The main problem for our community is financial, although we strive to provide self-management and nutrition classes for support. The majority of our patients with diabetes cannot afford supplies, especially insulin. Most of the people living with diabetes might only make a dollar (44 pesos) a day so spending 29 dollars (1,300 pesos) on a vial of insulin is untenable’. As a result of the experience from Typhoon Haiyan, Fernando and his team have developed two objectives for the Philippines Diabetes Association to

March 2014 • Volume 59 • Issue 1

health delivery

Insulin for Life: delivering hope An interview with Talia Raab and Juvy Holasca

Insulin for Life (IFL) is a tax-exempt, not-for-profit company registered in the state of Victoria, Australia with a network of independent non-profits worldwide. Established in 1999 by Ron Raab, the primary objective of the non-profit is to obtain diabetes medicines and supplies and deliver them to diabetes associations and other organisations for distribution to those in need. The International Diabetes Federation (IDF) collaborates with IFL to help fund distribution of emergency supplies. address in order to improve outcomes for people living through disaster with diabetes: ‘One, we need to create a National Standard Operating Procedure for helping people with diabetes in the Philippines; and two, we must create a type 1 diabetes registry so when disaster or a crisis develops we know exactly where to find these children and adults so they can get the insulin they need’.

For more information: Insulin for Life: www.ifl.org SEMPER: www.semper.stanford.edu Philippines Diabetes Association: www.diabetesphil.org Dr. Marian Denopol wants to be sure to thank all the people around the world especially Insulin for Life and friends in Japan, China and the USA because their donations and medical supplies have saved lives.

March 2014 • Volume 59 • Issue 1

Since the Cebu earthquake in October 2013 and Typhoon Haiyan (known as Typhoon Yolanda in the Philippines) in November 2013, IFL has been prioritising the delivery of insulin and other essential diabetes supplies to the devastated regions. In this special report on their relief effort, we learn from two insiders at IFL where the supplies go, how much has been sent and what’s next for the IFL team when they visit the Philippines later this year.

Can you give an overall idea of how groups in the area hit hardest by Typhoon Haiyan are working with IFL? IFL: One of our key partners, called Sweet Alert, is a grass roots diabetes advocacy group based in the city of Cebu, Philippines, led by Consul Armi Garcia. The partnership started in January 2012 with IFL sending donated insulin and other supplies to Dr. Marian Denopol, the Vice President and Medical Officer of Sweet Alert. IFL enables Sweet Alert to continuously supply many

poor patients with insulin and other essential supplies. Since the typhoon, we have helped Sweet Alert to supply insulin and diabetes supplies to people with diabetes in the Tacloban, Bohol, Tabogon and Bantayan areas in conjunction with the Vicente Sotto Memorial Medical Centre, where Dr. Denopol is a practicing diabetes specialist. In addition to diabetes supplies donated from IFL Australia, supplies were also sent from IFL colleagues in Taiwan and

DiabetesVoice 25

Health Delivery

by the IFL USA affiliate. The IDF- assisted transport fees cover the transportation of some of the supplies sent by IFL Australia and IFL USA. How many vials, test strips and syringes has IFL shipped to the Philippines? IFL: Since September 2013, IFL Australia has shipped to: Cebu (3 shipments): 6 cartons, 4,700 mls of insulin, 2,000 test strips, 1,200 syringes, 2,200 pen needles, 12 meters, 3000 lancets, 24 insulin pens. Dumaguete (6 shipments): 12 cartons, 12,100 mls of insulin, 5,000 test strips, 400 syringes, 6,500 pen needles, 46 meters, 1,600 lancets, 86 insulin pens. The Taiwanese Association of Diabetes Educators also sent supplies to the Philippines, as well as IFL USA. Their responses have been very quick. What cities are using the supplies primarily? IFL: The supplies have been sent to two major cities Cebu and Dumaguete. Two hospitals with clinics, Sweet Alert in Cebu on behalf of the Vicente Sotto Memorial Medical Centre in Cebu City, and Negros Provincial hospital in Dumaguete have organised parties to go out into the cities and rural areas to administer treatment to people with the resources supplied by IFL. The programme works because Filipinos are helping Filipinos, so there aren’t any language barriers and it is a culturally sensitive effort. IFL Australia is helping with resources, and has instigated IFL USA and Taiwanese Association

DiabetesVoice

of Diabetes Educators (TADE) to also help with supplies and resources. Some funding for shipping and handling costs has been donated by various individuals and organisations, such as the IDF, and the IDAF of Japan. Can you discuss how the diabetes supplies, from Australia for example, are packed and then distributed safely to the doctors and nurses who need them? How is insulin protected in cargo shipments? IFL: The supplies are sent by airmail directly to the medical organisation, from Australia. They track the supplies and make sure they receive them and then inventory is undertaken. The arrival time takes between 4-7 days normally, but, since the Typhoon, it is taking anywhere between 7-21 days. What is the feedback from the communities you are supporting? IFL: The various communities we are supporting are very grateful for the

help they receive. People with diabetes in the Philippines struggle generally. The cost of insulin is just too high for many. Like any natural disaster, the typhoon has created hardship in accessing insulin, supplies and medical attention. The City Medical Hospital we visited prior to the typhoon, for example, was badly affected by the October earthquake. Hospitals and pharmacies were shut down, electricity was off and medical staff were not at work. This presented many problems for people with diabetes. When will the IFL team go to the region affected by the typhoon next? IFL: No one from the IFL team has been since the typhoon, although our partnership with the local Sweet Alert team is very active. There is a plan for an IFL team from Australia and other countries including Japan, Taiwan and Vietnam to visit the Philippines in May to help operate the first IFL-Sweet Alert camp for children and adolescents with

Juvy Holasca (left) and Talia Raab (right) representing Insulin for Life

Australia

March 2014 • Volume 59 • Issue 1

health delivery

type 1 diabetes. During the same visit, the IFL and Sweet Alert teams will be evaluating the IFL-IDF emergency insulin supply response to the typhoon. At the camp, there will be doctors, nurses and IFL staff from those countries. It is hoped that more camps will be held in a number of other countries in the region with a similar IFL Australia and Global co-ordinated team. What is the greatest need today? How long do you believe IFL will be prioritizing the collection of money and supplies for people living with diabetes in the Philippines? IFL: The greatest need is insulin, test strips and other supplies, and funding to help pay for the shipping and handling costs. We estimate it will take 3-5 years before the areas in the Philippines we work in will recover – if they can ever completely recover from this disaster. IFL will support the Philippines as long as there is a need and as long as we are able to obtain the shipping and handling costs. How can people help IFL support the Philippines relief effort for people with diabetes? IFL: The main need is to receive assistance with funding for the shipping and handling costs. The insulin, test strips and other supplies are given at no cost by IFL. Details of the project and response is on are on the IFL Australia website www.insulinforlife.org and Facebook page www.face book.com/InsulinForLife

March 2014 • Volume 59 • Issue 1

Living with diabetes in war Elizabeth Snouffer

Syria, a country with a rich and ancient celebrated culture, is in the middle of an extremely violent civil war. At the time this report was written, international news reported that fighting between government forces and rebels had killed more 100,000 civilians and created two million refugees, half of them children. Since 2011, when the Syrian conflict began, many health issues have emerged including a rise in infectious diseases most notably polio, but there is also the problem of managing serious chronic disease like type 1 and type 2 diabetes. Estimates of how many people with diabetes are still living in different parts of Syria vary considerably. Managing diabetes has become a very difficult situation, especially for those who are insulin dependent. Dr. Nizar Albache, President of the Syrian Endocrine Society and ChairElect for IDF Middle East and North Africa (MENA) Region, and Eyad Al Safadi, General Manager for Novo Nordisk in Syria for the past 16 years, agreed to answer questions about how people living with diabetes and those caring for people with diabetes in Syria are coping today. In the following interview, Eyad Al Safadi and Dr. Albache took time to discuss the tragic situation in Syria.

What was the situation in Syria as it relates to people living with diabetes and professionals caring for them, before and after the start of the crisis? Dr. Nizar Albache: Before the crisis, people with diabetes had easy access to healthcare. The National Diabetes Programme

covers services for about half of all people with diabetes in Syria, and insulin and oral hypoglycaemic agents are normally available and free in centres around the country. Public hospitals are free for all people and treatments related to diabetes complications are available. The private sector covered the other 50%. Before the

DiabetesVoice 27

Health Delivery

crisis, there was little concern in Syria. The Syrian Diabetes Association also provided free education and helped to increase diabetes awareness across the county. Eyad Al Safadi: Syria is a country with more than 22 million inhabitants and it is estimated that 889,500 Syrian adults had diabetes in 2011, which is 8.2% of the adult population. In 2010, diabetes was estimated to cost 14% of the total Syrian medicine budget. In 2013 three years after the Syrian crisis began WHO estimates that 430,000 people with diabetes are still living in Syria and 40,000 are insulin dependent children who need help. Managing the thousands of children who need assistance for their diabetes has become more challenging as the months have passed. Are any of your colleagues still in Syria? Dr. Nizar Albache: Fortunately yes. I got a more precise idea about the current situation there during my last visit some three months ago. There are a lot of practitioners and diabetologists still working and helping people in many Syrian cities and villages outside the crisis zones, and they are providing healthcare to patients in the country. But we don’t have any real estimates for the number of doctors who are still working inside Syria. In my opinion, it may be around 40-60%. A larger part of them may be working in areas controlled by the government, but a smaller group may be working in areas controlled by armed opposition. It is in these areas where there is an absence of medical care where it has become very difficult to access medical supplies such as insulin or oral hypoglycaemic agents, and other drugs necessary to manage diabetes. Eyad Al Safadi: There are still a few Novo Nordisk colleagues based in Syria and

DiabetesVoice

13-year-old Reem at Al Za'atri refugee camp for Syrians, near Mafraq, Jordan. Photo: Ed Kashi.

safety of our employees is priority number one. Although some of them were offered to be relocated, a few decided to stay. Being there for the patients is a true example of what ‘Changing Diabetes’ really means. Sometimes helping out can be something as simple as a phone call. For example, when our medical representative Omar guided a mum to the outlet where she could get free insulin for her son who needed it for his type 1 diabetes. How many people who live with or care for someone with diabetes, such as a child, remain in Syria?

Dr. Nizar Albache: The Syrian population was approximately 22 million at the beginning of the crisis. Now the population is divided into four parts: areas controlled by the Syrian government; areas controlled by the opposition; areas inside Syria for internal refugees; and areas outside of the country including refugee camps where they live in very bad condition. Basic needs in refugee camps, including healthcare are completely absent – increasing risk of disease. There are a reported 900,000 to one million people with diabetes in Syria, 10% of whom live with type 1

March 2014 • Volume 59 • Issue 1

health delivery

people with diabetes were obliged to change treatment patterns because of accessibility and resources which definitely have led to many complications. Also treatment cost coverage has changed: many patients have become obliged to start paying out of pocket when, before the crisis, medical necessities like insulin were reimbursed.

diabetes. It is very difficult to give an accurate estimation of the number of people with diabetes who are still living in Syria. I believe there should be roughly 20-25% of the diabetes population who left the country and around 15-20% still living in areas controlled by opposing groups, and more the half of population still living in the areas controlled by the Syrian army.

It has been reported that the impact of the conflict for people in Syria has led to a lack of funds to cover the cost of medicines and treatment, many hospitals and clinics being destroyed, healthcare professionals leaving the country and risky roads making distribution of insulin extremely challenging. What is the result of this tragic situation? Dr. Nizar Albache: This is true because more than one hundred hospitals and clinics have been destroyed and many of them were hospitals with large populations such as the al-Kindi hospital in Aleppo. Many villages and smaller cities have no doctors, and drugs, particularly insulin are not available or are too expensive because people have lost their income. There is an urgent need for diabetes drugs. The roads are not safe, and transporting prescription drugs and other medical supplies is very dangerous. Shipping and tracking is difficult because goods get lost and the drivers are fearful of being kidnapped. To give an example: traveling from Aleppo to Latakia (190 km distance) can take anywhere from 12-24 hours. There is an urgent need to supply people in rural areas with insulin and oral hypoglycaemic agents, particularly for people with diabetes living in the refugee camps.

Eyad Al Safadi: Our estimation is that slightly less than half of the patients may have either left the country or have been displaced. Part of the remaining half of

Eyad Al Safadi: The main result in my view is simply that diabetes gets less attention and less priority as a ‘problem’ under such circumstances. Although

March 2014 • Volume 59 • Issue 1

this sounds very logical based on the fact that it is a macro crisis hitting the whole country, but this also means that people living with diabetes in Syria have double suffering. The first burden is coming from the overall situation and the second is caused by diabetes. Their extra suffering may not be only due to the lack of treatment, but in some cases diabetes guidance and support are out-of-reach. What options are left for people living with diabetes in Syria right now? Dr. Nizar Albache: Most people who live in the government sector have access to healthcare and can afford their treatment or get it for free from centres, but people in the other sectors have to manage diabetes with whatever is available. They switch from one type of insulin to another a lot. Eyad Al Safadi: When I ask this question to Rami Matarji our Product Specialist based in Syria he believes there is only one good option. All stakeholders that believe in fighting diabetes should stand together in Syria. IDF, WHO, the Red Cross, Red Crescent, NGOs, and local healthcare clinics and Novo Nordisk, who can help provide insulin, have a responsibility. If we put all our hands together then we can reach people with diabetes in need and perhaps, we can change the future of diabetes in Syria. Has it been difficult to ship or store insulin in Syria? Dr. Nizar Albache: Yes. Other than the problem of affordability and accessibility, there is the problem of how to store insulin safely because there is no electricity in many areas, or there is only electricity for a few hours a day or just a few hours a week. It’s important to note that all humanitarian help arrives and is distributed in the government sector, less or none of this aid arrives in the opposition sector.

DiabetesVoice 29

Health Delivery

Eyad Al Safadi: Shipping human insulin to Syria has become complicated especially due to the special storage conditions required of this medicine. Since Damascus airport is no longer very safe to use and many airlines stopped their flights there, our medicines are shipped to Beirut international airport from where it is carried by trucks to the Syrian-Lebanese border. At the border, shipments are reloaded on Syrian trucks, which travel many hours to reach Damascus. Up to 8-10 stakeholders play a role in this process and accurate timing and coordination between them is essential for the insulin to reach warehouses in the best quality. A journey that used to take two days in the past can now take more than 15 days. Have you had to balance decisions and make trade-offs related to security and safety and can you explain how? Dr. Nizar Albache: We need to work with local organizations working on the ground who know how to deal with all kinds of risks, and can help with transporting drugs and medical supplies to people who need them. Eyad Al Safadi: Making ‘fateful decisions’ under such an extreme environment was and will remain the most challenging for everybody in the Syrian team. We need to make decisions about whether we should stay or leave, whether we should donate or sell the insulin and decide on how many patients we can realistically reach out to considering our resources. So far, a few people from the office have decided to leave the country while some are still here. Sometimes we have donated insulin, but many other times we have sold it. It is constantly about making right and balanced decisions, which we believe we have done.

DiabetesVoice

Can you give one example of a dangerous situation when you or a colleague was tasked with delivering insulin – helping the diabetes community or saving a life? Dr. Nizar Albache: I haven’t had a recent personal experience regarding the delivery of diabetes supplies inside Syria, but I have a lot of difficulty organizing shipments and deliveries of insulin and other medical supply to Syrian refugees because of poor local infrastructure, and we need government support, which can delay humanitarian aid. Eyad Al Safadi: Two explosions basically took place in Damascus last year just a few hundred meters from where our office is located. We closed the office temporally for a couple of days after the explosions. Later, all our staff believed we needed to go back and perform our duties because of the value they feel they are offering to people in need. It’s more than just a job at this point. We can always look at crisis as something terrible and sad – which is true in this situation of course - but we can also look at it as something to learn from. What we have learned is very simple, but also very powerful: ‘Diabetes does not stop during a crisis!’ People may forget about diabetes during a crisis but it does not stop, it only gets worse.

Injecting aid Stéphane Besançon, Assa Traoré Sidibé,

For more than ten years in Mali, NGO Santé Diabète, in close collaboration with the Ministry of Health of the Republic of Mali, has undertaken efforts to strengthen the healthcare system for people living with diabetes. The collaboration prompted the establishment of 22 diabetes consultation centres that provide care as well as prevention and therapeutic education to more than 10,000 people with diabetes. The countrywide effort has also increased the capacity of membership associations for people with diabetes.1 Fortunately, the efforts of Santé Diabète have enabled the Republic of Mali to join the IDF Life for a Child Programme to improve early detection and management of type 1 diabetes in children and adolescents. In addition to on-site projects, Santé Diabète also contributes to university

For more information or how to help:

training of physicians in the

The Assistance Coordination Unit (ACU): http://acu-sy.org/HomeEn/

field of endocrinology, includ-

International Medical Corps: https://internationalmedicalcorps.org Syrian American Medical Society: http://sams-usa.net

ing a specialization course that leads to two types of degree for health professionals.2

March 2014 • Volume 59 • Issue 1

health delivery

into a forgotten region Bah Traoré, Djibo Amadou, Paulette Djeugoue, Anne-Laure Coulon and Serge Halimi

In March 2012, the unstable political situation in the Republic of Mali led to the occupation of the northern region of the country. Combat conditions had humanitarian consequences but the lack of medication coupled with the migration of a healthy workforce yielded an increasingly disastrous medical situation. In this context, and within just a few weeks, thousands of people with diabetes were faced with no access to treatment and medication.3

Thousands of people with diabetes were faced with no access to treatment and medication. Despite the commitment of the United Nations (Office for the Coordination of Humanitarian Affairs), the European Union (ECHO), and other emergency NGOs to overcome the threat of Noncommunicable Diseases (NCDs) including diabetes, help never reached the people most in need. A request to support people living with diabetes in the north of Mali was given to the Office for the Coordination of Humanitarian Affairs (OCHA), but the answer was appalling: ‘Diabetes is not in the framework and not an emergency’.

March 2014 • Volume 59 • Issue 1

Testing of blood glucose in the Timbuktu region, North of Mali

DiabetesVoice 31

Health Delivery

Regional Hospital of Timbuktu

Faced with the unresponsiveness of the majority of the partners, Santé Diabète managed to raise funds from the French Ministry of Foreign Affairs, the Agence Française de Développement and the Rhône Alpes Region and from various pharmaceutical companies such as Sanofi and Novo Nordisk. In response to this tragic humanitarian situation of people with diabetes in Mali, funds were used to establish the Fédération Nationale des Diabétiques du Mali (Fenadim) and provide the Hospital of Mali with a humanitarian response targeted at helping people with diabetes.

DiabetesVoice

From April 2012 to December 2013, this humanitarian response and funding allowed Santé Diabète to provide free medical treatment such as insulin and oral anti-diabetics to people with diabetes in the northern region and to those displaced in the southern region. In addition, diabetes emergency kits for problems related to ketoacidosis and foot care were distributed to medical centres. The impact of this initiative was more significant than expected, demonstrating that the demand was enormous. Indeed, the initiative provided:4

■ treatment to 1,800 patients in the northern zone; ■ treatment to 125 patients displaced to Bamako; ■ treatment for 15 diabetic coma cases; ■ treatment for 30 diabetic feet with severe complications. Between humanitarian aid and reconstruction Since the end of the occupation of northern Mali by the armed groups, healthcare is slowly returning to normal and there has been a progressive return of the population which had been forced to migrate. In October

March 2014 • Volume 59 • Issue 1

health delivery

2013, Santé Diabète and various endocrinology and diabetology teams at the Hospital of Mali decided to prolong the humanitarian aid for several months. At the same time, they initiated an in-depth evaluation of current diabetes management in Mali as a means to improve the status quo in 2014. Focusing on Timbuktu, Gao and Douentza, the evaluation focussed on three objectives for each city, prioritising: ■ on-site evaluation of health facilities; ■ targetted diabetes screening and ■ f ree consultations for people with diabetes. The evaluation process was established in a four-day workshop held in Bamako in November 2013. Various teams of the Hospital of Mali as well as the NGO Santé Diabète took part in this preparation meeting, supported by a team of endocrinology experts from the Centre Hospitalier de Grenoble in France. The hospital centre of Grenoble has a long history of development activities in the Republic of Mali, thanks to the financial support of the French Ministry of Health. The scope of the workshop was to prepare and validate all technical documents necessary for the progress of the humanitarian mission. The workshop also led to the implementation of three humanitarian missions

targeted at improving diabetes care and conducted by medical specialists in endocrinology and diabetology in the north of the country. The first mission sent four physicians to Timbuktu. The second mission stationed physicians in Gao and a third mission placed two physicians in Douentza all during mid to late December 2013. Activities conducted during the humanitarian mission People living with diabetes in Timbuktu, Gao and Douentza had not been seen by doctors for months, and private radio stations were used to inform and invite people with diabetes to the medical centres. Screening During the first two days of the missions, people at risk of or living with diabetes in each of the cities were invited to take a glycaemic test. This essential step attracted a large number of people, and the mission teams were able to further inform the invited population and offer targeted specialized medical treatment. Medical consultation for people with diabetes Taking into account the lack of medical support available for people living with diabetes during the months of the crisis, five days of specialized medical consultation were offered. These

Treatment for diabetes care was given to more than 1,800 people in the northern zone.

March 2014 • Volume 59 • Issue 1

medical consultations were established: ■ to verify and adjust treatments; ■ to detect and treat diabetes-related troubles such as infections or dehydration and ■ to manage acute complications. After each consultation, the patients received free anti-diabetic medicines offered by the NGO Santé Diabète. Assessment of diabetes-related healthcare facilities in the three cities During two days, the physicians were asked to assess the health facilities in collaboration with the local health authorities. The aim of this assessment was to evaluate diabetes-related health facilities on a staffing, laboratory equipment and medication resource level. Across all three cities, 797 people attended the screening tests. 354 of the attendees were previously diagnosed people with diabetes looking for access to specialized follow-up medical consultations. Santé Diabète provided 50% of the donations required for emergency treatments. The majority of all people living with diabetes received the treatment they needed which demonstrated how the humanitarian emergency mission was successful. Even though free treatment allowed many people to survive, the mission could not ensure quality diabetes self-management. The teams treated many diabetic foot cases as well as ketoacidosis in the hospital of Timbuktu. Medicines When the health facilities and the drug warehouses reopened a few weeks earlier in all three cities, no anti-diabetic medicines including insulin and oral

DiabetesVoice 33

Health Delivery

anti-diabetic medicine were available. Maintaining donations from Santé Diabète is therefore especially important for the period following the months of the mission in order to allow a better transition between emergent humanitarian action and long term development. Healthcare professionals In Gao and Timbuktu regional hospitals and specific healthcare centres, technical and human resources are provided and supported by various international NGOs. At the time of the mission though, we could not find any physicians providing diabetes consultations in any of these

DiabetesVoice

facilities. The city of Douentza was in a better position given that a referring diabetes physician who had left the area during the crisis came back, allowing for a swift reopening of the diabetes consultation centre. Consultation and laboratory material In all three cities, the minimum medical equipment and supplies required for physicians to assure qualitative diabetes consultations are missing. Furthermore, the basic material for laboratory work is also missing. Conclusion These humanitarian missions during the crisis of the Republic Mali

have demonstrated the tremendous impact of the humanitarian response conducted by Santé Diabète, the Fenadim and the hospital teams of Mali. The mission saved hundreds of people with diabetes. However, both the assessment of patients’ health status and of the healthcare facilities showed that there is now a critical need for effective management of diabetes in these three localities (Douentza, Gao, Timbuktu) as in the northern regions as a whole. Rebuilding the diabetes management services will have to be a priority among the partners engaged in the fight against diabetes in the Republic of Mali.

March 2014 • Volume 59 • Issue 1

health delivery

Disaster preparedness and recovery with diabetes



1. If you live with diabetes: ■ Carry a 3-day-supply of essential diabetes medication with you at all times. ■ Wear a form of diabetes identification at all times.

■ At least 25 glucose strips and lancets plus a test meter. ■ Ketone testing equipment. ■ A glucagon emergency kit and a form of glucose, like hard candy. ■ An extra pair of sturdy shoes.

2. If you use insulin: ■ Insulin once opened may be stored at room temperature (15°-30°C) for 28 days. ■ Insulin should not be exposed to excessive light, heat or cold. ■ Lantus, Levemir, Regular, Apidra, Novolog and Humalog insulin should be clear. ■ NPH insulin should be milky.

4. Remember these important points: ■ Remain well hydrated (water, unsweetened drinks). ■ Avoid salt tablets unless prescribed. ■ Avoid food, cans or packages that have been wet. ■ Seek emergency treatment if you feel fatigue, weakness, abdominal cramps, decreased urination, fever, and confusion. ■ Wear protective clothing and sturdy shoes. ■ Check your feet daily for an irritation, infection, open sores or blisters because heat, cold, excessive dampness and inability to change footwear can lead to infection, especially if your blood glucose is high.

* We acknowledge that in many developing regions of the world, access to these kinds of resources for individuals living with diabetes are not available.

March 2014 • Volume 59 • Issue 1

Elizabeth Snouffer is Editor of Diabetes Voice. Talia Raab is Social Media and Communications Manager for IFL Australia and IFL Global. Juvy Holasca is Liaison Officer for Philippines Project. Stéphane Besançon is General Director of the NGO Santé Diabète www.santediabete.org Assa Traoré Sidibé is Head of the Endocrinology and Diabetology Department at the Mali Hospital in Bamako.

Carolyn Robertson

3. Keep the following* in an accessible emergency bag: ■ A list of all your medications and documents. ■ Insulin syringes, insulin pen, pen needles (if used). ■ Insulin pump supplies: reservoirs, infusion sets (if used).

Elizabeth Snouffer, Talia Raab, Juvy Holasca, Stéphane Besançon, Assa Traoré Sidibé, Bah Traoré, Djibo Amadou, Paulette Djeugoue, Anne-Laure Coulon, Serge Halimi and Carolyn Robertson

For more general information related to disaster preparedness, see the International Federation of the Red Cross: www.ifrc.org/ en/what-we-do/disaster-management/

Bah Traoré, Djibo Amadou and Paulette Djeugoue are medical students specializing in endocrinology at the Mali Hospital. Anne-Laure Coulona and Serge Halimi are Physicians specialized in endocrinology, diabetology and nutrition related diseases at the Centre Hospitalier Universitaire de Grenoble, France. Carolyn Robertson is a member of the Diabetes Voice Advisory Group and is consultant to the Gonda Diabetes Center at University of California, Los Angeles, USA.

References 1. Sidibé AT, Besançon S, Beran D. Le diabète: un nouvel enjeu de santé publique pour les pays en voie de développement : l'exemple du Mali. Médecine des maladies Métaboliques 2007; 1: 93-8. 2. Drabo J, Sidibé A, Halimi S, et al. A multipartner approach to developing excellence in diabetes management training in four African countries. Diabetes Voice 2011; 56: 18-20. 3. B esançon S, Sidibé AT. Civil society facing down the diabetes emergency in Mali. Diabetes Voice 2012; 57: 40-42. 4. B esançon S. Afrique et diabète: la fin d'un paradoxe. Diabète et Obésité 2013; 72: 35-40.

DiabetesVoice 35

Clinical care

Diabetes treatment and cancer: five years after ‘breaking news’ Andrew Renehan

In June 2009, there was considerable excitement in the diabetes community when ‘breaking news’ of four epidemiological studies looking at the links between diabetes treatment and cancer were uniquely published collectively in the same issue of the journal Diabetologia. These papers focused the spotlight onto the risk between exogenous insulin therapeutic use, and in particular, that of the insulin analogue, glargine (Lantus®), and subsequent cancer development. All four studies had design limitations, and in short, it was not possible to draw firm conclusions. These four studies initially left the diabetes community confused, but positive outcomes then emerged. In 2010, I outlined the first two years of that journey in Diabetes Voice.1 Here, I update the past three years.

DiabetesVoice

One of the first constructive consequences of the 2009 events was the coming together of experts from diabetes and cancer. A visible example of this was the creation of the Diabetes and Cancer Research Consortium, an international group of investigators mainly working on pharmaco epidemiological queries, but also with a key aim to develop and optimise methodological approaches required to address the complex relationships between diabetes, diabetes treatment and cancer. This group published two framework papers: one on cancer incidence,2 the other on cancer mortality.3 Two important analytical features were emphasised: (1) accounting for ‘detection time bias’; and (2) setting up data to account for ‘time-varying exposures’. The former results in exaggerated risk associations due to the temporal co-occurrence of diagnosis of diabetes, or treatment commencement and cancer diagnosis; the latter refers to the real-life variation in prescription of medications with time,

and if not dealt with adequately, results in false risk associations in either positive or negative directions.

The Diabetes and Cancer Research Consortium develops and optimises methodological approaches required to address the complex relationships between diabetes, diabetes treatment and cancer. Insulin glargine Following 2009, several observational studies evaluated the putative link between insulin glargine and cancer risk, but in the main (even with robust methodological methods), no conclusive evidence emerged. However, the

March 2014 • Volume 59 • Issue 1

clinical care

Second, there was considerable contamination across the arms – 16.7% of patients in the glargine arm had discontinued glargine; while 11.5% of patients in the standard arm had commenced some insulin by the end of the study follow-up. In summary, the pendulum of evidence is swinging towards no association between insulin glargine and cancer risk. However, the highlighted caveats to the interpretation of the ORIGIN trial should encourage the ORIGIN trialists to analyze their data with longer follow-

Figure 1. Follow-up ‘drop-off’ by treatment allocation in the ORIGIN trial. Median FU

7000 6000 5000 No. of patients

publication of the ORIGIN trial in 2012 brought a clearer picture. The ORIGIN investigators randomly assigned 12,537 patients with impaired glucose tolerance or type 2 diabetes to receive insulin glargine versus standard care4 – the largest trial of its type. Although the protocol endpoints were cardiovascular non-fatal events or deaths, following the concerns raised by the papers in 2009, the investigators additionally detailed risk per cancer type by allocated treatment. There were no differences between treatment arms for all cancer incidence or deaths, and no differences between treatment arms for the following reported cancer types: breast, prostate, colon, lung, and melanoma. These data seemed definitive, leading some commenters to suggest ‘closure’ on this topic. However, there are caveats to the interpretation of the ORIGIN trial and cancer risk. First, although median follow-up was 6.2 years, there is a rapid drop-off thereafter such that only 14% of those recruited were followed to the seventh year (Figure 1). Many cancer epidemiologists would consider this lag period as too short to assess associations between an exposure and cancer incidence.

4000 3000 2000

Exposed to glargine Non-glargine exposure (standard care)

1000 0 0

3 Years

The numbers per arm have taken account of the numbers followed after randomisation minus those cases that discontinued glargine in the intervention arm, and commenced insulin in the standard care arm. FU: follow-up. Adapted from reference No. 4.

up and use a ‘per protocol analysis’ (i.e. comparing groups by including only those participants who were able to keep to the treatment to which they had originally been allocated) in addition to the already reported ‘intention to treat analysis’.

of the earlier epidemiological studies contained important time-related biases that artificially made the results look ‘protective’. Most importantly, there were biases known as ‘immortal time bias’. This statistical facet is conceptually difficult and was perhaps not well appreciated by the diabetes and cancer research communities. The bias occurs when the analysis fails to take account of the time off treatment between the beginning of a cohort study and the start of the therapy. Individuals have to survive to the start of exposure – hence, the name of ‘immortal’. The result is an advantage to the users of the drug of interest when the analysis is simply categorised by

The pendulum of evidence is swinging towards no association between insulin glargine and cancer risk.

March 2014 • Volume 59 • Issue 1

Metformin We now better understand the putative protective effect of metformin use and cancer risk. In particular, over the last few years, it has become clear that many

DiabetesVoice 37

Clinical care

‘ever’ or ’never’ use. This has been well illustrated by Suissa and colleagues5 – they found that immortal time bias was prevalent among many epidemiological studies that reported a reduced cancer risk associated with metformin use. By contrast, those studies that used analytical methods to avoid these biases reported no effect of metformin use on cancer incidence. The time-related biases identified in studies of metformin use and cancer incidence are also likely to be prevalent among survival studies in patients with cancer and using metformin. These uncertainties are now the subject of several randomized phase III trials in patients with cancer without diabetes. A notable example is the large adjuvant trial in early breast cancer, NCIC MA.32, with a primary endpoint of five-year invasive cancer-free survival. The trial target of 3,582 women completed recruitment in early 2013 – the results of this trial are eagerly awaited.

There is now a need to establish the appropriate dose of metformin for its proposed anticancer effects The third key appreciation in the story of metformin and cancer lies in the biology. There are now many laboratories across the globe exploring the role of metformin in cancer, and several novel anti-cancer mechanisms have been demonstrated and validated. However, it has become clear that many preclinical in vivo studies use concentrations of metformin

DiabetesVoice

higher than those safely obtained in the clinical setting. Additionally, most in vitro studies report using doses of metformin between 1 and 40 mM, which is well above the feasible therapeutic plasma levels (0.465–2.5 mg/L or 2.8–15 mM) in humans (Figure 2).6 It is possible that metformin causes an energy stress in these studies that far exceeds effects that would be seen clinically. In summary, the pendulum of evidence is swinging towards no association between metformin and cancer risk too. The dose of metformin currently used in oncology trials is that shown to be effective for glucose control; there is now a need to establish the appropriate dose of metformin for its proposed anti-cancer effects. Pioglitazone As investigators examined their databases, they stumbled upon the observa-

tion that pioglitazone exposure might be associated with increased risk of bladder cancer. The initial studies were based on relatively crude analyses of health insurance system databases with small numbers of bladder cancer cases – nonetheless, this ‘signal’ was enough to guide the drug regulation authorities in France and Germany to withdraw this agent, in June 2011. Since then, there have been at least three large analyses from the General Practice Research Database, UK,7 Systeme National d'Information Inter-regimes de l'Assurance Maladie, France,8 and the Kaiser Permanente Northern California (KPNC) diabetes registry, US9 – with large numbers of bladder cancer cases, and all suggesting an increased risk. However, here again, there may be biases clouding the interpretation. Recent updated analyses of the KPNC cohort study of pioglitazone and bladder cancer show that when

Figure 2. Concentrations of metformin used in laboratory studies Metformin concentrations

Dose Relative Dose*

Standard clinical use

In vivo preclinical studies

In vitro laboratrory studies

250 to 2250 mg/day

750 mg/kg per day

2 to 50 mM

0.15 to 1.0

2 to 45

25 to 1000

Clinical and epidemiological studies utilise metformin doses of up to 2250 mg/day. Conversely, in vivo preclinical and in vitro studies often involve extremely high, non-physiological concentrations of metformin that are in excess of the therapeutic levels safely achieved in human patients. Adapted from reference No. 6. *Relative to standard clinical use.

March 2014 • Volume 59 • Issue 1

clinical care

prospective trials. When prescribing pioglitazone, the clinician needs to be mindful of patients with a history or predisposition to bladder cancer. For incretin-based glucose-lowering medications, the evidence currently is too immature to impact meaningful on clinical practice.

Andrew Renehan Andrew Renehan is Professor of Cancer Studies and Surgery at the Institute of Cancer Sciences, University of Manchester, UK.

References 1. Renehan AG. Diabetes, diabetes treatment and cancer risk. Diabetes Voice 2010; 55: 38-40.

there is adjustment for albuminuria, the risk essentially goes away. These new analyses suggest that the bladder cancer association is due to a detection bias. Cleary, further studies are required to this question. Incretin-based glucose-lowering medications Incretin-based glucose-lowering medications were introduced to the US market in 2005 and have proven to be effective glucose-lowering agents â&#x20AC;&#x201C; both as glucagon-like peptide 1 (GLP-1) receptor agonists and as dipeptidyl peptidase 4 (DPP-4) inhibitors. However, over recent years, there have been cancer concerns regarding the long-term consequences of using these therapies. The issues raised are with regard to the potential of both classes to promote acute pancreatitis, and then initiate histological changes suggesting subclinical chronic pancreatitis with associated pre-cancerous lesions (for example, ductal proliferation), and potentially, in the long run, pancreatic cancer.10 There may be additional risk for an increase in thyroid cancer. These

March 2014 â&#x20AC;˘ Volume 59 â&#x20AC;˘ Issue 1

data are particularly challenging to interpret for several reasons: long-term use of incretin-based glucose-lowering is limited; it is unclear whether or not pre-clinical animal model data translate directly to human cancer development; and whether there had been adequate adjustment and modelling to take account of the biases and confounding outlined in the early paragraphs of this article. Conclusion So what do these wide-ranging observations mean for day-to-day clinical practice? In terms of use of long-acting insulin analogues, there is broad reassurance - there are theoretical reasons (based on laboratory studies) that these analogues may increase cancer risk, but in patients this increase is either negligibly small or absent. For metformin use, the continued exploration of this drug as anti-cancer agent in the laboratory should be encouraged. In clinical practice, the ad hoc prescription of metformin in non-diabetic patients with cancer cannot be justified; its use should be restricted to registered

2. Johnson JA, Carstensen B, Witte D, et al. Diabetes and cancer (1): evaluating the temporal relationship between type 2 diabetes and cancer incidence. Diabetologia 2012; 55: 1607-18. 3. R enehan AG, Yeh HC, Johnson JA, et al. Diabetes and cancer (2): evaluating the impact of diabetes on mortality in patients with cancer. Diabetologia 2012; 55: 1619-32. 4. G erstein HC, Bosch J, Dagenais GR, et al. Basal insulin and cardiovascular and other outcomes in dysglycemia. N Engl J Med 2012; 367: 319-28. 5. S uissa S, Azoulay L. Metformin and the risk of cancer: time-related biases in observational studies. Diabetes Care 2012; 35: 2665-73. 6. D owling RJ, Niraula S, Stambolic V, et al. Metformin in cancer: translational challenges. J Mol Endocrinol 2012; 48: R31-43. 7. A zoulay L, Yin H, Filion KB, et al. The use of pioglitazone and the risk of bladder cancer in people with type 2 diabetes: nested casecontrol study. BMJ 2012; 344: e3645. 8. N eumann A, Weill A, Ricordeau P, et al. Pioglitazone and risk of bladder cancer among diabetic patients in France: a population-based cohort study. Diabetologia 2012; 55: 1953-62. 9. L ewis JD, Ferrara A, Peng T, et al. Risk of bladder cancer among diabetic patients treated with pioglitazone: interim report of a longitudinal cohort study. Diabetes Care 2011; 34: 916-22. 10. Butler PC, Elashoff M, Elashoff R, et al. A critical analysis of the clinical use of incretinbased therapies: are the GLP-1 therapies safe? Diabetes Care 2013; 36: 2118-25.

DiabetesVoice 39

COUNTRY care Clinical PERSPECTIVES

Debate: long-term safety of insulin in type 2 diabetes More and more frequently insulin is being recommended as an ‘add-on’ to oral hypoglycaemic therapy for the achievement of blood glucose targets in people with established type 2 diabetes. Indeed, there are now trials of insulin therapy in type 2 diabetes from diagnosis. Concerns have been raised in the recent medical literature that long-term insulin therapy in type 2 diabetes increases

Insulin therapy in people with type 2 diabetes: is it safe in terms of the risk of cardiovascular disease, cancer and all-cause mortality?

Sarah Holden and Craig Currie

the risk of cardiovascular disease and some cancers. We have asked specialists in the fields of clinical diabetes and pharmacoepidemiology to comment on the question:

DiabetesVoice

Insulin has an unlimited potential to lower blood glucose and is a wellestablished treatment for type 2 diabetes. The International Diabetes

Federation (IDF) recommends that it should be used as an optional third line when a combination of metformin, where indicated, and one other glucose-lowering medication has failed to adequately control blood glucose. ADA and EASD guidelines recommend a patientcentred approach with the aim of achieving adequate glucose control while minimising side effects. Two common side effects associated with insulin injections are weight

March 2014 • Volume 59 • Issue 1

care COUNTRY clinical PERSPECTIVES

gain and hypoglycaemia. Weight gain is associated with an increased risk of cardiovascular disease and should be minimised in type 2 diabetes. Both insulin and hypoglycaemia may have vascular effects which are thought to be greatest in people with preexisting cardiovascular disease and diabetes.1,2 In addition, as a growth factor, insulin may affect cancer progression.3 However, this is a complex area where high glucose levels have also been linked to increased cancer risk.4 Some epidemiological studies have shown that the use of insulin is associated with an increased risk of cardiovascular events, cancer and allcause mortality in comparison with other glucose-lowering therapies.5,6,7 In one of these studies (a retrospective cohort study using data from the UK General Practice Research Database)6 mortality and other diabetes-related outcomes for just under 85,000 individuals were examined in relation to five diabetes therapies – monotherapy with either metformin, sulfonylurea or insulin, metformin plus sulfonylurea or insulin plus metformin. Treatment with insulin alone conferred a statistically significantly increased risk of a first major cardiac event or a first diagnosis of cancer ranging from 1.8 to 2.6 times the risk seen in those treated with metformin alone (the comparison group). This excess risk was lower in the group treated with insulin plus metformin than in the insulin monotherapy group, though was still significant at 1.3 times the risk of the comparison group. However, even though these results are consistent and despite the use of statistical adjustment, observational data such as these should be

March 2014 • Volume 59 • Issue 1

interpreted with caution due to the risk of a form of analytical bias that is termed ‘confounding by indication’. This form of confounding is a common feature of studies of outcomes in relation to drug and other therapies simply because the reasons patients have been prescribed the therapies may themselves be related to the perceived risks of any particular outcome occurring. In other words, people may be prescribed insulin partly because they are perceived of being at risk to adverse outcomes, including risk of cardiovascular disease. In contrast, large randomised controlled trials such as Action to Control Cardiovascular Risk in Diabetes (ACCORD) found no adverse safety signals associated with the use of insulin.8 However, these studies were designed to assess the benefits of intensive glucose control rather than the safety of insulin, and subjects could receive multiple glucose-lowering therapies making individual comparisons difficult. Also, the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial demonstrated that insulin glargine had a neutral impact on cardiovascular outcomes and cancers compared with standard treatment.9 However, it should be noted that people included in ORIGIN were newly diagnosed with type 2 or impaired glucose tolerance, impaired fasting glucose or only using one glucoselowering therapy. In addition, by the end of the study, 65% of the insulin glargine group were also using other glucose-lowering agents, including 47% using metformin.

with insulin. Metformin is thought to protect against cancer and have cardio-protective effects that cannot be fully explained by its ability to lower blood glucose.10 When used in conjunction with insulin, metformin has been associated with similar glucose control, but lower insulin doses and less weight gain.11 In addition, relative to the use of insulin alone, the use of metformin in combination with insulin has been associated with a reduced risk of cardiovascular events, cancer and death from any cause.6 Current ADA, EASD and IDF guidelines advocate that, when starting insulin, it should be added to existing metformin therapy and not replace it. Any potential risks associated with insulin therapy need to be seen in the context of its clear benefits for achieving good glucose control. However, the shortage of randomised controlled trials examining the risks and benefits of using insulin on long term clinical outcomes such as cardiovascular events, cancer and death from all causes needs to be addressed in order to provide more evidence on the safety of insulin in people with type 2 diabetes. In the UK, the Medical and Healthcare Products Regulatory Agency will soon report on the safety of insulin in people with type 2 diabetes. Regardless, there are question marks about the safety of insulin in type 2 diabetes. There is, therefore, a need to show caution while our lack of understanding of this potential problem is addressed, and we can recommend injection of insulin in people with type 2 diabetes with confidence.

When used in combination, metformin may attenuate any risks associated

DiabetesVoice 41

COUNTRY care Clinical PERSPECTIVES

YES

Steve Bain

Insulin is an established glucose-lowering therapy for both type 1 and type 2 diabetes. However, insulin is a growth factor. It is administered in an un-physiological manner and it is present in the circulation at levels that are far higher than in the non-diabetic population. For these reasons, concerns regarding insulin safety have been long-standing and this has led to them being extensively investigated and, to my mind, repudiated. First the concerns regarding cancer: these emerged following suggestions that the long-acting insulin analogue, glargine, increased the risk of cancer12 and were supported by papers suggesting that insulin or insulin secretagogues were associated with a higher cancer risk.7 However, slowly the picture became less certain. Scrutiny of the original report showed that the patients receiving glargine were on tiny doses of insulin, the cancer risk disappeared completely if they were on any other glucose lowering medications (including other insulins) and the increased risk was only seen after an 'adjustment' by the authors.12 Attempts to replicate the original findings floundered, despite analyses of huge data sets. Finally a prospective randomised clinical trial (RCT) was published which demonstrated that

DiabetesVoice

exogenous insulin therapy (with glargine) over more than six years' followup was associated with no evidence of increased risk of cancer.9 So, concerns raised by pharmacoepidemiology, which can only identify possible safety signals and generate hypotheses, were laid to rest by an RCT. The case of cardiovascular disease has been longer and more convoluted. Once again, insulin had been implicated because of its potential to act as a growth factor and thereby promoting and/or enhancing the development of atheroma in the circulation. This hypothesis seemed to be supported by observations from epidemiological studies suggesting an association between hyperinsulinaemia and cardiovascular mortality.13 Subsequently, a meta-analysis of data from eleven different studies in nondiabetic men and women concluded that hyperinsulinaemia was significantly associated with cardiovascular mortality.14 However, this does not imply causality since the fasting insulinaemia seen in these studies may have been a consequence of insulin resistance, and hence an innocent surrogate. An RCT was clearly needed – the United Kingdom Prospective Diabetes Study (UKPDS). In the seminal publication of 1998, the introduction clearly stated that ‘there is concern that sulphonylureas may increase cardiovascular mortality in patients with type 2 diabetes and that high insulin concentrations may enhance atheroma formation’. UKPDS conclusively demonstrated no such increase and, almost, showed a benefit from tight control using insulin and the sulphonylureas.15 Now the hypothesis had changed leading to attempts to demonstrate a beneficial impact of tight glycaemic control on cardiovascular outcomes; ultimately

this led to the controversy surrounding the ACCORD study.8 ACCORD enrolled middle-aged and elderly people with type 2 diabetes and a very high risk of cardiovascular disease. To the researchers' surprise, nearnormal glucose control, achieved with the use of multiple drugs, was associated with increased all-cause mortality and cardiovascular mortality. At five years of follow-up, nonfatal myocardial infarction was reduced, but five-year mortality was increased in patients who received intensive glucose-lowering therapy. Of note, over 75% of the intensive group were using insulin at study end. Meta-analyses were subsequently performed to include all major studies examining the impact of tight glycaemic control on cardiovascular outcomes and drew the opposite conclusion from that reported in ACCORD.16 These trials did not compare insulin with non-insulin regimens, however, all had higher proportions of insulin users in the intensive therapy arms. Given the large numbers involved in the studies, one might have expected that any intrinsic harmful effect of insulin would show up as a consistently increased hazard ratio in the intensive arms of the trials but it did not. Cue the pharmaco epidemiologists: Currie et al. conducted a retrospective database study of 84,622 primary care patients, defined a primary endpoint of all-cause mortality, incident cancer, or major cardiac adverse events, and reported hazard ratios (relative to metformin monotherapy) of 1.808 for insulin monotherapy and 1.309 for insulin plus metformin.6 Several other observational studies, based on databases, supported the association between increasing insulin use and serious events.17 Fortunately, an RCT

March 2014 • Volume 59 • Issue 1

COUNTRY clinical PERSPECTIVES care

was already in progress which, for most people, would settle the argument. The ORIGIN trial9 randomised 12,537 people with cardiovascular risk factors as well as impaired fasting glucose, impaired glucose tolerance or type 2 diabetes, to receive standard care or insulin glargine. The aim was to identify any intrinsic benefit on cardiovascular outcomes from early use of insulin and the population of ORIGIN included patients who were very well controlled (indeed, approximately 10% were non-diabetic), with HbA1c values of 6.3% or less in the insulin glargine group and 6.5% or less in the standard care group. Early use of titrated basal insulin had no impact on cardiovascular outcomes compared with standard guideline-suggested glycaemic control. The ORIGIN investigators pointed out that a large between-group difference in insulin use was achieved, and only a small difference in HbA1c; the results were therefore relevant to the effect of insulin therapy rather than the effect of glucose lowering on cardiovascular outcomes. Once again, an RCT had come to the rescue. The final question is whether the controversies about cancer and cardiovascular disease affect clinical practice. For people with type 1 diabetes, insulin is currently the only therapy option. For patients with type 2 diabetes, the progressive nature of the condition means that, given current therapies, everyone will eventually need insulin for symptomatic relief of hyperglycaemia (assuming they survive the complications of the condition). In the UK at least, the average starting HbA1c for insulin of over ~9.5%, suggests that neither patients nor clinicians feel that insulin is an easy or early treatment option. In this setting, the debates around safety can be seen as rather academic.

March 2014 • Volume 59 • Issue 1

Sarah Holden, Craig Currie and Steve Bain Sarah Holden is PhD student at the Department of Primary Care and Public Health, School of Medicine, Cardiff University, UK. Craig Currie is Professor of Applied Pharmacoepidemiology, The Pharma Research Centre, Cardiff Medicentre, Cardiff, UK. Steve Bain is Professor of Medicine (Diabetes), College of Medicine, Swansea University, Swansea, UK.

References 1. R ensing KL, Reuwer AQ, Arsenault BJ, et al. Reducing cardiovascular disease risk in patients with type 2 diabetes and concomitant macrovascular disease: can insulin be too much of a good thing? Diabetes Obes Metab 2011; 13: 1073-87. 2. N ordin C. The case for hypoglycaemia as a proarrhythmic event: basic and clinical evidence. Diabetologia 2010; 53: 1552-61. 3. Pollak M. Insulin and insulin-like growth factor signalling in neoplasia. Nat Rev Cancer 2008; 8: 915-28. 4. J ee SH, Ohrr H, Sull JW, et al. Fasting serum glucose level and cancer risk in Korean men and women. JAMA 2005; 293: 194-202. 5. C urrie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study. Lancet 2010; 375: 481-9. 6. C urrie CJ, Poole CD, Evans M, et al. Mortality and other important diabetes-related outcomes with insulin vs other antihyperglycemic therapies in type 2 diabetes. J Clin Endocrinol Metab 2013; 98: 668-77. 7. C urrie CJ, Poole CD, Gale EAM. The influence of glucose-lowering therapies on cancer risk in type 2 diabetes. Diabetologia 2009; 52: 1766-77. 8. A ction to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358: 2545-59. 9. O RIGIN Trial Investigators, Gerstein HC, Bosch J, Dagenais GR, et al. Basal insulin and cardiovascular and other outcomes in dysglycemia. N Engl J Med 2012; 367: 319-28. 10. Zakikhani M, Dowling R, Fantus IG, et al. Metformin is an AMP kinase-dependent growth inhibitor for breast cancer cells. Cancer Res 2006; 66: 10269-73. 11. Goudswaard AN, Furlong NJ, Rutten GE, et al. Insulin monotherapy versus combinations of insulin with oral hypoglycaemic agents in patients with type 2 diabetes mellitus. Cochrane Database Syst Rev 2004: CD003418. 12. Hemkens LG, Grouven U, Bender R, et al. Risk of malignancies in patients with diabetes treated with human insulin or insulin analogues: a cohort study. Diabetologia 2009; 52: 1732-44. 13. Despres JP, Lamarche B, Mauriege P, et al. Hyperinsulinemia as an independent risk factor for ischemic heart disease. N Engl J Med 1996; 334: 952-7. 14. DECODE Insulin Study Group. Plasma insulin and cardiovascular mortality in non-diabetic European men and women: a meta-analysis of data from eleven prospective studies. Diabetologia 2004; 47: 1245-56. 15. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837-53. 16. Ray KK, Seshasai SR, Wijesuriya S, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet 2009; 373: 1765-72. 17. Östgren CJ, Sundström J, Svennblad B, et al. Associations of HbA1c and educational level with risk of cardiovascular events in 32,871 drug-treated patients with type 2 diabetes: a cohort study in primary care. Diabet Med 2013; 30: e170-7.

DiabetesVoice 43

CLinical care

The Asian diabetes phenotypes: challenges and opportunities Juliana CN Chan, Roseanne Yeung, and Andrea Luk

DiabetesVoice

March 2014 â&#x20AC;˘ Volume 59 â&#x20AC;˘ Issue 1

clinical care

Asia is home to two-thirds of the world’s population, where the two most populous countries of India and China are undergoing rapid socioeconomic, technological, and cultural transitions. While these transitions have alleviated poverty, they have come with considerable health consequences.1 Amongst the 382 million people affected with diabetes in 2013, over 200 million come from Asia, including four of the top ten countries with the most cases of diabetes: China, India, Indonesia and Japan.1 The severity of this problem is best illustrated in China, where the most recent national study found that 12% of people were reported to have diabetes and 50% were reported to have prediabetes.2 Of particular concern is how diabetes is affecting younger people in Asia where the largest number of people with diabetes are aged 40-59 years old, compared to Europe where most people with diabetes are over 60 years old (Figure 1).3

Figure 1. Distribution of diabetes by regions and age groups with South East Asia (SEA) and Western Pacific (WP) Regions having the highest number of affected people especially in the 40-59 age group (International Diabetes Federation). IDF Region AFR

EUR

MENA

NAC

SACA

SEA

60K

40-59

Age Source: IDF Diabetes Atlas, 6th edn. International Diabetes Federation. Brussels, 2013. www.idf.org/diabetesatlas

March 2014 • Volume 59 • Issue 1

60-79

20-39

40-59

60-79

20-39

40-59

60-79

20-39

40-59

60-79

20-39

40-59

60-79

20K

20-39

Value

40K

Biologically, there is evidence to show that Asians are more likely to develop diabetes for the same level of body mass index or waist circumference than their Caucasian counterparts.4 This is thought to be partly due to their propensity to store fat viscerally rather than subcutaneously, which is not captured in the traditional measures of adiposity such as body mass index and waist circumference.5 Besides, even in relatively lean subjects, Asians are more insulin resistant than non-Asians with increased concentrations of free fatty acids and inflammatory markers.6 Further, Asian subjects exhibit higher glucose excursion during oral glucose challenge, suggesting lower beta cell function to overcome insulin resistance than nonAsians. These biological differences put Asians at high risk of developing diabetes in the presence of external stressors, such as obesity.7,8 Examples of common clinical features in Asian populations with diabetes are given in the table – the so called ‘Asian phenotypes’. Diabetes and its co-morbidities Diabetes is a disorder of energy metabolism which determines survival. Irrespective of the amount of energy intake and expenditure, blood glucose levels should be maintained between 5 and 8 mmol/L at all times through intricate interplays between insulin, the only hormone which lowers blood glucose and many other stress hormones which tend to elevate blood glucose. Failure to maintain this fine balance results in chronic hyperglycaemia which over time will cause generalized vascular and nerve damage with multiple organ failure.9 Thus, if undiagnosed, untreated, or uncontrolled, diabetes can reduce life expectancy by six years on average. In Asia, 1%-3% of people with diabetes die every year.10 However, the considerable

DiabetesVoice 45

clinical care

diversity in socioeconomical development and cultures as well as subtle differences in genetic makeup give rise to many subphenotypes and consequences in Asian populations. For example, in East and Southeast Asia, where traditional diets contain high carbohydrate, low fat and high sodium content, the low incidence of coronary heart disease and high prevalence of hypertension may give rise to high rates of kidney disease while coronary heart disease remains an important cause of death in South Asian populations.11 In Asia, the diabetes-cancer link is a major health threat where endemic low grade infections and environmental toxins may contribute to the high rates of cancer in the region, further amplified by the abnormal metabolic milieu associated with diabetes and obesity. Against this backdrop, especially in areas where access to medications, revascularisation and renal replacement are limited such as the Pacific Islands, end stage renal disease, stroke, sepsis and leg amputation are often the leading causes of death. In more developed areas with better healthcare, coronary heart disease,

heart failure, chronic kidney disease and cancer have become major causes of premature mortality and morbidities in Asian people with type 2 diabetes.1,9 These life-threatening consequences of diabetes are particularly important to young subjects who face long disease duration. These young subjects pose major therapeutic challenges as they often have poor risk factor control, poor follow-up rates within the healthcare system, and poor treatment compliance. Apart from the silent and nonurgent nature of diabetes and its risk factors, competing priorities, difficulty accepting lifelong disease and delayed intervention by healthcare providers over uncertain long term side-effects of chronic medications are some possible reasons for suboptimal control in these young subjects.12 In a nine-year follow up study of over 2000 Chinese people diagnosed before the age of 40 years, 10% had type 1 diabetes, 60% were overweight type 2 diabetic patients, and 30% were normal-weight type 2 diabetic patients. Overweight type 2 diabetic patients had

Table. Examples of clinical features in Asian populations with diabetes, so called ‘Asian phenotypes’ which may be applicable to populations which undergo rapid acculturation and socioeconomic transition. Low body mass index Increased body fat, especially visceral fat High rate of central obesity and metabolic syndrome Increased inflammatory markers Insufficient beta cell response to counter insulin resistance Low rate of autoimmune type 1 diabetes High rate of young-onset type 2 diabetes High rate of childhood obesity High rate of gestational diabetes Social disparity and psychosocial stress High rate of renal disease High rate of cancer especially those with viral causes, e.g. liver cancer

DiabetesVoice

the worst metabolic profile with 15-fold higher risk of cardiovascular disease and 5-fold higher risk of kidney failure compared to people with type 1 diabetes who had the lowest event rates.12 Heterogeneity of diabetes in youth and young adults Type 1 Diabetes In Caucasians, the majority diagnosed with diabetes under the age of 40 have autoimmune type 1 disease presenting with acute symptoms such as thirst, weight loss, frequent urination, precoma, or coma. By contrast, less than 10% of young Asian people with diabetes have typical type 1 presentation. Compared to a diagnosis rate of 4-45 per 100,000 person-years in the European population, the corresponding diagnosis rate of childhood type 1 diabetes was 2 per 100,000 person-years in Japan.1 Type 2 Diabetes While the incidence of type 1 diabetes among Asian children and adolescents has remained static over time, the incidence of type 2 diabetes has doubled or even tripled in some countries, closely mirroring the rising rates of childhood obesity. With the introduction of urine glucose screening programmes in countries like Japan and Taiwan, more cases of childhood type 2 diabetes are being detected with a rate of 3 per 100,000 person-years in Japan.13,14 China has reported type 2 diabetes in 4%–6% of people in the 18-40 age group. Moreover, features of the metabolic syndrome are present in a substantial proportion of these young subjects at the time of diabetes diagnosis.2 Challenges in diabetes classification With the rise in obesity prevalence, atypical presentation of diabetes with features of both type 1 and type 2 diabetes, also called ‘double diabetes’, are

March 2014 • Volume 59 • Issue 1

clinical care

Professor Juliana Chan (left) with her patient Ms. Lee Hei-Ting (centre) and Ms. Kitman Loo (right) at the Chinese University of Hong Kong – Prince of Wales Hospital.

increasingly common and reflect the challenges of a disease that is subject to the lifestyle changes of modernization, among many other secular changes. The changing face of diabetes poses diagnostic and therapeutic challenges, as our traditional classification systems must evolve to account for emerging disease types.15 Furthermore, developments in antibody testing and laboratory measurement of hormones are enabling us to better characterise autoimmune diabetes, although large gaps exist. In a large Chinese study involving ketosis-free subjects with diabetes over 30 years old, 6% were considered to have latent autoimmune diabetes in adults (LADA) based on positivity of glutamic acid decarboxylase antibodies (GADA).16 These subjects also tended to have lower body mass index and were less likely to have the metabolic syndrome, with predominant beta cell insufficiency. Still, a large proportion of

March 2014 • Volume 59 • Issue 1

Chinese patients with type 2 diabetes are lean with low C-peptide levels at diagnosis, have strong family history of diabetes, but do not exhibit autoimmunity based on absence of circulating islet cell antibodies. Other large scale and family-based genetic studies have discovered genetic variations implicated in beta cell biology and protein metabolism which support their causal roles especially in young subjects with familial diabetes.17,18 Advances in genetics have also allowed for better characterisation and classification of diabetes. In the early 1990s, small case series indicated that 10%-20% of young adult Asian subjects diagnosed before the age of 40 had monogenic diabetes, a form of diabetes due to the mutation of a single gene. Unlike most patients with type 2 diabetes, these subjects are often lean and fail to control their blood glucose with oral drugs alone, requiring insulin for disease control earlier than one would expect

for those with type 2 diabetes.19 Access to genetic testing for these subtypes is still a barrier for most living in Asia, but hopefully the cost and availability of these tests will improve as technology progresses. Ongoing and future genetic studies offer an opportunity for better identification of specific subsets of diabetes and targeted therapies to allow for more personalized treatment. Nature meets nurture Apart from genetic causes, we now recognize the field of epigenetics where environmental or ‘nurture’ exposures affect gene expression. For example, fetal exposure to maternal malnutrition during pregnancy may result in a fetal phenotype that promotes survival in a nutrient poor environment but substantially increases the risk of diabetes and cardiovascular-renal disease during a time of nutrient abundance. Asian women have a high prevalence of gestational diabetes, which is another important risk factor linked to future diabetes

DiabetesVoice 47

COUNTRY care Clinical PERSPECTIVES

development by the offspring. Metabolic health in childhood has also been associated with future risk of obesity and diabetes, where childhood obesity increases the risk of future diabetes development. These factors result in increased trans-generational diabetes with increasingly early onset of disease, thus setting up a vicious cycle of ‘diabetes begetting diabetes’.20 In Asia, while diabetes has been a ‘rich man’s disease’, it is becoming more of a ‘poor man’s disease’ as seen in more affluent societies due to a combination

of poverty, poor education, poor food quality, and high level of physical inactivity. The lack of awareness and health literacy often result in high rates of smoking, consumption of energy-dense food, poor sleep hygiene, and sedentary time on the computer and television. These adverse lifestyle choices can be further compounded by psychosocial stresses associated with rapid acculturation.21 Additionally, chronic exposure to endemic low-grade infections (e.g. hepatitis B infection) and environmental pollutants may result in abnormal neuro-hormonal responses manifesting

Ms. Lee Hei-Ting was diagnosed to have young-onset type 2 diabetes at the age of 28 and started on insulin eight years later. She is managed at a multidisciplinary diabetes centre and has received education with regular comprehensive assessment for risk factors/complications and attainment of multiple treatment targets. She has led an

DiabetesVoice

as obesity, metabolic syndrome, and diabetes.11 Reducing social disparity and setting up systems to prevent the preventable Considerable advancement has now been made in our understanding of the natural history and management of diabetes and its complications. From a public health perspective, reduction of poverty, social disparity and health illiteracy through a multisectorial strategy22 and using a life course approach such as maternal and child health, vaccination programmes, nu-

active working life and raised three children. She is now 60 and works as a peer supporter after retirement. In the photo, Ms. Lee discusses her personalized reports with Professor Juliana CN Chan and Ms. Kitman Loo, a diabetes nurse specialist at the The Chinese University of Hong Kong – Prince of Wales Hospital – IDF Centre of Education.

March 2014 • Volume 59 • Issue 1

COUNTRY clinical PERSPECTIVES care

tritional policies, universal education and health coverage, tobacco control and city planning are needed to create a health-enabling environment. In order to protect the most vulnerable, outreach detection and support programmes targeting difficult-to-reach populations such as the manual workforce and the socially deprived and isolated may give high yield of positive cases for early intervention. Such programmes need to be fully integrated with a seamless healthcare system to ensure that intervention measures proven to be effective, e.g. structured lifestyle modification and early drug therapy can be introduced in a timely manner to prevent silent deterioration of disease with late presentation.1,23 Despite the highly preventable and treatable nature of diabetes and its complications, a major task at hand is to translate the existing evidence into clinical practice.24 We need to develop innovative solutions to ensure that people with or at risk of diabetes have the necessary information to change behaviour, minimize risk, and manage their health. Care providers need the information to stratify risk, assess needs, and individualize intervention. Given the growing size of the problem and the need to sustain our healthcare systems, policymakers and payers need information to ensure that these individuals are detected early and treated to multiple targets (HbA1c, blood pressure, LDL-cholesterol) to reduce risk of expensive and difficult to treat complications. To achieve these interlinking goals, a multipronged strategy including changing workflow, task delegation, case management, registry, decision support and patient empowerment with ongoing evaluation are some measures which have been proven to be effective in improving risk factor control (Figure 2).25

March 2014 â&#x20AC;˘ Volume 59 â&#x20AC;˘ Issue 1

Figure 2. The multiple challenges (upper panel) and opportunities (lower panel) posed by the epidemic of diabetes in Asia.

Poverty and social disparities Poor access to care and fragmented system

Genetics & suboptimal maternal health

Asian Diabetes Phenotypes Unhealthy lifestyle & psychosocial stress

Rapid transition in high risk environment* with low awereness

Gestational diabetes and childhood obesity

* these include but not limited to low grade infections, pollutants and environmental toxins

Government leadership and multisectorial intervention* Lifecourse strategy starting maternal/ child health

Community & peer support

Prevention & Control of Diabetes Early detection & risk stratification

Holistic and team-based care Registry & information technology

* these include but not limited to tobacco control, nutrition policies, maternal and child health, capacity building, workplace/school intervention, health care and financing reform

DiabetesVoice 49

COUNTRY care Clinical PERSPECTIVES

The way forward A disease epidemic is typically caused by rapid changes in the ecology of the host population resulting in biological maladaptation.26 In Asia, the rapid modernisation from an energy-scarce to energy-rich environment has led to high rates of metabolic syndrome and diabetes. Depending on different combinations and permutations of external stressors, such as infection, pollution, nutrition, lifestyle, psychosocial stress, and access to care, genetically predisposed subjects can have different clinical outcomes ranging from health preservation to multiple organ failure. These clinical features have also been reported in Pima Indians and indigenous populations who underwent rapid acculturation, suggesting that these ‘Asian phenotypes’ may also be expected in other emerging economies, each with its own characteristics and nuances.9 During the last three decades, the multidimensional nature of this epidemic including societal, technological and behavioural factors continues to unfold in Asia. Importantly, Asia has risen to the challenge and provided notable examples of prevention, such as tobacco control for global risk reduction, national detection programmes for childhood diabetes, lifestyle modification programme for prevention of diabetes, information technology for care integration with decision support, diabetes registry for quality assurance and protocol-augmented collaborative care for prevention of diabetic complications. While different countries and areas in Asia are at different stages of this journey of health evolution, the diabetes epidemic in Asia has provided many insights in our common goal to reverse this trend of adversity to new hopes through societal, system and personal changes.1

DiabetesVoice

Juliana CN Chan, Roseanne Yeung, and Andrea Luk Juliana CN Chan is Professor of Medicine and Therapeutics at the International Diabetes Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China. Roseanne Yeung is a Visiting Scholar, Endocrinology at the International Diabetes Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China. Andrea Luk is Associate Consultant at the International Diabetes Centre of Education, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.

References 1. C han JC, Cho NH, Tajima N, et al. Diabetes in the western pacific region – past, present and future. Diabetes Res Clin Pract 2013: http://dx.doi.org/10.1016/j 2. Xu Y, Wang L, He J, et al. Prevalence and control of diabetes in Chinese adults. JAMA 2013; 310: 948-59. 3. International Diabetes Federation. IDF Diabetes Atlas, 6th edn. IDF. Brussels, 2013. 4. Yoon KH, Lee JH, Kim JW, et al. Epidemic obesity and type 2 diabetes in Asia. Lancet 2006; 368: 1681-8. 5. M isra A, Khurana L. Obesity and the metabolic syndrome in developing countries. The Journal of Clinical Endocrinology and Metabolism 2008; 93: S9-30. 6. K ing GL, McNeely MJ, Thorpe LE, et al. Understanding and addressing unique needs of diabetes in Asian Americans, native Hawaiians, and Pacific Islanders. Diabetes Care 2012; 35: 1181-8. 7. M a RC, Chan JCN. Type 2 diabetes in East Asians: similarities and differences with populations in Europe and the United States. Annals of New York Academy of Sciences 2013; 1281: 64-91. 8. Ramachandran A, Ma RC, Snehalatha C. Diabetes in Asia. Lancet 2010; 375: 408-18. 9. K ong APS, Xu G, Brown N, et al. Diabetes and its comorbidities – where East meets West. Nature Review Endocrinology 2013; 9: 537-47. 10. Seshasai SR, Kaptoge S, Thompson A, et al. Diabetes mellitus, fasting glucose, and risk of cause-specific death. NEJM 2011; 364: 829-41. 11. Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA 2009; 301: 2129-40. 12. Luk AO, Lau ES, So WY, et al. Prospective study on the incidences of cardiovascular-renal complications in Chinese patients with young-onset type 1 and type 2 diabetes. Diabetes Care 2014; 37: 149-57. 13. Kitagawa T, Owada M, Urakami T, et al. Epidemiology of type 1 (insulin-dependent) and type 2 (noninsulin-dependent) diabetes mellitus in Japanese children. Diabetes Res Clin Pract 1994; 24: S7-13. 14. Wei J, Sung F, Lin C, et al. National surveillance for type 2 diabetes mellitus in Taiwanese children. JAMA 2003; 290: 1345-50. 15. Pozzilli P, Guglielmi C. Double diabetes: a mixture of type 1 and type 2 diabetes in youth. Endocr Dev 2009; 14: 151-66. 16. Zhou Z, Xiang Y, Ji L, et al. Frequency, immunogenetics, and clinical characteristics of latent autoimmune diabetes in China (LADA China study): a nationwide, multicenter, clinic-based cross-sectional study. Diabetes 2013; 62: 543-50. 17. Kong APS, Chan JCN. Other disorders with type 1 phenotype. In Holt R, Goldstein B, Flyvbjerg A, Cockram CS, eds. Textbook of Diabetes, 4th edn. Wiley-Blackwell. UK, 2010. 18. Chan JC, Ng MC. Lessons learned from young-onset diabetes in China. Current Diabetes Reports 2003; 3: 101-7. 19. Chan WB, Tong PC, Chow CC, et al. The associations of body mass index, C-peptide and metabolic status in Chinese type 2 diabetic patients. Diabetic Medicine 2004; 21: 349-53. 20. Ma RC, Chan JC, Tam WH, et al. Gestational diabetes, maternal obesity, and the NCD burden. Clinical Obstetrics and Gynecology 2013; 56: 633-41. 21. Fisher EB, Chan JCN, Nan H, et al. Co-occurrence of diabetes and depression: conceptual considerations for an emerging global health challenge. Journal of Affective Disorders 2012; 142: S56-66. 22. LaVeist TA, Thorpe RJ Jr, Galarraga JE, et al. Environmental and socio-economic factors as contributors to racial disparities in diabetes prevalence. Journal of General Internal Medicine 2009; 24: 1144-8. 23. Western Pacific Declaration on Diabetes Steering Committee. Plan of Action (2006–2010) for the Western Pacific Declaration on Diabetes: from Evidence to Action. World Health Organization Western Pacific Regional Office. Manila, 2008. www.wpdd.org 24. Chan JC. Diabetes and noncommunicable disease: prevent the preventables. JAMA 2013; 310: 916-7. 25. Tricco AC, Ivers NM, Grimshaw JM, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet 2012; 379: 2252-61. 26. Diamond JM. Diabetes running wild. Nature 1992; 357: 362-3.

March 2014 • Volume 59 • Issue 1

COUNTRY clinical PERSPECTIVES care

Addressing the challenge of GDM in the developing world: perspectives from rural western Kenya Sonak D. Pastakia, Beryl Ajwang’ Onyango, Mercy Nabwire Ouma, Astrid Christoffersen-Deb and Carolyne Cherop

The Academic Model Providing Access to Healthcare (AMPATH) is a partnership between Moi University School of Medicine, Moi Teaching and Referral Hospital in Kenya and a consortium of North American universities and schools led by Indiana University. AMPATH’s mission is to provide and expand sustainable access to high quality care through: the development of passionate leaders in global health; research focused on local needs and global solutions; and the establishment of critical healthcare infrastructure and systems. An AMPATH study group is in process of developing a strategy for screening and diagnosing gestational diabetes mellitus (GDM) in resource-constrained settings, and our contributors have submitted this report from rural western Kenya.

March 2014 • Volume 59 • Issue 1

The growing burden of diabetes has been well documented in the developed world; in contrast, an under-studied diabetes crisis continues to grow at troubling rates in the developing world. IDF estimates that the prevalence of diabetes will double in sub-Saharan Africa by 2035. Sub-Saharan Africa has the highest proportion of undiagnosed diabetes at 63% and the highest mortality rate for diabetes in the world. This emerging prevalence combined with the high mortality highlights the need for an organized prevention programme in the developing world.1

DiabetesVoice 51

Clinical care

GDM is one of the most poorly understood and undiagnosed conditions in the region. GDM typically presents during the later stages of pregnancy as glucose intolerance resulting in mildly elevated blood glucose levels. Untreated GDM leads to serious health problems for mothers and their children.2

Sub-Saharan Africa has the highest mortality rate for diabetes in the world. Moi Teaching and Referral Hospital (MTRH) serves as the main referral centre for the whole of western Kenya. Although access to healthcare is limited in rural areas of Kenya, the antenatal clinic at MTRH serves up to 12,000 new mothers annually.3 In 2009, through partnership between MTRH, the Kenyan Ministry of Health and

the Academic Model Proving Access to Healthcare (AMPATH), one of the largest diabetes care programmes in Sub-Saharan Africa was developed and implemented.4 This was created to address the growing need to provide quality healthcare to a population that was quickly beginning to experience chronic diseases alongside other infectious diseases. The diabetes programme is a branch of the Chronic Disease Management programme within AMPATH which now offers high quality diabetes services including, but not limited to, home based screening, village and facility based care, and a unique phone based home glucose monitoring (HGM) programme.3 Is there a feasible strategy for screening and diagnosing GDM in resourceconstrained settings? With the limited availability of contextualized laboratory testing methodologies

Phone based delivery of remote care: staff within the chronic disease management programme make weekly phone calls to pregnant women with diabetes to provide education and management advice based on the results of home glucose monitoring.

DiabetesVoice

Staff providing point-of-care GDM screening. The MTRH antenatal care (ANC) clinic provides GDM education and screening for pregnant mothers who consent.

March 2014 â&#x20AC;˘ Volume 59 â&#x20AC;˘ Issue 1

clinical care

Patients who become staff: These two women were part of the initial group of patients included within the home glucose monitoring programme hired as full-time staff in the clinic’s gestational diabetes programme.

and GDM data for rural, resource-constrained populations, there is a pressing need to identify a practical and scalable screening method. Prior to the initiation of this project, mothers receiving care at the MTRH antenatal care (ANC) clinic, would only receive urine screening for diabetes via a urine dipstick. This method is highly inadequate and does not meet any current diagnostic standards for GDM detection. In September 2013, through funding from the Indiana University Center for Translational Sciences Institute, we set out to compare point of care screening

March 2014 • Volume 59 • Issue 1

devices against the standard laboratory based methods for diagnosis. In this study based at the MTRH ANC clinic, mothers are first provided with educational materials on GDM to help explain the risks associated with the condition. Mothers who meet the inclusion criteria are informed of the different procedures within the study. In order to meet the recommended screening guidelines only women who are between 24 and 32 weeks gestational age are enrolled.5 After the mother consents, she is given a blood glucose test using finger-stick or point-of-care testing on day 1 and

then guideline recommended fasting venous lab testing alongside point of care testing on day 2. This combination of point of care tests will then be compared against the guideline recommended tests to identify a more portable strategy that might be replicated throughout the developing world. Women diagnosed with GDM are followed up within MTRH’s high risk ANC clinic and referred to our unique phone based home glucose monitoring (HGM) programme. Within HGM, patients are provided with a glucose testing device

DiabetesVoice 53

Clinical care

and strips to test their blood glucose twice a day. They also receive a weekly phone call where education and medication dosage adjustments are conveyed based on the results of the home glucose monitoring. Six weeks after the pregnancy, the new mothers receive repeat testing to access if GDM has evolved into a diagnosis of type 2 diabetes. Linda’s story: hope after GDM diagnosis Linda is a 35-year-old mother of three who is currently expecting her fourth child. Last year was a distressing year for Linda. She was only 16 weeks into her pregnancy when she woke up one morning and started bleeding. She rushed to the hospital only to be informed that she had lost the pregnancy. The only other thing Linda remembers about her

previous pregnancies is that the doctor informed her that her babies were all larger than average.

Linda never heard about GDM and assumed diabetes is only a disease of the rich.

We met Linda one year later at the ANC clinic when she was 28 weeks pregnant. She had never heard about GDM previously and assumed that diabetes is only a disease of the rich. Linda agreed to participate in clinic’s screening method and completes all phases of the study. Upon completing day 2 of the study, Linda’s results are consistent with a diagnosis of GDM and her many fears and concerns about what this means for her and her baby are carefully addressed with a trained staff. The MTRH ANC clinic staff reassures her that despite everything she may have heard about diabetes, there is hope that she and her baby can expect to live a happy and healthy life if several basic lifestyle changes and treatment recommendations are followed. After participating in the HGM programme and following up at the high risk clinic, Linda now feels confident, that through the support of the clinic’s care programme, her pregnancy will proceed well and she will not have to relive the difficulty that she experienced last year when she prematurely lost her baby. Linda is glad she agreed to the GDM screening and Sonak Pastakia at the Sally Test Pediatric hopes many other women Care Center for Orphaned and Vulnerable throughout Kenya will have Children. the same opportunity.

DiabetesVoice

Sonak D. Pastakia, Beryl Ajwang’ Onyango, Mercy Nabwire Ouma, Astrid Christoffersen-Deb and Carolyne Cherop Sonak Pastakia is Associate Professor at Purdue University College of Pharmacy in Indiana, USA and serves key roles in AMPATH within the chronic disease management programme at Moi University School of Medicine in Eldoret, Kenya. He is also the principal investigator on the GDM study described in this article. Beryl Ajwang’ Onyango is Pharmacist at the Moi Teaching and Referral Hospital in Eldoret, Kenya. Mercy Nabwire Ouma is Pharmacists at the Moi Teaching and Referral Hospital in Eldoret, Kenya. Astrid Christoffersen-Deb is Assistant Professor at University of Toronto, Department of Obstetrics and Gynaecology and AMPATH-RH Field Director, Canada. Carolyne Cherop is Clinical Officer at the Moi Teaching and Referral Hospital in Eldoret, Kenya.

References 1. International Diabetes Federation. IDF Diabetes Atlas, 6th edn. IDF. Brussels, 2013. 2. Zeck W and McIntyre DH. Gestational diabetes in rural East Africa: a call to action. Journal of Women’s Health 2008; 17: 403-11. 3. IU-Kenya Partnership. www.ampathkenya.org 4. Pastakia SD, Karwa R, Kahn CB, et al. The evolution of diabetes care in the rural, resource-constrained setting of western Kenya. Ann Pharmacother 2011; 45: 721-6. 5. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010; 33: 676-82.

March 2014 • Volume 59 • Issue 1

clinical care

IDF Diabetes Atlas reveals high burden of hyperglycaemia in pregnancy Ute Linnenkamp

Hyperglycaemia is one of the most prevalent metabolic disorders occurring during pregnancy. It can be a result of either existing diabetes in a pregnant woman or the development of insulin resistance and hyperglycaemia during pregnancy.

For the first time, the International Diabetes Federation (IDF) has produced estimates of hyperglycaemia in pregnancy for the 6th edition of the IDF Diabetes Atlas. In 2013, 21.4 million (16.9%) out of an estimated 127.1 million live births to women aged 20–49 were affected by hyperglycaemia in pregnancy. Approximately 16% of those 21.4 million cases may be caused by diabetes in pregnancy (including previously undiagnosed diabetes detected in pregnancy, and live births in women with known diabetes). These statistics reflect the growing influence of the type 2 diabetes epidemic on pregnancy. A staggering 91.6% of cases of hyperglycaemia in pregnancy was reported in low- and middle-income countries, where access to maternal care is often limited. The consequences of unmanaged hyperglycaemia in pregnancy can be severe and include an increased risk

March 2014 • Volume 59 • Issue 1

for caesarean section, obstructed labour and pre-eclampsia which can be especially serious in low-resource settings. Education for women and health professionals, and allocation of resources towards management is essential to meet the challenge of this important burden in current maternal and child health care. More information is available at www.idf.org/diabetesatlas

Ute Linnenkamp Ute Linnenkamp is IDF Diabetes Atlas Project Officer.

DiabetesVoice 55

Clinical care

Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) 2014: fact, frustration and future needs David Hadden and David McCance

The concept of gestational diabetes mellitus (GDM) or hyperglycaemia in pregnancy has long been recognised but is still the subject of much controversy.1 Many different screening protocols and clinical guidelines exist, but no international consensus, and even within countries there is considerable confusion as to what constitutes best practice. Two randomized clinical trials (RCTs) however recently confirmed that treatment of mild hyperglycaemia (largely lifestyle alteration) is effective for a variety of maternal and fetal endpoints.2,3 This leaves the question of how best to define hyperglycaemia in pregnancy, and how to identify it during the pregnancy. The definitive Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) Study,4 an international observational

DiabetesVoice

study of over 23,000 pregnant women in 15 centres worldwide, confirmed that milder degrees of hyperglycaemia in later pregnancy are associated with increased fetal fatness, caesarean delivery and clinical neonatal hypoglycaemia, all on an underlying biological basis of increased fetal insulin production. HAPO also showed that the relationship of hyperglycaemia to adverse outcome was independent of the mother’s BMI.5 The problem is that the association of glucose with these outcomes is a continuum, without a defined cut-off point, necessitating a consensus definition on the level of maternal glycaemia at which intervention might be both clinically useful and cost effective. After much consultation, the recommendations of the International

Association of Diabetes in Pregnancy Study Groups (IADPSG) were published in 20106 (Table). Intense international discussion has subsequently taken place seeking to translate the IADPSG recommendations into international reality.7 Endorsement has come from the American Diabetes Association (ADA), The Endocrine Society and the World Health Organization (WHO) , but frustration still exists and some outstanding questions remain. For example, the American College of Obstetricians and Gynecologists recommends retention of its traditional approach (50 g glucose challenge test followed, if abnormal, by a 100 g oral glucose tolerance test [OGTT]) based on concerns about the large numbers of women likely to be diagnosed by the new criteria (approximately 18% of pregnant women),

March 2014 • Volume 59 • Issue 1

clinical care

uncertainty of treatment benefit and the medicalization of pregnancy. (Given the high global prevalences of maternal obesity, diabetes and prediabetes, there should be no surprise at this high figure.) Two RCTs2,3 have shown benefits of treatment and 80%-90% of women can be treated with diet alone, minimising medical intervention. The other IADPSG recommendation of a universal screening 75 g OGTT means a two-hour procedure and an overnight fast. In some countries, this may be difficult logistically and economically

and alternative paradigms need to be explored.7,8 Equally, in some low risk settings, it should be possible to devise a more customised strategy or individual risk engine guided by an economic analysis.8 The rapid increase of type 2 diabetes worldwide means that many women will already have unrecognised diabetes. These women should be diagnosed and treated as early as possible in the pregnancy – ideally pre-pregnancy. We currently lack evidence on how best to do this, but as a minimum, some estimate of blood glucose at the first antenatal ‘booking’ (fasting or random or

(a) Recommendations for the diagnosis of hyperglycaemia in pregnancy, and overt diabetes in pregnancy (IADPSG criteria)

≥ 92 mg/dL or

≥ 5.1 mmol/L or

Overt diabetes

1-hour plasma glucose

≥ 180 mg/dL or

≥ 10.0 mmol/L or

2-hour plasma glucose

≥ 153 mg/dL

≥ 8.5 mmol/L

≥ 126 mg/dL

1. Carpenter MW. Diagnosis of hyperglycaemia in pregnancy. In : A Practical Manual of Diabetes in Pregnancy. Eds. McCance DR, Maresh M, Sacks DA. Wiley-Blackwell 2010; 57-64.

≥ 7.0 mmol/L

HbA1c

≥ 6.5%

Random plasma glucose*

≥ 200 mg/dL

≥ 11.1 mmol/L

(b) Early detection of hyperglycaemia in pregnancy First prenatal visit Fasting plasma glucose, HbA1c or random plasma glucose *on all (or only on high risk women)

If results not diagnostic of overt diabetes, and a) Fasting plasma glucose ≥92 and < 126 (≥5.1 and < 7) diagnose as hyperglycaemia in pregnancy b) Fasting plasma glucose < 92 (5.1) test at 24-28 weeks with 75 g oral glucose tolerance test

24-28 weeks gestation 75 g oral glucose tolerance test after overnight fast

On all women not already diagnosed as Hyperglycaemia in Pregnancy or overt diabetes at first visit

* A random plasma glucose to diagnose diabetes during early pregnancy should be confirmed by a fasting plasma glucose or HbA1c. The 75g oral glucose tolerance test thresholds represent the average value at which the odds for birth weight and percent body fat, and cord blood c-peptide (representing fetal insulin) exceeded 1.75 times the estimated odds of these outcomes compared with mean glucose values for the whole HAPO population. Adapted from Reference 7

March 2014 • Volume 59 • Issue 1

David Hadden is Professor at the Regional Centre for Endocrinology and Diabetes, Belfast, UK.

References

one or more of 75g oral glucose tolerance test thresholds must be equaled or exceeded Fasting plasma glucose

David Hadden and David McCance

David McCance is Professor at the Regional Centre for Endocrinology and Diabetes, Belfast, UK.

Table

Hyperglycaemia in pregnancy

HbA1c) is required (Table). Finally, the validity of these new criteria as predictors of long term outcomes will require particular scrutiny. A new NIH-funded HAPO Follow Up Study (2013-2017) is currently following 10,000 of the original HAPO mothers and their 8-12 year old offspring. These data, with their transgenerational implications, may be the most important of all.

2. C rowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005; 352: 2477-86. 3. Landon MB, Spong CY, Thom E, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med 2009; 361: 1339-48. 4. The HAPO Study Cooperative Research Group. Hyperglycemia and Adverse Pregnancy Outcomes. N Engl J Med 2008; 358: 1991-2002. 5. The HAPO Study Cooperative Research Group Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study: associations with maternal BMI. Br J Ob Gynecol. 2010; 117: 575-84. 6. Metzger BE, Gabbe SG, Persson B, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010; 33: 676-82. 7. T he IADPSG Consensus Panel Writing Group and the HAPO Study Steering Committee. J Mat-Fetal and Neonatal Medicine 2012; The diagnosis of gestational diabetes mellitus. New paradigms or status quo? ISSN 1476-7058 print/ISSN 1476-4954 online. DOI: 10.3109/14767058.2012.718002 8. R ound JA, Jacklin P, Fraser RB, et al. Screening for gestational diabetes mellitus: cost-utility of different screening strategies based on a woman’s individual risk of disease. Diabetologia 2010; 54: 256-63.

DiabetesVoice 57

Diabetes in society

New IDF Guideline for diabetes in older people Trisha Dunning, Alan Sinclair and Stephen Colagiuri

Just over 8.3% of the global population has diabetes.1 Increasing age is a significant risk factor for type 2 diabetes but the diagnosis is often missed or delayed because the clinical presentation is different from that in younger people. Diabetes is a major cause of complications, reduced quality of life and changed physical and mental functioning in older people.2,3,4 It is also a leading cause of death in older people from cardiovascular and other related medical co-morbidities. In addition, many older people have additional risk factors for diabetes and may have undiagnosed complications. The International Diabetes Federation (IDF) launched a Global Guideline for Managing Older People with Type 2 Diabetes in a Satellite Symposium about diabetes in older people held in association with the World Diabetes Congress in Melbourne in December 2013. The essential messages in the IDF Guideline are described in this paper. It is important to recognise that older people with

DiabetesVoice

March 2014 â&#x20AC;˘ Volume 59 â&#x20AC;˘ Issue 1

Diabetes in society

managing type 2

diabetes are highly individual and that the data from published studies, even when these are well designed, cannot always be generalised or extrapolated to older cohorts. It is important to consider the individual’s health status, social situation and available support from family and/ or the community.

Diabetes is a leading cause of death in older people. Planning care with older people with diabetes The goal of involving the older person in care decisions is to reach a shared understanding of their specific situation and life. Chronological age does not indicate how an older person manages their life and does not predict treatment outcomes. It is better to plan care according to the person’s functional status, degree of medical co-morbidities present, the impact of any diabetes-related vascular complications, and whether frailty or dementia is present. When

March 2014 • Volume 59 • Issue 1

frailty is present, many older people are less able to tolerate the stress of illness and this is likely to increase the risk of falls and admission to hospital. Planning care for older people with diabetes can be very challenging because of the effects of diabetes complications, e.g. sensory changes with reduced sight and hearing; mental challenges including confusion, depression, delirium and dementia; and physical changes such as arthritis and other disorders in joints and tissues which are often present. These factors increase the person’s risk of falling and developing pressure ulcers including foot ulcers and pain, which are often

not recognised or treated appropriately. When these factors operate at the same time, the risk of medicine-related adverse events and admission to hospital or a care home for the aged increases significantly. In addition, diabetes complications, frailty and dementia make it difficult for the person to exercise and undertake diabetes and other self-care activities. Medicine There is strong evidence that many medicines commonly prescribed for older people should not be used or, alternatively, should be used with caution. Such medicines include antipsychotic medicines to manage

Frailty and dementia make it difficult to exercise and undertake diabetes and other self-care activities.

DiabetesVoice 59

Diabetes in society

behavioural problems associated with dementia, and some sulfonylureas, used to lower blood glucose, especially if they are long acting. There is also concern about using sliding insulin scales5 to manage hyperglycaemia. Thus, regular comprehensive medicine checks are needed, especially when several doctors prescribe medicines for the same person. Medicine reviews can be undertaken at home. Many medicines prescribed to manage diabetes and its complications are classed as high-risk because of their side effects and the way they are used and metabolised in the body. Key issues to consider when planning care Care plans need to be developed with the individual and their family caregivers to suit the individual’s health status and life expectancy and keep the individual living safely and independently as long as possible. Care plans could encompass: ■ Screening older people for undiagnosed diabetes. ■ Proactively undertaking comprehensive risk assessments to identify and manage:

■ diabetes complications including renal and liver disease which affect medicine choices; ■ inadequate nutrition, which also affects medicine choices; low vitamin D and B 12 are common; ■ pain; ■ falls risk; ■ delirium; ■ increasing frailty; ■ unsafe driving; ■ hypoglycaemia and hyperglycaemia risk; ■ geriatric syndromes, see box. ■ Setting blood glucose, HbA1c, blood pressure (BP) and other care targets to suit individual requirements; for example, a high functionally independent rating should target HbA1c 7.0–7.5% (53–59 mmol/mL) and BP <140/90 mmHg; functionally dependent: HbA1c 7.0–8.0 (53–64 mmol/mL), BP <140/90 mmHg; and frail and dementia: HbA1c up to 8.5% (70 mmol/mL), BP <150/90 mmHg. ■ Preventing or managing cardiovascular disease. If cardiovascular disease is present, it needs to be treated early and effectively using a healthy diet

Common geriatric syndromes The term ‘geriatric syndrome’ refers to a group of conditions that often occur together and affect the person’s health and self-care capacity and include:

■ f alls; ■ pain; ■ urinary tract infection; ■ c ognitive impairment which can be assessed using Mini-Mental State Examination, Mini-Cog, or the Clock drawing test;

■ d epression, which can be assessed using the Geriatric Depression Scale, or Patient Health Questionnaire (PHQ2);

■ h ypoglycaemia; ■ d elirium; ■ p olypharmacy, which usually means using more than five medicines.

DiabetesVoice

and physical activity approach; and lipid lowering medicines, aspirin and antihypertensive medicines when indicated and safe. ■ Controlling hyperglycaemia to promote comfort, reduce cardiovascular risks and microvascular disease, enhance self-care, reduce falls risk, manage hyperglycaemia-related symptoms such as tiredness, thirst and frequent urination, and dehydration and the associated risk of ketoacidosis, hyperosmolar states, delirium, cognitive impairment and depression. However, ‘tight’ blood glucose control is not usually warranted and may place the person at significant risk of hypoglycaemia. ■ Conducting regular comprehensive medicine reviews including asking about herbal medicines and vitamin and mineral supplements and other complementary therapies use as well as self-prescribed conventional medicines. Safe medicine use (pharmacovigilence) can be achieved using a quality use of medicines (QUM) approach.6 QUM is a decision-making framework that applies to the entire medication pathway, but clinically it means: ■ selecting medicines wisely based on a comprehensive health assessment; ■ using non-medicine options where possible but choosing a suitable medicine if indicated;

March 2014 • Volume 59 • Issue 1

Diabetes in society

■ using medicines safely and effectively for the individual older person and monitoring the outcomes, which encompasses regular clinical assessment and medicine reviews. Many medicines should be used with caution or are contraindicated in older people.5 ■ Assessing physical status (functional status), kidney and liver function, mental health, cognitive functioning and self-care regularly; at least annually and whenever health or the management regimen changes.

Trisha Dunning, Alan Sinclair and Stephen Colagiuri Trisha Dunning is Chair in Nursing for the School of Nursing and Midwifery at Deakin University and Director for the Centre for Nursing and Allied Health Research in Geelong, Australia. Alan Sinclair is Dean at the Bedfordshire and Hertfordshire Postgraduate Medical School, and Director of the Institute of Diabetes for Older People (IDOP) in Luton, Bedfordshire, UK. INTERNATIONAL DIABETES FEDERATION ION INTERNAT FEDERAT IONAL DIABETES DIABETES IONAL FEDERAT INTERNAT ION

MANAGING OLDER PEOPLE MANA LE GINGOLDE RRPEOP OLDE GING PEOP LE MANA WITH TYPE 2 DIABETES WITHGLOBAL GUIDELINE ETES TYPE 22DIAB DIAB TYPE ETES WITH

■ G eneral health assessments such as mammograms, prostate checks, bowel checks, thyroid function, immunization status and sexual health and well-being should be assessed regularly in addition to regular diabetes-related assessments. Such assessments may be needed more frequently than annually. ■ Developing a plan indicating when to stop driving.

EE GLOBAL GUIDELIN GUIDELIN GLOBAL

References

Summary Management focuses on safety, maintaining independence and functional status and quality of life, managing symptoms, reducing the impact of diabetes complications and other diseases. Individualising management targets is essential.7,8 Involving the older person and their family or other carers in management decisions is essential.

■ Implementing medical alert and call systems to enhance safety, especially for community dwelling older people, when indicated.

2. Sinclair AJ, Barnett AH. Special needs of elderly geriatric patients. BMJ 1993; 306:1142-43. 3. G u K, Cowie C, Harris M. Mortality differences between adults with and without diabetes in a national sample 1973–1993. Diabetes 1997; 46: 26A. 4. Zhang Y, Hu G, Yuan Z. Glycosylated haemoglobin in relationship to cardiovascular outcomes and death in patients with type 2 diabetes; a systematic review and metaanalysis. PLoS One 2012; 7: e42551. 5. American Geriatrics Society, American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication use in Older Adults. J Am Geriatr Soc 2012; 60: 616-31.

7. Sinclair A, Morley JE, Rodriguez-Manas L, et al. Diabetes mellitus in older people: Position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP) and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc. 2012; 13: 497-502.

■ Supporting carers.

March 2014 • Volume 59 • Issue 1

1. International Diabetes Federation. IDF Diabetes Atlas, 6th edn. IDF. Brussels, 2013.

6. Department of Health and Aging. National Strategy for Quality Use of Medicines. Australia, 2002. www.health.gov.au/internet/main/publishing. nsf/Content/nmp-pdf-natstrateng-cnt.htm

■ Developing a plan for end of life care.

Patient safety in a complex illness such as diabetes must be a priority. Safe use of medicines is a key component of care planning.

Stephen Colagiuri is Professor of Metabolic Health at the University of Sydney at the Boden Institute, University of Sydney Camperdown, New South Wales, Australia.

www.idf.org/sites/default/files/IDFGuideline-for-older-people-T2D.pdf

8. Dunning T, Savage S, Duggan N. McKellar Guidelines for Managing Diabetes in Residential Aged Care Facilities. Centre for Nursing and Allied Health Research. Geelong, 2014.

DiabetesVoice 61

Diabetes in society

Diabetes voices: the power of learning for life

Diabetes education is one of the most formidable tools for helping to defeat the diabetes epidemic of the 21st century. It is essential for exerting influence on public policies for the prevention and management of diabetes as a means to safeguard public health. For healthcare professionals, diabetes education aids in ensuring evidence-based recommendations are put into practice and, for the general public, it is a call to raise diabetes awareness, to highlight its warning signs and to promote early diagnosis. Finally, people who live with diabetes require education for empowerment and the chance for a better life. In our first 2014 instalment of Diabetes Voices, we turn our attention to diabetes educators and people who live with diabetes from Peru and Pakistan for insight into the power of this all to often under-utilised resource.

DiabetesVoice

Vicky Motta Montoya in Lima, Peru: my experience as a diabetes educator ‘Diabetes is a complex, multifactorial disease that needs professional multidisciplinary treatment. Diabetes education is best facilitated as a partnership between the healthcare professional and patient because successful treatment and outcomes depend on the active participation of the person living with diabetes.

‘ Without diabetes education, people with diabetes are less prepared to make decisions.’ Education is one of the most important resources to stop the growing incidence of type 2 diabetes and is key for mastering type 1 diabetes therapies. As a diabetes educator, I can say that the effective treatment of diabetes goes beyond medication and requires education

and individual motivation which can be provided by existing educational tools and professional support. Without diabetes education, people with diabetes are less prepared to make decisions and changes in their behaviour in anything related to diabetes. In my role as an educator, I don’t only look at just improving diabetes control, but I also see the complete person who lives with the disease. I work hard to understand their feelings, and perhaps, what they believe and how they manage their life. I try to help answer their questions and guide them towards ways to better manage and live with their diabetes. I do my best to motivate the patient to take responsibility and commit to strategies for leading a healthier life without complications. Often I even help prevent diabetes in the community. I enjoy my work and improving the health of my patients.

March 2014 • Volume 59 • Issue 1

Diabetes in society

etes management Vicky Motta Montoya discusses diab with one of her patients

In my practice, I have an educational programme for gestational diabetes mellitus (GDM) where pregnant women receive education about how to take care of their pregnancy and their unborn baby. This educational programme is interactive; pregnant women participate in groups in a friendly and fun environment on different aspects of GDM, sharing their knowledge, feelings and experiences about the disease and taking responsibility for their own care in order to have a healthy baby. In conjunction with the Diabetes Association of Peru, through workshops, we are training diabetes educators and other healthcare professionals to better care for people living with diabetes. Our aim is to help these healthcare professionals assume the role of the "educator" in order to be able to reach out more comprehensively to all people with diabetes. My mission and commitment is to continue working as an educator helping people to better understand diabetes prevention while also sharing my knowledge and experience with diabetes educators worldwide.’

Vicky Motta Montoya is a clinical nutritionist and Certified Diabetes Educator (CDE) for the Diabetes Association of Peru (ADIPER) and the Education Program for gestational diabetes mellitus at the National Maternal Perinatal Institute in Lima, Peru.

March 2014 • Volume 59 • Issue 1

What I learned about my gestational diabetes from my educator: four women with GDM talk about their experience in Lima, Peru

Hyperglycaemia in pregnancy is found in around 11% of pregnant women in the South American and Caribbean Region of IDF.1 Of this 11% GDM forms an important part. GDM care requires a complete health team: the endocrinologist, and Certified Diabetes Educator (CDE) provide directions, recommendations and a treatment plan for a healthy pregnancy and birth. Gestational diabetes education plays an important role to assist the pregnant woman to make healthy decisions about how to care for her diabetes and baby, and includes steps for a healthy diet, physical activity and the importance of selfmonitoring blood glucose. In this segment of Diabetes Voices, we hear from four woman diagnosed with GDM and how they found success in managing their condition with diabetes education.

Julia, diagnosed with GDM at 32 weeks of gestation: ‘When I was diagnosed with GDM, I realised that my food intake was a mess, but after learning a bit more about this disease and the risks for me and my baby, I made the most important decision of my life; I changed my eating habits. Although it took a lot of determination, every sacrifice has a reward and this one resulted in good health. My mother lives with diabetes and now I can say that it all depends on us. Today, we share many things related to diabetes and I am teaching her what accounts for bad habits and how she can change for the better or leave unwanted habits behind. We both support each other about our diet. I wouldn’t have been able to learn everything without the help of my diabetes

educator, Vicky Motta. Vicky’s patience and knowledge helped me realise that I had all the tools to fight and treat this disease. I will always be grateful for the education I received because when I was 32 weeks pregnant my junk food diet was a mess, but today I can say that my diet is much healthier for me, my mother and also my children who are the reason for my life.’

Magdalena, 33 years old, was diagnosed with GDM during her third pregnancy: ‘I am very happy with the outcome of my pregnancy. When I began the diabetes educational programme, I learned to eat healthy as well as take care of my baby. When I was diagnosed with GDM I was very scared, but I learned the only treatment that works

DiabetesVoice 63

Diabetes in society

is to learn to eat well, for example avoiding foods with sugar. I gave birth to my baby Camilita and all went well. The educational support is wonderful and very important for all pregnant women. Thank you very much to my diabetes educator.’

Teresa, 40-years-old, was diagnosed with GDM June 2013: ‘I am 40 and finishing my third pregnancy successfully. I am grateful to the diabetes educational programme which guided me gently on my new diet, because before I learned how to eat well my diet was inadequate. I have learned to have a balanced diet which has helped improve my quality of life and by doing so, symptoms like headaches, depression or other complications that I used to treat with pills, have disappeared.’

Ana María, diagnosed with GDM last August, gave birth in October 2013: ‘Before starting my treatment for GDM, I was unaware of this disease, but as I was being educated I started to learn. I realised that taking care of me helped me control my weight, and how having a good diet and exercise helped prevent my baby from being born overweight with diabetes or malformed. Thanks to God and the education I received because I have a beautiful, healthy baby! I especially learned that it is best to prevent diabetes rather than fear it.’

DiabetesVoice

Erum Ghafoor in Pakistan: my experience as a diabetes educator ‘I am Erum Ghafoor from Karachi, Pakistan where I am a full time diabetes educator, IDF-expert trainer for Diabetes Conversation Map™ Education tools and a faculty member of IDF Young Leaders in Diabetes Programme. I am also a person living with type 2 diabetes. Currently, I am working in the Baqai Institute of Diabetology and Endocrinology (BIDE), Centre of Education which is supported by the IDF – a pioneer of diabetes education in Pakistan. I began to work in the field of diabetes education when there was no concept of it in our country. As a trainer for the Conversation Map™ Education tools since 2009, I have facilitated assistance for more than 30,000 people and trained 830 other diabetes education facilitators across Pakistan.

per nurse. These are the basic hurdles in implementation of diabetes education in our country but as the time passes people have started realising that it’s an essential part of diabetes self-care management. BIDE has initiated a university-based diploma in diabetes education in Pakistan for the training of diabetes educators to provide access to quality care. So far, we have trained 108 diabetes educators. There is still a lot more to do but when I look back at the last era, the picture of diabetes care has been turned upside down for the better so we can only hope for a more promising future.’

‘I am a full-time diabetes educator and I am also a person living with type 2 diabetes.’ As a healthcare professional, I have observed that people are eager to learn about diabetes care solutions; people want to live healthily with diabetes but they also want to avoid having to pay for expensive treatment for their families. In many situations, diabetes education can solve the majority of diabetes related self-care problems. In Pakistan 30% (42M) of the population live below poverty line, and 60.3% of the population earn under $2 a day. Approximately 40% (54M) of the population have no access to even basic health services. Resources for diabetes care are scarce: there are about 1,225 people assigned to each doctor and 2,501 people

etes Erum Ghafoor gives training on Diab TM s tool n catio Edu Conversation Map

Erum Ghafoor is a full time diabetes educator, IDF-expert trainer for Diabetes Conversation Map™ Education tools and a faculty member of IDF Young Leaders in Diabetes Programme in Karachi, Pakistan.

March 2014 • Volume 59 • Issue 1

Diabetes in society

Shaikh Waqar Ahmed, 22-years-old, diagnosed with type 1 diabetes at age 18: ‘My name is Shaikh Waqar Ahmed and I am 22 years old. I spent my childhood as an energetic hyperactive child but when I turned 18, I felt my energy levels go down. I felt weak and suddenly started to lose weight. I got tired easily and then I was diagnosed with type 1 diabetes at the Baqai Institute of Diabetology and Endocrinology. At the same time, my younger sister was also diagnosed with type 1 diabetes. Diabetes was a big shock for me and my family. I lost hope to live, and I left my friends behind because I was scared and ashamed. This was the time when my diabetes educator gave me great support and told me type 1 diabetes can happen to anyone at any time. She made me realise that type 1 diabetes is a lifelong disease and I had to manage it with proper self-care management. I learned that I need to take my insulin and check my blood glucose levels regularly, do some physical activity and watch what I eat. It was her support and encouragement which helped me to accept this challenge. Although sometimes I’ve had severe hypos (hypoglycaemia or low blood sugar episodes), I do not allow diabetes to defeat

me. My diabetes educator introduced me to other persons having similar problems so I did not feel alone, but she also confirmed how I am super exceptional. I have learnt that there’s no problem one cannot face. People say diabetes will remain with me for the rest of my life, but I laugh in their faces because I have left diabetes behind me, and taken the word out of my dictionary. I have never, and will never let diabetes interfere with my life. I want to move forward. I am confident that I can spend a healthy and happy life with diabetes and with hard work and dedication I will achieve my goals one day.’

‘ My diabetes educator introduced me to other persons having similar problems, so I did not feel alone.’

References 1. I nternational Diabetes Federation. IDF Diabetes Atlas, 6th edn. IDF. Brussels, 2013.

March 2014 • Volume 59 • Issue 1

DiabetesVoice 65

VOIceBOX

The diabetes voicebox Voicebox continues to feature a selection of readers’ comments. Keep them coming! More can be found on-line: www.idf.org/diabetes voice/voice-box

IDF and Diabetes Voice’s sharing of Novo Nordisk’s DAWN2 study results is almost singular and heroic. Few in the diabetes space, including endocrinologists and diabetes educators and nurses, pay much attention to the emotional aspect of living with and managing diabetes. I have just returned from working with an amazing diabetes clinic that treats the poor in Bangalore, India. There I had the rare opportunity to share my ideas and tools for ‘flourishing with diabetes’ with the medical staff. In India, where poverty, illiteracy, lack of access to medicine and test strips and a traditional highcarbohydrate diet pose crucial obstacles to blood sugar management, the doctors and educators embraced my work, helping patients do better by creating connection, trust, support, exploring patient strengths and inspiring confidence and hope. Riva Greenberg, living with type 1 diabetes 42 years; Wellcoaches Certified Health Coach; Huffington Post Columnist; DiabetesStories.com & DiabetesbyDesign.com

I am so excited to see the results of a large and comprehensive study on the psychosocial issues of diabetes - this condition is 24/7, and the day-to-day emotional and physical roller coaster takes a major toll on patients and caregivers. DAWN2 is a huge step in the right direction, as it casts a light

The DAWN2 study has produced a huge amount of information helpful for tailoring

local and global action to improve the lives of people with diabetes. Although it has

CMY

been necessary to make a selection concentrating on the most significant results, the

Special Issue of Diabetes Voice has provided a highly balanced and objective overall message making it easier for the interested reader to look for more detailed and specific findings in the already available vast scientific literature.

on the unmet needs in diabetes care. Massimo Massi Benedetti, President and Scientific Director of Hub for International health ReSearch HIRS (Italy) Adam Brown, Close Concerns Sr. Associate and diaTribe Co-Managing Editor

I would like to see Diabetes Voice shine a spotlight on diaFinally, a study that speaks to the daily experience of actually having diabetes. It is, in fact, a daily burden, and we need a complete understanding of how different technologies, therapies, and psychosocial issues shape the experiences

betes innovators; people who are doing new things to help people with diabetes live better. Diabetes innovators may be professionals working in diabetes care, people who live with diabetes or people who care for someone with diabetes.

of all of those concerned. Melissa Ford Holloway, type 1 (United Kingdom) Kelly Close, Editor-in-Chief, diaTribe

DiabetesVoice

March 2014 • Volume 59 • Issue 1

AL DIABE INTERNATION

ION TES FEDERAT

PLE O E P R E D L O M A N AG I N G ES T E B A I D 2 E P WITH TY GLOBAL GUID

ELINE

NEW GUIDELINE AVAILABLE www.idf.org

DIABETES RESEARCH AND CLINICAL PRACTICE Official Journal of the International Diabetes Federation “Diabetes Research and Clinical Practice has for over 25 years served as a trusted international diabetes research journal. It publishes high-quality original research articles and expert reviews, the aim being to advance diabetes understanding and care. With a high-quality review process and a growing international readership, I invite you to submit your next article to DRCP.” S. Colagiuri MD, Editor-in-Chief, University of Sydney, Australia

NEW: MANUSCRIPTS PUBLISHED ~1 WEEK AFTER ACCEPTANCE

Reasons to Submit Your Next Paper to Diabetes Research and Clinical Practice ●

High-quality research journal

●

Fast and expert peer review

●

Global readership: >15 million ScienceDirect users

●

No publication fees

For free content, including full-length articles from the 6th edition IDF Diabetes Atlas, and to submit your manuscript, go to:

www.diabetesresearchclinicalpractice.com Endocrinology, Diabetes and Metabolism