Diabetes Voice

Global perspectives on diabetes

Volume 57 – July 2012

ronment The right envi for all World Day Diabetes side poster in

tetusre: bouer fu ia D t tec pro www.worlddiabe

t e s d a y. o rg 6/6/2012 2:27:39 PM

Untitled-1 1

Jamie Oliver starting a revolution

36 30

14 40

DiabetesVoice

33

27

Contents

Diabetes Views

4

News in Brief

6

T H E G LOBAL CA M PAI G N Building capacity for care and prevention in Malawi

12

Timothy Ntambalika

h e a lt h d e l i v e r y How to protect the children of the Food Revolution – Interview with Jamie Oliver

14

World Diabetes Day 2012 – expanding the circle of influence

Isabella Platon

17

Diabetes and climate change: two interconnected global challenges

25

Creating a network to tackle diabetes and NCDs in Latin America

27

Katie Dain and Lucy Hadley

Noël Barengo and Ruby Trejo

CLINICAL CARE IDF breaking new ground – building BRIDGES around the world 30 Ronan L’Heveder

Exploring ethnicity in people with type 2 diabetes in Australia Margaret McGill and Stephen Twigg

33

DIABETES IN SOCIETY Haiti fights for a brighter future

36

Philippe Larco and Nancy Charles Larco

Civil society facing down the diabetes emergency in Mali

Stephan Besançon and Sidibe Assa Traore

40

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.

This publication is also available in French and Spanish.

Editor-in-Chief: Stephanie A Amiel, UK Managing Editor: Olivier Jacqmain, olivier@idf.org Editor: Tim Nolan, tim@idf.org Advisory group: Pablo Aschner (Colombia), Ruth Colagiuri (Australia), Patricia Fokumlah (Cameroon), Attila József (Hungary), Viswanathan Mohan (India).

Layout and printing: Luc Vandensteene, 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: +32-2-5431626 – Fax: +32-2-5385114 – olivier@idf.org

© International Diabetes Federation, 2012 – 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.

ISSN: 1437-4064 Cover photo : Jamie Oliver © Jamie Oliver

July 2012 • Volume 57 • Issue 2

DiabetesVoice

3

Diabetes views

Widening IDF's footprint During the first quarter of this year, we began to see the impact and results of the alliances and partnerships forged over the previous 12 months. We are seeing the increasing strength and influence of IDF’s Member Associations, amplified through global alliances which underline our external focus. Diabetes is a complex condition – from its multi-pronged aetiology and relentless disease path to the multifaceted approach required to manage diabetes on a daily basis. Moreover, the world is waking up to the interplay between the multiplicities of interconnected external factors whose influence is exacerbating the global rise in NCD numbers. In today’s world of intricately interwoven economies and globalized means of production and retail, diabetes appears to have found dangerously fertile ground – particularly among poor and underserved people in low- and middle-income countries. Diabetes and other NCDs are stealthily engulfing even those communities that were previously considered low-risk.

At the recent Rio+20 summit, the world leaders and experts came together to find effective solutions to the many deep fissures that are weakening the very fabric of human societal development – driven by the inexorable implosion of an inherently flawed and unjust financial system. Unfortunately, the event will change very little.

The dismal results prove that there is still much work to be done in changing the mentality of governments and decision-makers worldwide. Diabetes is a real health issue with critical links to the environment and economic growth of countries.

It is far from coincidence, then, that the launch of the World Diabetes Day 2012 campaign also aims to expand our circle of influence beyond the borders of diabetes, while remaining focused on our core disciplines, including the development, publication and distribution of clinical guidelines. We are all part of the solution to this diabetes epidemic. Therefore, we are convening the different stakeholders and catalyzing dialogue. Our aim is to change the way people think of diabetes on two levels. Our target audience is those who refuse to accept that diabetes is any of their business, those already affected and those at risk. We are engaging these groups by drawing the direct links between diabetes and global health issues.

A good example is the climate change event at the recent World Health Assembly in Switzerland – a groundbreaking collaboration with a sector that is new to the all-of-society campaign being mounted by IDF against the current pandemic of NCDs and diabetes. The private health company, Bupa, was IDF’s joint host at the expert dialogue on diabetes and climate, where health and climate sectors gathered to discuss how jointly to tackle these serious challenges. The event brought type 2 diabetes and climate change into the spotlight, as two of the most urgent challenges of the 21st century. Highlighted the connections between climate change and type 2 diabetes that are repeatedly overlooked in global policy dialogue.

A promising victory emerged from the 2011 UN High-Level Meeting on NCDs in New York: the target-25% by 2025. I would like to take this opportunity to acknowledge IDF Member Associations for their role in these achievements. However, we still have to fight for the other targets to be passed.

4

DiabetesVoice

Jean Claude Mbanya is IDF President for the period 2009 to 2012. He is Professor of endocrinology at the University of Yaounde, Cameroon, and Chief of the Endocrinology and Metabolic Diseases Unit at the Hospital Central in Yaounde.

July 2012 • Volume 57 • Issue 2

Diabetes views

Phoenix rising: a better future for diabetes care?

Diabetes is, depressingly, coming of age – as has been forewarned incessantly in these pages over the past decade by a succession of IDF presidents, editors and expert authors. The paradox of the modern world offsets the potential benefits of globalization and rising prosperity (for some) with the personal and economic costs of the rising tide of diabetes and other costly chronic diseases – adding to the constellation of other serious socioeconomic and health challenges facing the world. Geography, poverty, social re-structuring, under-developed infrastructure and disruption by war and civil unrest threaten the lives of people with type 1 diabetes and feed the rising number of people with type 2 diabetes.

Growing wealth in some sections of society bring about lifestyle change by revolution, not evolution, driving the diabetes pandemic by mechanisms that remain unsuspected until after the event – and with unexpected side effects. In this issue, we learn that the obesity pandemic now may be a threat to the very processes that created it in the first place (like those obscure biochemistry formulae that describe reactions that can go in either direction in textbooks with two arrows pointing in opposite ways) through a little-discussed impact on climate change (page 25). But initiatives are underway that offer reason for optimism.

Santé Diabète was created in Mali some 20 years ago as the first development-related NGO to focus on protecting people with diabetes. It was a tiny outfit operating in a country facing multiple social and economic difficulties, including an epidemic of HIV/AIDS. Two decades later, with about half the population subsisting on USD 1.25 per day and multiple societal challenges – including political unrest and recent military activity in some regions – further complicating life in Mali, the activities of Santé Diabète have become crucial to the survival of people with diabetes. The group’s founder provides us with an update on the situation in Mali and brings a message of hope.

Another report from one of our Member Associations describes the challenges facing people with diabetes and their healthcare providers in Malawi, the ‘Warm Heart of Africa’. Malawi too is drinking from the poisoned chalice of development. As its economy improves (Malawi has become a net exporter of food), more and more Malawians living in rural areas are drawn to the many opportunities – for employment, health and social care – offered by life in the cities. As we have seen elsewhere, that rapid urbanization brings with it a sharp increase in risk factors for type 2 diabetes.

Public awareness of the risks from diabetes to individual health has grown exponentially over the past decade – partly because there appears to be no one left these days who either does not have diabetes or does not know someone with the disease!

When any country is affected by extreme circumstances and multiple health challenges, people with diabetes tend to find themselves at the

July 2012 • Volume 57 • Issue 2

end of a dangerously long queue for aid and life-sustaining medication.

Although insulin is classified by the World Health Organization as an essential medicine, people with diabetes in Port au Prince faced agonizing periods without insulin in the aftermath of the earthquakes that struck Haiti in 2010. We have recorded in earlier issues how civil society in Haiti, in the form of another small but highly motivated diabetes NGO, the Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC), strove to plug those gaps in care provision. An update from Haiti in this issue reports on the situation in Haiti two years on. FHADIMAC has become a reference of the government’s plans to tackle diabetes. From the ashes of failing healthcare systems, new and sustainable structures might arise to improve previous provisions of care for diabetes and beyond.

New initiatives look not just at treatment for existing diabetes but also at its prevention. Noël Barengo’s article describes the development of a network for diabetes prevention under construction in Latin America; IDF’s Bridges projects develop and test deceptively simple interventions in both treatment and prevention.

Meanwhile, Diabetes Voice is pleased to include a contribution from an English celebrity chef, Jamie Oliver, who has given prominence to the axiom that if you want to change a society you start with the children. Mr Oliver makes clear that in terms of healthy food and how to prepare it, the developed world has much to learn from the developing world – those biochemistry arrows again! They can and should go in both directions and one of the political imperatives must be the recognition that the developed world does not have all the answers. The Phoenix has her work cut out, but we at IDF are there to give her a flying start!

Stephanie A Amiel is the RD Lawrence Professor of Diabetic Medicine at King's College London and Consultant physician to diabetes services at King's College Hospital, UK.

DiabetesVoice

5

News in brief

More evidence on environmental factors driving up diabetes An international team of researchers has studied the spatial patterns relating to the spread of obesity and diabetes. Their findings suggest that overweight, a key risk factor for type 2 diabetes, may have more to do with collective behaviour than genetics or individual choices after all (Scientific Reports 2012. 454 doi:10.1038/srep00454).

Moreover, the research exposed relationship between the geography of the obesity epidemic and patterns of food marketing and distribution. For example, a relationship was seen between the prevalence of obesity and the growth of ‘the supermarket economy’.

The study did not look at causality – whether market forces are driving obesity or the market is being influenced

6

DiabetesVoice

by behaviour that promotes obesity.

However, lead researcher Hernán Makse concluded that genetics are unlikely to play a major role in the obesity epidemic and that the spread of this major risk factor for type 2 diabetes cannot be tackled by focusing on individual behaviour.

The prevalence of NCDs appears to develop in clusters, and the spread of obesity has been seen to be affected by global economic drivers. The researchers used microdata provided by the US Centers for Disease Control Behavior Risk Factor Surveillance Systems from between 2004 and 2008 to investigate spatial correlations for specific years. According to their spatial map of obesity in the USA, neighbouring areas tend to have similar levels of obesity and type 2 diabetes.

To assess the properties of these spatial arrangements, the researchers studied population density, prevalence of adult obesity and diabetes, cancer mortality rates and economic activity. At critical points, long-range correlations appear, which may signal the emergence of “strong critical fluctuations in the spreading of obesity and diabetes”.

The team of investigators believed that the correlations of fluctuations in the prevalence of obesity might be linked to demographic and economic variables.

To test their hypothesis, they compared the spatial characteristics of industries involved in food production and points of sale – supermarkets, shops selling food and soft drinks, restaurants and bars – with other sectors of the economy.

Areas with above-average concentrations of food-related businesses had high-than-normal prevalence of obesity and diabetes. Professor Makse’s conclusions lend credence to the premise that environmental factors are influencing the virus-like spread of NCDs, and wrest importance from genetics, arguing that were it genetics alone that determined obesity, the team would not have seen the correlations.

July 2012 • Volume 57 • Issue 2

News in brief

Obesity a major threat to food security The UN predicts that by 2050 there could be 2.3 billion more people living on our already crowded planet. Concerns over the demand for natural resources and the effects of overpopulation on the environment and national economies have prompted some observers to call for measures to control birth rates – particularly among women in developing countries. However, researchers in the USA warned recently of a concomitant and comparable threat: the impact on the environment of the flabby bodies of people in the developed countries, the USA in particular.

This groundbreaking research, undertaken by scientists at the London School of Tropical Medicine (UK), looked at the average weight of adults around the world and found that increasing population fatness could have implications for world food energy demands similar to an extra one billion people on Earth. Put together, the adult population currently weighs some 287 million tonnes. A staggering 15 million tonnes of this is due to overweight, with 3.5 million tonnes due to obesity.

Using data from the UN and WHO, the researchers found that the average US adult weighs 81 kg, almost 20 kg more than the global average adult, 62 kg. They found other interesting

July 2012 • Volume 57 • Issue 2

regional differences, which also point to different stages in the development of the obesity epidemic that is fuelling the global diabetes emergency. Across Europe, for instance, the average weight was 70.8 kg, compared to 57.7 kg in Asia. More than half (55.6%) the people living in Europe are overweight while only 24.2% of Asians are overweight; staggeringly, almost 75% of people living in North America are overweight.

Very serious concerns have been raised by the researchers’ projection of the effect on our planet of a global population equivalent in terms of body weight to that of the USA. They predicted that if all people had the same average body mass index as people in the USA, the total human biomass would put on another 58 million tonnes, which would impact heavily on the energy requirements of our species.

Professor Ian Roberts, who led the research, said: "Everyone accepts that population growth threatens global environmental sustainability - our study shows that population fatness is also a major threat. Unless we tackle both population and fatness, our chances are slim."

For more on the links between diabetes and environmental issues, see the article on page 25 of this issue.

DiabetesVoice

7

News in brief

Brands finding new ways to market to children A recent study has exposed the range of advertising tools employed

Approximately 16% of the 1678 food references identified were

to market potentially harmful food and drink products in children's

portrayals of branded food products (or food brands). However,

magazines in Australia (Pediatr Obes 2012; 7: 220-9). According to

only 83 of these 269 were clearly identified as advertisements. Of

the authors, children's magazines ‘blur the lines’ between editorial

the 269 branded food references, 86% were for non-core (broadly,

content and advertising, and have escaped calls for government

less healthy) foods, including all but seven of the advertisements.

restrictions that are currently associated with food advertisements aired during children's television programming. The aim of this

The researchers concluded that the recent reductions in televised

study was to address gaps in the evidence base in relation to com-

promotions for non-core foods, and industry initiatives to reduce

mercial food messages in children's magazines by investigating

the targeting of children, have not carried through to magazine

the nature and extent of food advertising and promotions over a

advertising. They wrote that their study adds to the evidence base

12-month period. The research team collected and examined for

that the marketing of unhealthy food to children is widespread, and

references to foods or beverages all issues of Australian children's

often covert, and supports public health calls for the strengthening

magazines published in 2009.

of advertising regulation.

Photograph a famous face for World Diabetes Day Join the global campaign

Go to the IDF website (www.idf.org) and

The blue circle is the universal symbol for

click on the World Diabetes Day links to view

diabetes awareness and this year IDF wants

the Pin a Personality gallery of famous faces.

to make sure that want everybody knows it.

You can help. Join the World Diabetes Day

Beat the deadline

Pin a Personality campaign. The aim is to

Upload your photos before November 14 to

photograph a well-known person wearing

the World Diabetes Day Facebook page or

a blue circle pin.

on Twitter using #WDDPin. Make sure you include a couple of lines telling the world

Choosing a person to pin

why you chose that person.

Your personality should be someone you think will catch people’s eye and draw their

Whom you would like to portray with a pin

attention to the blue circle badge. Or some-

for diabetes? When you are ready to take

one who contributes to IDF’s mission to

on the Pin a Personality Challenge, email

promote diabetes care, prevention and a

the World Diabetes Day team at wdd@idf.

cure worldwide. He or she might be some-

org and we will send you a pack of blue

one from the entertainment world or an

circle pins.

athlete or politician. Or they could be a local diabetes hero – like a nurse, a volunteer, a teacher or trainer.

8

DiabetesVoice

See the report on page 17 of this issue for more Good luck and happy snapping!

on this year’s World Diabetes Day campaigns.

July 2012 • Volume 57 • Issue 2

News in brief

IDF launches Diabetes Roadmap to the Future Development Agenda

diabetes federatio n’s s federatio al diabete

the international

n’s

admap to o r s e t e b dia o a petn a m d d a g o a t r n e s m p e o l t e v e e d b e r a u the fut di n-d2a015 e g a 2 1 t 0 n 2 e m p e develo 5 the futur 2012-201 ation the intern

IDF recently launched a new advocacy programme, Diabetes Roadmap to the Future Development Agenda (The Roadmap).

Following in the footsteps of the landmark IDF Diabetes Roadmap Programme that was dedicated to securing strong diabetes outcomes from the UN Summit on NCDs, IDF has designed a successor programme for the period 2012-15. The opportunities for change during this period are immense. For the first time we have political agreement on diabetes and NCDs with the unanimously adopted UN Political Declaration on NCD Prevention and Control; for the first time the global diabetes community has a clear vision and solutions for the next decade in IDF’s Global Diabetes Plan 2011-2021; and for the first time since 2000 the world will discuss and define what comes after the end date of the Millennium Development Goals (MDGs) in 2015.

The Roadmap will build on the achievements of our UN Summit campaign and maximize this unique opportunity to integrate diabetes and NCDs into the future development agenda. IDF has always given our full support to the MDGs, but the absence of diabetes and NCDs in the MDGs has been a major obstacle to mobilizing leadership and resources. Now is our chance to change this. The door is open to catalyze a paradigm shift in the global development agenda that would benefit the millions of people with diabetes worldwide.

IDF’S DIABETES ROADMAP

FUTURE DEVELOPMENT AGENDA 2012-2015

015

AGENDA 2012-2 FUTURE DEVELOPMENT AP

IDF’S DIABETES ROADM

July 2012 • Volume 57 • Issue 2

1

1

Continuing with our twin track approach of working both for diabetes and influencing NCD level work through the NCD Alliance, IDF will drive forward an ambitious and comprehensive programme of work to achieve our aims.

DiabetesVoice

9

News in brief

Industry fury at New York initiative against potentially harmful drinks

Diabetes, fructose and liver risk

The decision taken recently by the mayor of New York to ban the sale of sugary

Researchers at the US Johns Hopkins

drinks over 470 ml (and 25 kcal/100 ml) at restaurants, cinemas, sports venues and on public transport provoked a strong negative reaction by the food and beverage industry. The lobby group Center for Consumer Freedom ran a full-page advertisement in the New York Times featuring a digitally edited photograph of mayor Bloomberg as a nanny with the tagline, "New Yorkers need a mayor, not a nanny." Center for Consumer Freedom was founded to oppose bans of smoking in restaurants and bars.

University suspected that high consumption of fructose might provoke liver damage, so they looked closely at data from the Look Ahead Fatty Liver Ancillary Study, an observational, cross-sectional study involving people in the USA. Obese people with type 2

Formerly called the Guest Choice Network, the group’s advisory board is comprised largely of representatives from the restaurant, meat and alcoholic beverage industries.

It organizes media campaigns opposing the efforts of scientists, doctors, health advocates and environmentalists, and its reaction to this initiative, which is designed to protect health, was echoed by others in the industry. A spokesperson for McDonalds commented in the New York Times called the ban narrowly focused and misguided.

Meanwhile, the Director of the Rudd Center for Food Policy and Obesity at Yale University, Professor Kelly Brownell, commented that, "There's very strong scientific evidence that when people are served more they eat more, or in this case drink more. The Mayor's proposed ban will affect enough people in a strong enough way to create a pretty significant public health benefit."

diabetes who reported high daily consumption of fructose experienced reduced levels of adenosine triphosphate in the liver – reflecting impaired liver function – compared with those who consumed less (Hepatology doi: 10.1002/ hep.25741). The investigators also determined that elevated uric acid may serve as a marker of impaired liver function following consumption of fructose in people with type 2 diabetes.

244 adults with type 2 diabetes aged between 45 and 76 years completed a questionnaire on their daily fructose consumption. The researchers also recorded levels of uric acid and measured hepatic adenosine triphosphate.

In their conclusion, they underlined the urgent need for increased public awareness of the risks related to high fructose consumption.

10

DiabetesVoice

July 2012 • Volume 57 • Issue 2

News in brief

Questions over drug trials in developing countries A paper in the British Medical Journal by an emeritus professor of diabetes in the UK has accused producers of insulin and other medications of carrying out drug trials to increase sales in developing countries. Although not required by licensing authorities, post-marketing studies are often carried out in order to determine the performance of a medication in the real world – without the regular, close monitoring of the clinical trial. Edwin Gale’s article questioned the purpose and usefulness of such trials.

Gale looked at post-marketing trials of analogue insulins, which are markedly more expensive than the conventional human insulin – although according to England’s National Institute for Health and Clinical Excellence, analogues do not offer significant benefits for most people with diabetes.

According to the report, since 2005, nearly 400,000 people have been recruited into post-marketing trials of analogue insulins, mostly in middle- or lower-income countries. Gale pointed to the unnecessary cost burden placed on people with diabetes and healthcare systems in the developing countries hosting the post-marketing trials: “The patient or healthcare system pays for a more expensive agent instead of one that is cheaper and equally effective, and the public is offered misleading claims of comparative merit based on studies of limited scientific value.”

July 2012 • Volume 57 • Issue 2

DiabetesVoice 11

The global campaign

Building capacity for care and prevention in Malawi Timothy Ntambalika

A impromptu meeting of people with diabetes at the Queen Elizabeth Central Hospital in the country’s capital, Blantyre, generated the impetus to establish the Diabetes Association of Malawi. The author of this report was among those founding voices to call upon other people with diabetes to come together to form an organization that would advocate for the health rights of people with the disease. Although diabetes awareness and knowledge were generally low among people with diabetes, as well as the wider public, in Malawi, people with diabetes in the country are only too aware of the very serious shortfalls in the provision of care, and the oftendifficult access to essential medications. With type 2 diabetes emerging as a major health concern in the country, the Diabetes Association of Malawi is working hard to warn the health authorities, political leaders and the general population of the grave threat to development, as well as health and wellbeing, posed by an epidemic of type 2 diabetes. Timothy Ntambalika reports from Malawi.

More than half the population of Malawi lives below the poverty line and the majority of Malawians live in rural communities, farming a small plot of land.

In recent years, the country has made progress towards achieving economic growth. Healthcare, education and environmental conditions have improved.1 But Malawi’s food supply is precarious and the country is prone to disaster

12

DiabetesVoice

situations provoked by climatic extremes from drought to heavy rains. This forces Malawi to rely on international food aid and limits people’s diets to imported industrially processed foods – and, of course, places further strain on Malawi’s already stretched healthcare services.

Malawi is one of the most densely populated countries in the world1 and rapid

population growth, particularly now in urban areas, is driving an increase in lifestyle diseases that are established among the urban poor living in postindustrial countries. The obesity that is being unleashed upon young people in Mexico and increasingly elsewhere in Latin America, or the diabetes-related stroke and heart disease epidemics that are sweeping South-East Asia are appearing in Malawi. Malawi has been striving to overcome the impact of a growing HIV/AIDS problem, which kills tens of thousands of Malawians every year. The increase in risk factors for non-communicable diseases (NCDs), including type 2 diabetes, is severely compounding the country’s already considerable disease burden.

The outlook for many Malawians is uncertain. Maize meal prices climbed by more than 60% in the last four months of 2011.2 The prices of many basic items have gone up by as much as 50%.3 The USAID-funded Famine Early Warning Networks (FEWS NET) in its latest report has warned that price rises in the

July 2012 • Volume 57 • Issue 2

the global campaign

south may accelerate, worsening the nutritional levels of the urban poor.3 It is people living in towns and cities on a low income, without access to fresh, nutritious foods or, indeed, a healthful environment, who are at increased risk for type 2 diabetes and other NCDs.

Our main objectives are to provide diabetes education and sensitize the general public to the threat from diabetes.

The main objectives of the Diabetes Association of Malawi are two-fold: to provide diabetes education to those with the disease; and sensitize the general public, via public awareness campaigns and community events, to the threat from diabetes and the ways it affects individuals, communities and even the economic wellbeing of the country.

A survey conducted by doctors from the Blantyre College of Medicine found diabetes awareness among people diagnosed with the condition was low, and diabetes care in most of the referral hospitals – even in district hospitals – to be sub-standard. Meanwhile, the disease profile of Malawi continues to worsen, with diagnoses of diabetes and diabetes-related deaths growing every month. The immediate impact of diabetes is felt by people with the condition and their family – in terms both of the emotional strain and the economic burden – but diabetes is set also to have serious effects on economic activities in Malawi. Risk factors for diabetes are already accumulating among people of working age. Those who go on to develop the disease are very likely to lose working days, leaving them out of pocket and representing a loss to their employers, unless the government and society as a whole

July 2012 • Volume 57 • Issue 2

engage in preventative efforts at both community and national levels.

It is against this background of impending threat, not only to our health services but also to our socioeconomic development, that we launched the Malawi Awareness project. The UN summit on NCDs in 2011 gave diabetes the highlevel political recognition it needed rise up the agenda of national governments worldwide. In Malawi, the government has engaged the Diabetes Association of Malawi to discuss the nation’s response to diabetes.

The status of diabetes in Malawi From our experience on the ground, we know that diabetes is a serious and growing problem in Malawi. While the World Health Organization estimates the prevalence among adults to be 5.6%, we put that figure at around 15% of the adult population. It is imperative that we get a clear picture of the status of diabetes in order to measure and prepare the required response. We have always faced a lack of resources to conduct a countrywide survey. Efforts are underway to secure funding for this and other initiatives, such as a diabetes education programme among schoolteachers.

In Malawi, the government has engaged the Diabetes Association of Malawi to discuss the nation’s response to diabetes.

Training the trainers We hope to receive backing to organize and conduct workshops throughout the country, teaching the basics of diabetes to teachers in order to create a ripple effect of broadening diabetes awareness. The role of Association will be to

monitor and supervise the project and evaluate its performance against the intended objectives. This will be a sustainable project involving Association member volunteers.

Protecting our future As an Association, the severe lack of funds is our principal challenge. Applications have been made to the World Diabetes Foundation and we receive valuable support from IDF but as the burden from diabetes and other NCDs increases, so do the needs of people with and without a diagnosis of diabetes in Malawi.

Currently, we have an urgent need to provide formal training for at least five of our diabetes educators.

The Diabetes Association of Malawi is young and diabetes in today’s numbers is new to our country. We have grown quickly and are hoping to develop into a strong, well-resourced organization, capable of rising to the challenges ahead.

Timothy Ntambalika Timothy Ntambalika is President of the Diabetes Association Of Malawi.

References 1 C entral Intelligence Agency. The World Fact Book. www.cia.gov/library/publications/ the-world-factbook/geos/mi.html 2 T he World Bank. Food Price Watch January 2012. http://siteresources.worldbank.org/ EXTPOVERTY/Resources/336991-1311966520397/ FoodPriceWatchJanuary2012.htm 3 U N Office for the Coordination of Humanitarian Affairs. MALAWI: Rising prices and looming maize shortages. www. irinnews.org/Report/94825/MALAWI-Risingprices-and-looming-maize-shortages

DiabetesVoice 13

Health Delivery

How to protect the children of the Food Revolution

Interview with

Jamie Oliver English chef and restaurateur Jamie Oliver’s television programmes are shown in more than 40 countries around the world and Oliver has become a global media personality.

But it is his relentless campaigning on food issues that has increasingly become the focus of his work. In the UK, his campaign against the use of processed foods in schools has had a lasting effect on the nation’s diet and its psyche. Oliver is committed to changing the public’s approach to food and dietary health, particularly among young people. His latest campaign, Food Revolution Day, attempts to transform the way people eat by educating all children about food, giving families the skills and knowledge they need to cook and motivating people to “stand up for their rights to better food”. He took time out recently from his busy schedule and preparations for Food Revolution Day to speak to Diabetes Voice.

14

DiabetesVoice

July 2012 • Volume 57 • Issue 2

Health delivery

Diabetes Voice: Why are you so passionate about fighting childhood obesity?

Jamie Oliver: I am passionate about food education for everyone, but I think it’s crucial for children to learn about food – where it comes from, how it affects their bodies and how you can cook incredible, nutritious meals with fresh ingredients. I worry that we are in danger of losing the basic life skill of cooking; three generations ago, pretty much every household had someone who knew how to cook and ready meals were unheard of. And now, just 30 or 40 years later we have kids and young families growing up without the knowledge or skills to cook even the most basic of things, and so they have no choice but to live off reheated meals with loads of additives and, in many cases,

July 2012 • Volume 57 • Issue 2

fast food every day. So it is no wonder we have a situation where both adult and child obesity are spiralling out of control. Something has got to be done and there are hardly any governments in the world who are currently really tackling the problem.

DV: You have previously highlighted the connection between obesity and the exploding numbers of children being diagnosed with diabetes. How can we reverse this potentially disastrous trend? Why do you think this health issue remained neglected for so long?

JO: It is not a sexy subject so it is hard for the mainstream media to get excited about it. This is not like war, a highprofile shooting, a major earthquake

or something where the news media is all over it; it is something that is getting worse every single day, but because it is happening slowly, it gets ignored.

And yet, if you walked down the street 40 years ago and then suddenly rolled time forwards to today, the difference in people’s body size would shock you.

How can we reverse this trend? Well, first of all, I do not have all the answers! It is a massive problem and it will take a number of measures – some of them unpopular – to really make a dent in the situation. But I do believe that food education from an early age is the key. In the UK, I have two pilot schools with kitchen gardens, where the kids are growing their own food

DiabetesVoice 15

Health Delivery

and then cooking it. The feedback I receive from the teachers and parents is amazing. They have said that the kids are so engaged, are already learning an incredible amount, and are completely loving every minute of their time in the garden and the kitchen – which is brilliant, and exactly what this is all about.

All kids need, and should be armed with, those all-important life skills. We also have kids in high schools in the UK and Australia doing cooking classes, and again all the reports back are saying that these young people – some of whom cannot pay attention in other classes, like maths and geography – are 100%

focused during cooking classes because it clearly interests and inspires them.

DV: What is the vision for your Food Revolution Campaign and your Kitchen Garden Project?

JO: Via the Kitchen Garden Project, which has only just started in the UK, I would like to reach a place where every child in primary school has access to a garden where they can help to grow food and then cook it. Clearly, that is a huge ask. But I believe it really will make a difference. When I started working in schools, both in the UK and the USA, I was very shocked by the fact that children could not identify basic vegetables – some as common as carrots or potatoes. In my mind, this is not acceptable. In California, one teenager thought that honey came from bears!

This is an outrage.

So for Food Revolution, it is really a change for people all over the world to stand up and say: “We don’t accept the way things are. We don’t accept that our children leave school without knowing how to take care of themselves. We don’t accept all those nasty ingredients that the big food companies add to our food that we shouldn’t be eating, and we stand up for change.”

DV: How will you measure the Food Revolution Day campaign? What will need to happen to make is a success?

JO: I think it is already a success because even in this first year, Food Revolution Day is on the map with media coverage, social media, support from businesses and celebrities, and not forgetting all the incredible people all over the world who are giving their time and energy to take Food Revolution Day into communities everywhere. The last time I looked there was something happening in 36 countries. For a first year, that is amazing!

16

DiabetesVoice

DV: You have consistently shown that there is a dissonance between people and the food they eat, where ingredients come from and how to eat seasonally. How can we improve this lack of knowledge and awareness? How can we make healthier food accessible to everyone, rich or poor, regardless of where they live?

JO: It comes down to food education every time. When I hear people say that it is too expensive to eat fresh food, I know it is wrong because I have been to some of the poorest parts of Europe and I have been to townships in South Africa and I have seen people with very little money cooking and eating wonderful food, simply because they have the knowledge. They can make bread with a bit of flour and water. They can create a delicious stew using some cheaper cuts of meat and some root vegetables. They can use leftovers to get an extra two or three meals out of, say, a roast chicken. So I think educating our children is key, but also educating our adults, which is already happening at the Food Revolution Centres and Truck in the USA and at the Ministry of Food Centres in the US and Australia, is important too.

Find out more… http://www.jamieoliver.com/ kitchen-garden-project/ http://www.jamieoliver.com/us/foundation/ jamies-food-revolution/home

July 2012 • Volume 57 • Issue 2

health delivery

World Diabetes Day 2012 – expanding the circle of influence Isabella Platon

World Diabetes Day unites the world against diabetes by celebrating people who are touched by diabetes every day and raising public awareness of this killer epidemic. International Diabetes Federation leads this global grassroots campaign inspiring advocates, organisations and individuals to come together on November 14 to put the spotlight on diabetes. Together with its member associations, IDF put diabetes on the global health agenda by securing the 2006 UN resolution, making WDD an official UN Day. We salute those who work to make a life with diabetes like any other life, and those who strive to make diabetes a thing of the past – like insulin pioneer, Frederick Banting, whose birthday provides the date – 14 November. Every year, World Diabetes Day generates more momentum, makes more noise and shines more light on diabetes than it did the year before. In fact, the celebration that was established in partnership with the World Health Organization in 1991 to highlight the risks from diabetes has developed into an ambitious five-year-long campaign implemented across multiple media worldwide.

IDF’s head of communications Isabella Platon reports.

July 2012 • Volume 57 • Issue 2

Social media platforms, such as Facebook and Twitter, link millions and millions of people from all walks of life and across all continents. The global accessibility of web-based social media and the immediacy of the communications they facilitate are transforming communications strategies worldwide.

Facebook and Twitter in particular have become essential tools for any organization – from the mighty multinational company to the local community action group – with a message it wants to deliver to as many people as possible, as quickly as possible. They have becomes the tools of our trade.

IDF is engaged in conversations with huge numbers of people via Facebook

DiabetesVoice 17

Health Delivery

and Twitter – and those numbers are growing every day. Our communications strategy is a blueprint for massive mass communication, broadcasting advocacy messages to audiences worldwide, disseminating diabetes data (from IDF’s Diabetes Atlas and Guidelines) and highlighting essential reading for an informed and effective response to diabetes. In essence, IDF’s online campaign is playing a principal role in resolving one of the Federation’s historic challenges: to explore and engage the enormous reserves of support lying untapped within a global audience, while remaining relevant, accessible and useful for IDF’s Member Associations.

A case in point was the online storm of activity that was sparked last year by the intervention of IDF President, Jean Claude Mbanya in a web-based forum with the online diabetes community in the USA – which includes diabetes bloggers, collectively the ‘diablogosphere’, individual diabetes advocates and others. Mbanya highlighted the human rights issues that underpin access to essential medications, like insulin. He did not mince his words when referring to IDF’s Life for Child Programme and the injustice that leaves millions vulnerable to the deadliest aspects of diabetes.

And he touched a nerve in the USA in particular when he laid out IDF’s conviction that “accidents of geography should not decide whether a child with diabetes lives or dies.”

This stark reality put the diabetes challenge in a different context for the USbased bloggers. A nationwide debate followed with contributors from all over the country showing their shock and indignation at the fate of the kids and adults who continue to die just because they cannot afford to pay for insulin. This

18

DiabetesVoice

Racing car driver, Miguel Paludo, Blue Circle Champion

soon developed into a global discussion involving people affected by diabetes around the globe. Posts and tweets rained in from all sides echoing the heart-felt outrage sparked by the depressing statistics on children with type 1 diabetes in developing countries. That conversation with the world was a turning point in IDF’s social media presence.

No sooner had IDF begun engaging via Facebook and Twitter with key

organizations, bloggers and other online advocates, that meaningful dialogue was underway. The social media platforms facilitate open and blinkof-an-eye, two-way communications.

This enables IDF to hear – through real comments and opinions of real people affected by diabetes and real diabetes health professionals – about the needs and wishes of the myriad groups that form the global diabetes community.

And we are listening and learning.

July 2012 • Volume 57 • Issue 2

health delivery

The online community in the USA is an interesting one for a number of reasons. Firstly, it is huge and very noisy!

Prolific bloggers and frequent tweeters count their followers in the hundreds of thousands. Indeed, the US-based community is the most mature in terms of its experience with social media and has shown itself to be proactive as well as responsive.

Active listening for a customized response IDF’s role in the conversation reflects a sophisticated and highly audience-sensitive approach to maximize every moment and every movement online. We believe that listening is the cornerstone to any open conversation – and we listen ‘actively’ so that any internet-mediated communication from IDF is appropriate to its intended audience. This means that every message is tailored specifically to the needs and sensitivities of an audience that we know and understand.

A principal concern of the Federation has always been to gather and catalogue data on its global constituency in order to be able to deliver relevant messages and real-world solutions to millions of people living in a myriad different sociocultural and economic conditions. This simple approach is working, as reflected in the better-than-anticipated numbers so far: by the time of writing, IDF had seen a 65% increase in its followers on Twitter and a 25% increase on Facebook over the previous 18 months.

Thinking very big Communications via the social media allow us to think big. The relevant technology is almost universally available.

Internet connections reach thousands of previously unconnected families and communities every single day throughout the developing world – and figures

July 2012 • Volume 57 • Issue 2

show that where there is internet, there is Facebook. IDF’s presence there will allow people in low- and middle-income countries, where 80% of deaths attributable to non-communicable diseases (NCDs) occur, to receive early warning of the threat to their health and wellbeing posed by diabetes.

The links are explained between the risk factors for diabetes and the state of the planet’s health.

WDD 2012 – educate, protect, enjoy This year’s World Diabetes Day campaign is a worldwide clarion call to action to protect the health of our future generations. The campaign aims to convey the urgency with which the diabetes epidemic must be approached.

Uniquely for a global campaign of any kind, WDD exposes and explains the links between the epidemic of risk factors for diabetes and the worsening state of the planet’s health. Even more importantly, WDD focuses on the ways in which health-protective changes in our behaviour, from the individual to the multinational-corporation level, will help us to protect the future of individuals, communities and, indeed, an entire species.

Knowledge in the right hands can bring power to those how are most in need.

Simply put, in order to reduce the impact of diabetes, and thus protect ourselves

for generations to come, basic knowledge on the prevention and optimal management of diabetes must reach the hands of people with diabetes, those at risk from the disease and our healthcare providers. Policy makers must be made aware of the socioeconomic benefits of our messages and spurred into action by an informed general public.

Young people will be the driving force behind activities to promote and disseminate educational and preventive messages. In 2012, WDD will warn the world about the dangers of diabetes and inspire communities to fight back and think of the future. Our messages are clear and simple and powerful, and go out to individuals, communities and civil society, as well as the private sector that plays such a fundamental role in moulding our environment: use your power to protect and take the right steps to health. Together, we can reduce the risks for everyone and protect the health of the world.

Protect our future!

The campaign focuses the attention of the world on the urgent need to address three pillars of concern for the diabetes community – burning issues that are having a closely related and concomitant impact on wider society.

■ Access to education is a basic human right.

■ The way we live puts our health at risk.

■ People with diabetes face stigma and discrimination.

People have power to protect and take the simple steps to health.

DiabetesVoice 19

Health Delivery

This year, with children and adolescents at the centre of its slogan, IDF is identifying individuals and organizations based outside the diabetes community who are active in promoting health and a healthy future among this key demographic. Diabetes has come a long way in terms of public awareness, particularly since the 2006 UN ‘World Diabetes Day’ Resolution, and the successful UN High-Level Meeting on NCDs last year – where diabetes and IDF were notable protagonists. This year, we are counting on your help to make diabetes a mainstream issue where it is not one already – and make sure it stays that way where it is!

IDF is partnering beyond the diabetes community with very active organizations that share our goals and values in order to get diabetes included on everyone’s wellness and nutrition agenda. For instance, celebrity chef, restaurateur and food activists, Jamie Oliver, has created the Food Revolution, which aims to return us to traditional, healthful and, very importantly, sustainable ways of cooking and eating. (Read what Oliver has to say about the Food Revolution on page 14 of this issue in an exclusive interview with Diabetes Voice).

World Diabetes Day Champions World Diabetes Day Champions are being recognized in this year’s campaign for their efforts to improve and protect health. Jamie Oliver’s Food Revolution Day was a recent champion. A group called Wellness in the Schools is another recent Champion that focuses on healthy eating. A non-profit, community-based organization, it was founded in 2005 to help improve the environment, food and fitness in public schools in the USA. In collaboration with Save the Children, Wellness in the Schools promotes healthy eating, fitness, and

20

DiabetesVoice

sustainability as a way of life for young people of school age. Visit the WDD website by following the links at www. idf.org for more on these and other WDD Champions and to access the wealth of information and freely available campaign resources.

Pin a Personality Other initiatives this year include the Pin a Personality Campaign, which was launched to increase the profile of the blue circle (the globally recognized symbol of diabetes). We encourage anyone and everyone to photograph a well-known person wearing a blue circle pin and post it on Facebook (see News in Brief for more on this campaign). The campaign is already proving to be popular across the IDF on-line community, not to mention its effect on the burgeoning international diabetes paparazzi! The Pin a Personality gallery, which you can view on our website, is already filling-up with international personalities like former UN Secretary General, Kofi Annan, French DJ, Quentin Mosimann, and Olympic gold medallist Gary Hall.

Shine a light!

World Diabetes Day has earned its place among the key dates on the world’s campaign calendar. Each year, it generates more noise and more hope that the last.

The groundbreaking Blue Monument Campaign, which last year saw nearly 700 landmark buildings and monuments bathed in diabetes blue, is a firm favourite of the diablogosphere and beyond, and a beautiful way to leave a very serious mark on the night sky. There is room for everyone on the WDD train this year.

Visit our website. Follow us on Twitter.

‘Friend us’ on Facebook. Together, we can help protect the health of the world.

Stay in touch with WDD Visit the website www.idf.org/worlddiabetesday Join us on Facebook World Diabetes Day Follow us on Twitter http://twitter.com/#!/wdd Isabella Platon Isabella Platon is IDF head of communications.

July 2012 • Volume 57 • Issue 2

t n e m n o r i v n e t h g The ri for all

w w w. w o r l d d i a b e t e s d a y. o rg

Diabetes: protect our future

health delivery

Diabetes and climate change: two interconnected global challenges Katie Dain and Lucy Hadley

Against the backdrop of the 65th World Health Assembly in Geneva, the International Diabetes Federation (IDF) and the private health insurance company, Bupa, convened an expert dialogue on two of the most urgent challenges of the 21st century: the global diabetes epidemic and climate change. Both are global phenomena, and have been identified separately as threatening to derail human development and economic growth; both are rapidly accelerating and are fuelled by changes in the way we live and work; both are impacting on all countries – with no government having these challenges under control; and both will have intergenerational effects on the health, wellbeing and security of future generations.

Recognition of the sheer size and impact of both challenges has been increasing. A new sense of urgency to act has resulted in a number of political commitments for each challenge. The UN Resolution on diabetes in 2006 was followed by the landmark UN Political Declaration on NCD prevention and control last year, and the UN Climate Change Conference advanced the international community’s response to climate change mitigation with the adoption of the Durban Platform for Enhanced Action. However, despite growing political recognition of the urgent need to prevent type 2 diabetes and climate change, recognition of the

July 2012 • Volume 57 • Issue 2

connections between the two issues, and approaches capable of jointly mitigating their risks and repercussions, has been missing from policy dialogue.

Where are the links?

Type 2 diabetes and climate change are directly and indirectly interconnected.

The direct connections refer to how type 2 diabetes and climate change adversely impact on each other. For example, climatic extremes such as drought, disasters and long periods of extreme heat increase people’s exposure to diabetes risk factors because traditional food supplies are damaged

and opportunities for physical activity are curtailed. Starvation among pregnant women may even set the scene for type 2 diabetes in their children. Meanwhile, people with established diabetes suffer adverse health outcomes or are left without access to essential medicines because of weakened health systems.

The indirect connections refer to the common global forces and trends that are fuelling both of these disasters. For example, patterns of rapid urbanization and fast-changing demographics, and global food industry practices are contributing to high-carbon obesogenic environments. Combined, the direct and indirect links form a rationale for an aligned policy agenda.

Collaborating with Bupa With support from Bupa, IDF has developed a pioneering policy report that will bring these two challenges together.

It outlines the interconnections between climate change and diabetes; establishes the benefits of combating two global risks in an integrated policy agenda;

DiabetesVoice 25

te change Mapping the interconnections: type 2 diabetes and clima Direct Impact Global Diabetes Epidemic Today there are 366 million people with diabetes, and by 2030 that number will reach half a billion. Globallydiabetes kills 4.6 million people a year, it is among the top causes of disability, and costs the world USD 465 billion in healthcare expenditure every year. Four out of five people with diabetes now live in lowand middle-income countries. Diabetes impoverishes families, hampers labour productivity and overwhelms health systems.

Carbon-intensive health systems

Food insecurity Weakened health systems

Climate Change

Greenhouse gas emissions are expected to grow by 52% by 2050, raising the earth’s temperature to exceed the safe threshold. There is now unequivocal evidence for human induced climate change. While high-income countries contribute almost all emissions, it is the poorest countries that suffer the greatest consequences. If nothing is done, climate change will cost 5–20% of the world GDP every year,3 and will impact on malnutrition, increased infectious and non-communicable diseases (NCDs), poverty and inequity.

Pathways Mechanised transportation Poor urban design and slum growth Sedentary lifestyles

Ageing populations Depleting natural resources

Animal source food production Industrial food processing Global food and agriculture trade Unhealthy diets and consumption patterns

Global Vectors Rapid Urbanisation Over half of the world’s population live in cities today. By 2030, an estimated 5 billion of the world’s 8.1 billion people will live in cities, and 2 billion of them will live in slums. The speed and scale of urbanisation globally is impacting upon climate change, and in developing countries and for socially disadvantaged populations it is compromising human and planetary health.

Fast-Changing Population Demographics By 2050 the world’s population will have grown from 7 billion to 9 billion, and the biggest increase will be in Asia and Africa. Overall global population is ageing, but many developing countries will witness increasingly young populations. These changing demographic trends place a strain on already insufficient resources, aggravate environmental problems, and contribute to shifting disease patterns.

Globalised Food System The 21st century food system is framed by globalisation, liberalisation and industrialisation.

While the benefits of a globalised food system are apparent, industrial food production, processing, trade, marketing and retailing are a major stressor to the planet and contribute to the nutrition and epidemiological transitions taking place in developing countries.

June International Diabetes Federation, Diabetes and Climate Change Report,

and informs the broader global discussion on health and sustainable development. The report has been developed with support from an informal advisory group including experts in the field of health and the environment. It was this piece of work that provided the basis for the expert dialogue at WHA. The event was co-hosted by Bupa Chairman Alexander Leitch and IDF PresidentElect Michael Hirst, and included respected panellists, Ruth Colagiuri, IDF Vice President, George Alleyne, Director-Emeritus of PAHO, Maria Neira of the World Health Organization, and John Tooke, Chairman of Bupa’s medical advisory panel.

We held this dialogue at WHA in order to engage the health policy-makers of

26

DiabetesVoice

the world on these two urgent issues.

Consequently, we launched our policy report around the UN Conference on Sustainable Development – also known as Rio+20 – as we believe it provides a useful lens for understanding the broader interconnections between health and environment. Moreover, it supports the case that health must be at the heart of sustainable development. Health is not only a critical outcome of sustainable development; it is a vital precondition to achieving progress across the three pillars of sustainable development - social, economic and environmental. The prevention and treatment of diseases like diabetes represent an opportunity to alleviate human suffering and social inequity, support economic development and lessen the environmental burden of health systems.

2012

At IDF, we believe in protecting and promoting health through effective mutually beneficial policies, working through strategic alliances and partnerships. Our report on diabetes and climate change is further evidence for the end of the era of fragmentation between health and environment, which has prevented us from tackling the root causes driving diabetes and climate change. Our world is interconnected and only joint action will prevent human suffering and environmental disaster. Business as usual is no longer an option.

Katie Dain and Lucy Hadley Katie Dain is the Global Advocacy Manager of IDF. Lucy Hadley is a Junior Professional Officer in Policy and Advocacy at IDF.

July 2012 • Volume 57 • Issue 2

health delivery

Creating a network to tackle diabetes and NCDs in Latin America Noël Barengo and Ruby Trejo

Diabetes has become a critical health issue in Latin America. From Mexico, in the north, to Argentina in the south, sweeping ruralurban migration and the worldwide nutrition transition to high-fat, low-nutrient processed foods – especially among poor people – are driving a potentially devastating explosion in the numbers of people affected by noncommunicable disease (NCD). The diabetes population, estimated at around 16 million people, is set to double within a decade if effective steps are not taken in protect atrisk communities. The authors describe the objectives, activities and achievements to date of a growing network throughout Latin America that aims to translate robust findings on chronic disease prevention into real-world initiatives to reduce risk factors for diabetes and NCDs in the community.

July 2012 • Volume 57 • Issue 2

Registered in Mar de Plata in Argentina, the Fundación para la Prevención y Control de las Enfermedades Crónicas no-trasmisibles en América Latina (FunPRECAL) operates in North, Central and South America. Founded in 2010, FunPRECAL’s mission is to contribute to the planning, implementation and evaluation of population-based initiatives to prevent and control diabetes and non-communicable diseases (NCDs) in Latin America.

The basic premise underpinning FunPRECAL is derived from the experiences of the North Karelia Project in northern Finland. That 1972 community-based intervention provided convincing evidence that it is possible to improve lifestyle habits and reduce risk factors for NCDs via the creation of a broad community network, the reorganization of the local community, and the implementation of educational campaigns providing the tools needed to improve lifestyles.

The FunPRECAL network In the short time since its inception, FunPRECAL has built a collaborative network of universities, health ministers and private companies in order to facilitate health promotion and the implementation of initiatives to prevent and control diabetes, cardiovascular diseases. At the moment, FunPRECAL is partnered with entities in 10 Latin American countries: Argentina, Brazil, Colombia, Cuba, Ecuador, Guatemala, Mexico, Paraguay, Peru and Uruguay. The aim of the Foundation is to bring together individuals and organizations in most of the

DiabetesVoice 27

Health Delivery

Latin American countries, establishing by the end of 2012 a strong network for the prevention and control of diabetes and NCDs throughout the region.

Key figures in health promotion, such as Pekka Puska, Jaakko Tuomilehto, Ricardo Uauy and Michael Pratt have offered their support and collaboration to FunPRECAL’s activities.

The Foundation was one of the NGOs invited to take part in the CARMEN 2012 Forum in Brasilia, organized by the PanAmerican Health Organization (PAHO), to discuss how to implement the prevention and control of NCDs in the region.

FunPRECAL encourages healthcare professionals who are engaged in effective projects in their country to share their findings.

How we work FunPRECAL applies a range of preventive strategies.

Sharing data and ideas FunPRECAL encourages collaborating healthcare professionals who are engaged in effective projects in their country to share their findings with the rest of the network – using the most popular channels of communication, such as Facebook and Twitter. The Foundation also promotes exchange stays between healthcare professionals working in different countries.

Applying results to study the population FunPRECAL encourages the application in the region of findings from high-level scientific studies of the general population outside Latin America. An example is the implementation in Argentina, Colombia, Cuba and Paraguay of the Finnish Diabetes Prevention Study. To this end, the first step is to use the Finnish diabetes risk questionnaire, FINnish Diabetes Risk SCore or FINDRISC. This is currently underway in Paraguay, Colombia, Cuba and Argentina. The questionnaire involves eight questions about body weight, family history of diabetes, physical activity and other risk factors for type 2 diabetes.

The second step is to apply FINDRISC at the primary care level. An excellent example is the DEMOJUAN project, organized by the local FunPRECAL partner, the Health Research Centre (CIIS Ltd) in Barranquilla, Colombia. That project, which receives the majority of its funding from the International Diabetes Federation (IDF) via a grant from BRIDGES – an IDF initiative to promote translational

28

DiabetesVoice

research, which is supported by an educational grant from Lilly Diabetes (see page 30 for more about BRIDGES) uses FINDRISC to identify people in the community who are at high risk for diabetes.

The key objective is weight control and the use of regular physical activity to prevent diabetes.

If someone scores higher than 13 points, he or she is referred for an oral glucose tolerance test; people are found to have impaired glucose tolerance or impaired fasting glucose are provided with health education and the tools they need to switch to healthier eating and increase their physical activity. The key objective is weight control and the use of regular physical activity to prevent diabetes. A similar strategy is planned for implementation in 2012 in Mar de Plata, Argentina.

Another project, ‘Peru Migrant’, is determining the prevalence of type 2 diabetes using fasting glucose and HbA1C testing.

This is very significant in the region as the impact of using HbA1C as a diagnostic criterion for diabetes in Latin America has not yet been studied.

Promoting community-based projects In Mar de Plata, Argentina, 40 health workers were selected to receive training through a project called Guardacorazon – a prevention programme run by the Argentinean Programme to Prevent Atherosclerosis (see www.propia.org.ar for more information). The project, which was funded by PAHO, selected some 30 people from the community. They received training via a specially developed teaching manual covering the most important issues around the prevention of NCDs. These include blood pressure, cholesterol, diabetes, healthy nutrition, physical activity and mental health. Twenty health workers completed the training and have been integrated into local health centres in order to provide community health education about diabetes and NCD prevention. Future plans include using the experience from Guardacorazon to replicate the approach in other parts of Latin America.

Developing national demonstration sites In Paraguay, FunPRECAL is collaborating with the University of Oriente to create a demonstration site for diabetes and cardiovascular disease prevention in the city of Minga Guazú.

The cross-sectional population study, DemoMinga, reached the local population through lifestyle questionnaires, which

July 2012 • Volume 57 • Issue 2

Photo: Tim Nolan

health delivery

Findrisc being applied in Barranquilla, Colombia

were completed in 2011, and included blood tests and laboratory tests (lipids, fasting blood glucose).

This year, FunPRECAL plans to stage courses in Paraguay, Argentina and Colombia.

Training for healthcare professionals One of FunPRECAL’s newest projects is Exercise is Medicine, with the US American College of Sports Medicine, the Centers for Disease Control (USA) and University of the Andes (Regional Coordination Centre, Bogotá, Colombia) as key partners. The project aims to train physicians in prescribing physical activity, providing them with education on the scientific evidence about the benefits of physical activity, and give advice to the public on engaging in physical activity. This includes awareness of the benefits of physical activity, both in people at high risk of diabetes and those with established diabetes.

Looking ahead So the wave of health protection and disease prevention that swept through Finland nearly 40 years ago has finally reached Latin America. Here, we are confident that if all parties engaged in the prevention of type 2 diabetes and NCDs collaborate effectively, contributing knowledge and experience to the network, we will have a major impact in improving lifestyles, reducing risk factors for diabetes throughout the population of the entire continent. ¡Viva América Latina!

As general practitioners are often the first point of contact for people at high risk of diabetes, it is important that they are well trained in how to motivate such people to increase levels of physical activity in order to reduce their risk of diabetes.

FunPRECAL’s Exercise is Medicine courses are organized in collaboration with our partner institution in Argentina and Uruguay, the Physical Activity Network of Uruguay (RAFU).

July 2012 • Volume 57 • Issue 2

Noël Barengo and Ruby Trejo Noël Barengo is the President of FunPRECAL (noel.barengo@funprecal.org).

Ruby Trejo, field epidemiology training programme, FunPRECAL. For more about FunPRECAL and their activities, visit www. funprecal.org or them Facebook (www.facebook.com/pages/ FunPRECAL/155116047880355) or Twitter (@FunPRECAL).

DiabetesVoice 29

Clinical care

IDF breaking new ground – building BRIDGES around the world Ronan L’Heveder

With its latest round of funding complete, the International Diabetes Federation’s translational research programme, BRIDGES, has raised its game again, receiving 57 applications from 32 countries. This round of financial support ensured USD 65,000 per project and was dedicated to short-term projects lasting a maximum two years. Having undergone rigorous screening by recognized experts, nine of the projects were selected and will benefit from financial backing from IDF. Ronan L’Heveder describes the latest innovative projects to quality for BRIDGES funding.

30

DiabetesVoice

July 2012 • Volume 57 • Issue 2

clinical care

“The quality and geographical spread of the applications received is unprecedented,” said Professor Linda Siminerio, Chair of the BRIDGES Executive Committee. “Through this fourth round, we will address the needs of communities in new countries such as Thailand, Fiji and the Netherlands.

Now, more countries will be able to reap the benefits of translational research.”

These new BRIDGES projects, like those already underway, will test innovative ideas for the prevention of type 2 diabetes (primary prevention) and the chronic, potentially disabling complications of diabetes (secondary prevention). This time around, these ideas include the use of community theatre in diabetes education in Fiji; a lifestyle intervention for overweight children in Tunisia; and the development of a peer leader system in six countries in the Caribbean.

Using community theatre to promote diabetes education and prevention in Fiji University of the South Pacific, Fiji Previous investigations undertaken by these researchers in the South Pacific has shown that people being treated for diabetes pay little heed to brochures, pamphlets, or posters most commonly used by Health Ministries to provide public health information. This project proposes to transmit the message of healthy lifestyles through community theatre, using professional actors to dramatize some practical approaches to dealing with illness and the best methods to prevent developing diabetes. The acting professionals will audition local community members to establish a network of community theatre ‘cells’ in Fiji to ensure the sustainability of the concept and its ability to address the increasingly severe problem of diabetes in the South Pacific region.

July 2012 • Volume 57 • Issue 2

Pathway to Health – a lifestyle intervention to prevent diabetes in China Shanxi Evergreen Service, Uci District, People’s Republic of China In response to the recent surge in the number of people in China with type 2 diabetes, this project proposes to test the feasibility of a nine-month lifestyle intervention, Pathway to Health (PATH), to reduce risks for diabetes in Chinese women. Based on the successful US Diabetes Prevention Program, the China Da Qing Diabetes Prevention Study and the accumulative work of the research team, PATH is built on the infrastructure of the recently restructured Chinese healthcare system. It is hoped that this project, if successful, will be replicated and maintained throughout China.

Integrated care through a community hospital model in Beijing Beijing Tongren Hospital, Beijing, People’s Republic of China Diabetes has become a major public health problem in China; chronic complications are the major causes of disabilities and death for people with the condition. It is well known that good control of blood glucose, blood pressure, lipids and aspirin use reduce the risk of complications. This project, whose methods are based on the previous Beijing Community Diabetes Study, describes a community hospital integrated management system for people with diabetes in Beijing, China, which aims to optimize control of blood glucose, blood pressure and lipids.

Bridging the knowledge gap in a rural Pakistan United Arab Emirates University, Gilgit Baltistan Province, Islamic Republic of Pakistan The primary prevention of chronic diseases such as diabetes, coronary heart disease and stroke is a public health

DiabetesVoice 31

clinical care

priority throughout Pakistan. Noncommunicable diseases in rural populations place a particularly heavy burden on healthcare system. This project will pull together the existing expertise of team members with diverse backgrounds. Most of them already have established networks that cross disciplinary boundaries. The objective is to assess the effectiveness of home-based lifestyle intervention on blood glucose and other cardiovascular risk factors in adults aged between 18 and 64 living in a rural area.

drain on health resources is compounded by the high numbers of healthcare pro-

a school-based intervention to manage overweight and obesity among school-age adolescents in the region of Sousse. This oneyear behavioural intervention will include components focusing on nutrition, physical activity and psychological issues.

There are 38 projects underway in 35 countries thanks to IDF’s support through BRIDGES.

A pioneering model to reduce cardiovascular risk in the Netherlands The EMGO Institute for Health and Care Research, Netherlands Medical and lifestyle interventions can reduce diabetes complications. A key component for targeting these interventions is to assess using prediction models a person’s risk of developing a complication within a defined time period. But current models are flawed, targeting the wrong people for prevention of complications and resulting in both under treatment and overtreatment. This project aims to develop an improved and practically applicable prediction model for cardiovascular complications in people with type 2 diabetes. Using this model, it is hoped, treatment plans will be improved, leading to a reduction in complications and treatment costs.

Innovative diabetes education for adults with type 2 diabetes in the English-speaking Caribbean Diabetes Association of Jamaica, Jamaica, Grenada, Antigua, Belize, St Lucia, Barbados Diabetes is the third leading cause of death in the Caribbean. The consequent

32

DiabetesVoice

fessionals, particularly nurses, migrating away from the region. So diabetes education plays an integral role in diabetes management – and a lack of education might contribute to poor management and increased complications. This study aims to evaluate existing diabetes education curricula to determine whether these are easily used by non-healthcare professional educators in each of the participating Caribbean countries.

Community-based diabetes prevention in Thailand School of Nursing, Walailak University, Thailand This community-based project will test a pre-designed knowledge management programme to prevent or delay of type 2 diabetes in people at high risk. This will be a sizeable project involving 32 primary care units and 2,240 people at high risk of diabetes. The participants will be assigned randomly either to the intervention programme or in the usual care group.

Protecting children in Tunisia from overweight and obesity University Hospital Farhat Hached Sousse, Tunisia The prevalence of diabetes is increasing dramatically throughout Tunisia in association with obesity – a key risk factor for type 2 diabetes. Worryingly, obesity among children constitutes a major public health challenge in Tunisia and worldwide. This project proposes the implementation and evaluation of

Smile Healthy with Your Diabetes – health coaching for people with diabetes in Denmark University of Copenhagen, Denmark In Denmark, diabetes type 2 and oral diseases constitute major public health concerns with an increasing burden among adults. Poor oral health contributes negatively to blood glucose control; and poor diabetes management negatively affects oral health. This project aims to design and evaluate a new behavioural intervention based on oralhealth coaching among adults.

Bringing research in diabetes to global environments BRIDGES (Bringing Research in Diabetes to Global Environments and Systems) is an International Diabetes Federation programme, supported by an educational grant from Lilly Diabetes. There are 38 projects underway in 35 countries thanks to IDF’s support through BRIDGES. You can find a description of each of them on the BRIDGES website (www.idf.org/ BRIDGES/4th-round).

Ronan L’Heveder Ronan L’Heveder is in overall charge of BRIDGES. Contact Ronan at bridges@idf.org for more information on any aspect of BRIDGES.

July 2012 • Volume 57 • Issue 2

Clinical CARE

Exploring ethnicity in people with type 2 diabetes in Australia Margaret McGill and Stephen Twigg

In 2011, the Royal Prince Alfred Hospital Diabetes Centre in Sydney, Australia, joined the voluntary network of International Diabetes Federation (IDF) Centres of Education. There are currently eight such centres providing excellent diabetes care and education services in Latin America, Asia (including the Indian sub-continent and China), Europe and now Australia. Central to the aims of the Centres of Education are efforts to increase regional capacity to respond to the diabetes epidemic. Here, Margaret McGill and Stephen Twigg report from the Royal Prince Alfred on work to understand the nature and impact of demographics, specifically in terms of ethnicity, on blood glucose control, complications and diabetes outcomes in general. The lessons learned in this field in Sydney will be translated into effective initiatives to improve equity in access to care and education elsewhere in Australia and abroad.

July 2012 • Volume 57 • Issue 2

The multicultural nature of the diabetes service at the Royal Prince Alfred Hospital Diabetes Centre in Sydney often comes as a surprise to many people. Our catchment population comprises people of Anglo-Celtic, Mediterranean, European, Arabic, Chinese, Indian, South-East Asian, Aboriginal, and Torres Strait Islander origins. In fact, almost 60% of the people we see are from a non-English-speaking background. This diversity brings its own complexities to diabetes management and education, and our staff need to be familiar with and sensitive to the many cultural differences among our diabetes population.

Many of our first-generation of migrants have not received formal education in their first language.

Fortunately, the New South Wales Ministry of Health provides interpreters who are fully trained in a multitude of languages and dialects. It is the policy of our Diabetes Centre that all people who have difficulty speaking or understanding English must have an interpreter present at each consultation. Moreover, many of our first-generation of migrants have not received formal education in their first language, so in many cases providing written material as an adjunct to education is not useful.

DiabetesVoice 33

Clinical CARE

In our experience, education is successful when it is provided through interactive ethnicity-specific groups. These are conducted by our dietitian and nurses. As part of the education programme, each participant brings a traditional dish to be analyzed for carbohydrate, fat and protein content and portion size, and – respecting these caveats, of course – enjoyed. The support the participants receive from each other is demonstrated in the difficulty we have in getting them all to leave when the group session has finished!

Promoting excellence in education and care An IDF Centre of Education is an institution selected to form part of an international voluntary network to initiate, facilitate, conduct, coordinate and evaluate high-quality education for health professionals in diabetes and other related chronic diseases.

The goals of the Centres of Education are to increase accessibility to high quality interdisciplinary diabetes education for health professionals; increase regional capacity to respond to the diabetes epidemic; and build a network that supports centres to advance their education programming and influence system change.

Eight institutions have been designated as International Diabetes Federation Centres of Education: Assoçiacão Protectora dos Diabéticos de Portugal, Lisbon, Portugal Dr Mohan’s Diabetes Specialties Centre and Madras Diabetes Research Foundation, Chennai, India Asociación Colombiana de Diabetes, Bogotá, Colombia Vivir con Diabetes Education and Information Centre, Cochabamba, Bolivia Associação Nacional de Assistência ao Diabético, Sao Paulo, Brazil Baqai Institute of Diabetology and Endocrinology, Karachi, Pakistan Diabetes Centre of the Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia Chinese University of Hong Kong – the Prince of Wales Hospital Diabetes and Endocrine Centre, Hong Kong, People’s Republic of China.

Visit www.idf.org/idf-centres-education for more about the Centres of Education and how to apply to join the network.

34

DiabetesVoice

This melting pot of nationalities places us in a unique position to examine differences in blood glucose control and complications across the various ethnic groups. In an audit of our clinic population of 9822 people with type 2 diabetes, the most commonly seen ethnic group after Anglo-Celts (38% of the total) is from the Mediterranean region (23%) – reflecting post-World War II migration. In addition to, and maybe because of, the challenges around self-management education, there is a great diversity in terms of phenotype, surrogate markers of risk and complication status among the different ethnic groups. For example, in our audit, the diagnosis of diabetes in all non-Caucasian groups occurs at a significantly younger age than in Caucasian groups.

Moreover, these non caucasian groups, including Indigenous Australians have comparatively poorer blood glucose control. This translates into higher rates of microvascular and in some cases macrovascular complications, such as an overall higher prevalence of retinopathy and ischaemic heart disease compared with the Anglo-Celtic population.

What role is played by migration in access to healthcare delivery?

Why do these differences in outcomes occur? Is it due to environmental or genetic factors or a mixture of both? And what role is played by migration and culture in accessing healthcare delivery?

The answers to such questions are likely to be complex. And there is an additional question: should we have ethnicity-specific clinical targets? This issue is recognized for BMI amongst Asian populations, where a reading of 23-25 kg/m2 puts an Asian person in the overweight range, whereas a Caucasian with the same reading remains in the normal range.

Yet the major reversible risk factors for the micro- and macrovascular complications of diabetes, as per IDF’s clinical care guidelines, have the same general targets across all ethnic groups. How, then, can we improve HbA1c, blood pressure and albuminuria in those people who have higher levels, such as Australian Aboriginal and Torres Strait Islander populations, despite receiving similar care to people of Anglo-Celtic origin, based on the percentage of prescribed insulin and treatment to regulate blood pressure?

An initiative by the Australian Federal Government, ‘Closing the Gap’, aims to reduce the difference in health outcomes between indigenous and non-indigenous Australians by taking the following steps:

July 2012 • Volume 57 • Issue 2

Clinical CARE

Our immediate challenge is to achieve high-quality clinical outcomes in all people, irrespective of their ethnicity.

promoting and supporting good health initiatives through the involvement of local communities and delivering healthy lifestyle programmes

Non-Caucasians have poorer glycaemic control and higher rates of microvascular complications, such as retinopathy. s upporting accredited Indigenous health services and general practices by providing new funding for the delivery of better healthcare for Indigenous Australians removing barriers in order to improve access to essential follow-up services, such as allied health, specialist care and the medicines available via the pharmaceutical benefits scheme building the capacity of the primary health care system to care for people by increasing the range and skills of the Indigenous health workforce.

July 2012 • Volume 57 • Issue 2

Our experiences providing diabetes care to such a variety of ethnicities place us in a unique position to reach out to our regional and global partners. Our highly skilled multidisciplinary team has developed an understanding of the cultural differences and sensitivities inherent in modern diabetes care.

Our immediate challenge is to achieve high-quality clinical outcomes in all people, irrespective of their ethnicity.

Margaret McGill and Stephen Twigg Margaret McGill AM is Adjunct Associate Professor in the Sydney Medical School, University of Sydney and Manager of the Royal Prince Alfred Diabetes Centre, Sydney Australia.

Stephen Twigg is Professor in Medicine at the Sydney Medical School, senior endocrinologist and Deputy Head, Department of Endocrinology at Royal Prince Alfred Hospital and the University of Sydney, Australia.

DiabetesVoice 35

Haiti fights for a brighter future Philippe Larco and Nancy Charles Larco

The devastating earthquake that struck Haiti on 12 January 2010 killed over 200,000 people and left more than 1.5 million homeless. Two years later, more than half a million people still live in tents in relief camps and 50% of the rubble is yet to be removed. The earthquake exposed infrastructural weaknesses and institutional shortcomings. Haiti is struggling with reconstruction efforts that, according to the authors of this report, have been hampered by political paralysis and the lack of coordination in international aid. Yet from among the debris of Haiti’s decimated healthcare system is arising a renewed force capable of protecting the current and future health and wellbeing of people with diabetes.

Diabetes in society

In the immediate aftermath of the 2010 earthquake, healthcare services quickly became saturated by the urgent needs of people rescued from the rubble with multiple trauma. With this extraordinary and overwhelming demand on healthcare, medical attention was diverted away from people with diabetes and hypertension; their cases were not considered urgent. Drug supplies were complicated due to the collapse of several pharmacies in the affected areas.

In the days after the earthquake, the Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC), a private Haitian foundation, was the only organization to provide services to people with diabetes and other chronic diseases. FHADIMAC had been contacted by the Ministry of Public Health and Population (MSPP), which made the Foundation the reference centre for the management of people with diabetes and hypertension. In April 2010, the Ministry and FHADIMAC signed a Memorandum of Understanding for the development and implementation

of a national plan to combat diabetes and cardiovascular disease.

Without the intervention of FHADIMAC, diabetes surely would have killed many of the people who had survived the initial impact of the disaster. More than 1500 people affected by chronic disease were seen in the FHADIMAC facilities, and received free care – medical consultations, blood glucose monitoring, medication, educational sessions – for the first six months following the earthquake. Many of these people arrived with high blood glucose, inappropriately treated and with a lack of any diabetes knowledge.

Without the intervention of FHADIMAC, diabetes would have killed many of the survivors.

Improving care Seeing the poorly supported people who had been transferred from other health institutions confirmed the ex-

istence of a huge need for training of medical staff. In an attempt to meet this need, FHADIMAC decided to develop a national protocol for the treatment of diabetes and launched an extensive training programme for health personnel. This began in February 2011 with sessions for doctors, nurses, pharmacists, laboratory technicians and social workers, and has continued since with numerous seminars over the years.

When returning to their respective institutions, these healthcare providers reported feeling more comfortable with the assessment and management of people with diabetes.

Many people were unable to attend appointments due to difficulties making the journey to their clinic. In response, and in addition to its daily clinical premises in downtown Portau-Prince, FHADIMAC (with the help AmeriCares) opened four outreach clinics throughout the capital. After nine months, that essential work was taken up and extended through another project supported by AmeriCares and the World Diabetes Foundation, which established 12 healthcare centres in the west of the city – the area most affected by the earthquake.

FHADIMAC operates outreach clinics in neighbourhoods throughout the capital, including those most affected by the earthquake.

Screening and awareness FHADIMAC also conducted a screening campaign in relief camps, churches, workplaces, markets and at public events in order to identify people with diabetes and provide treatment as early as

38

DiabetesVoice

July 2012 • Volume 57 • Issue 2

Diabetes in society

possible. Some 10,000 people underwent screening in metropolitan Port-au-Prince and several other regions, including Cape Haitien, Les Cayes, Jacmel, Gonaives and Hinche. People identified with diabetes were referred to the closest health centre with trained personnel.

NGOs and health institutions regularly contact FHADIMAC for training or for support to manage people with diabetes.

The screening campaign was complemented by intensive diabetes awareness campaigns. Videos, pamphlets and posters about the symptoms of diabetes and hypertension have been released with the support of the International Diabetes Federation (IDF) and the French Society of Diabetes.

FHADIMAC managed to organize its first camp for children and adolescents with diabetes (and some mothers). It was an amazing experience for the 24 children who took part in this camp.

"These days at the camp were undoubtedly the happiest days of my life," declared one of the camp participants.

as the number of referrals increased daily. NGOs and health institutions regularly contact FHADIMAC for training or for support to manage people with diabetes. FHADIMAC now plans to expand its activities and develop several sections to take care of screening and treatment for diabetes complications.

Special support for young people FHADIMAC provided psychological support for young people with diabetes, who received special attention and participated in special sessions with psychologists.

In those sessions, children and parents shared their experiences managing diabetes in exceptional circumstances.

In June 2010, FHADIMAC joined IDF’s Life For A Child programme. Currently, more than 50 children in Haiti are supported by this project and the aim is to reach 150 per year.

The earthquake of January 2010 was an opportunity for FHADIMAC to intensify its struggle to defend the rights of people with diabetes and develop a comprehensive programme of diabetes awareness and support. The ongoing lack of human and financial resources continues to limit the actions of FHADIMAC. However, thanks to the dedicated approach of its employees and supporters, the Foundation is trying to carry out a range of activities to ensure a better life for people affected by diabetes and cardiovascular diseases.

In February 2012, FHADIMAC organized its first camp for children and adolescents with diabetes – and some parents.

For several years prior to the earthquake, FHADIMAC had dreamed about organizing a camp for children with diabetes. These camps can provide young people with diabetes with an opportunity to learn and share their knowledge and experiences with their peers. In February 2012, after several months of preparation and with the support of Francine Kaufman (Past President of the American Diabetes Association), Neal Kaufman, Evelyne Fleury-Milfort (University of Southern California) and Merith Basey (from the NGO AYUDA),

July 2012 • Volume 57 • Issue 2

Advocating policy change For several years, FHADIMAC has been striving to push chronic non-communicable diseases (NCDs) like diabetes and hypertension up the agenda of the Ministry of Health of Haiti. After several meetings with authorities, FHADIMAC was invited to form part of the government delegation that attended the UN high-Level Meeting on NCDs in September 2011.

After that historic UN summit, FHADIMAC continued its advocacy work and established with the Ministry of Health the National Committee Against NCDs. Other Haitian institutions working in the field of NCDs, particularly cancer, are part of this committee.

Fighting adversity for a brighter future To meet the needs of the community and the demand for services in diabetes, FHADIMAC has had to double its staff.

Our premises quickly became too small

Philippe Larco and Nancy Charles Larco Philippe Larco is the Vice-President of the Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC).

Nancy Charles Larco is internist and diabetologist, is the Project Coordinator at the Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC).

DiabetesVoice 39

Diabetes in society

Civil society facing down the diabetes emergency in Mali Stéphane Besançon and Sidibe Assa Traore

Santé Diabète emerged in response to a double emergency: the lack of access to care for people with diabetes in Africa and the lack of recognition on the part of the development actors that this is even a problem. Santé Diabète’s overarching objective is to improve the prevention and management of diabetes in Africa. Founded in 2001, it was the first international development-focused NGO to concentrate on the fight against diabetes.

40

DiabetesVoice

July 2012 • Volume 57 • Issue 2

Diabetes in society

Since its inception, Santé Diabète has consistently taken on a holistic approach, covering all the bases required to establish quality diabetes prevention and management. The approach was developed in the field, in close collaboration with the Mali Ministry of Health, the Department of EndocrinologyDiabetology of the National Hospital and other institutional partners. This positioning in technical assistance to support the policies of national fight against diabetes has yielded very significant advances for many people with diabetes in Mali. The decentralization of care has helped establish 22 diabetes clinics, supporting more than 10,000 people with diabetes. All these centers have equipment for analysis and educational materials. Access to medications has been greatly improved through extensive work with the Ministry of Health. Insulin is available at the clinics at a 50% reduction (down from EUR 10 to EUR 5 per vial) on the previous price – and oral blood glucose-lowering medications with a discount 10%.

In regions where no drugs are available, people with diabetes remain trapped in a medical desert.

A major threat to diabetes care A crisis situation was provoked in Mali in March 2012 after on a military coup in the capital, Bamako, and an attack of the Tuareg rebels in the north of the country. This has been very dangerous for the hundreds of thousands people with diabetes and the more than 100 children registered with type 1 diabetes.

An increasingly critical situation in the north Most physicians have left the northern region of Timbuktu, Kidal, Gao and

July 2012 • Volume 57 • Issue 2

Douentza; recently, only one private pharmacy in Timbuktu had diabetes medications – although these were on sale at very high prices, keeping them beyond the reach of many people. In Gao, Kidal and Douentza, where at the time of writing no medicines at all were available, people with diabetes continue to find themselves trapped in a barren medical desert. The critical circumstances that have arisen as a result pose a grave threat. For example, two children with type 1 diabetes in the region (one in Timbuktu and the other in Douentza were found recently to have run out of insulin entirely and risked imminent death if a supply was not organized very quickly.

Care needs have skyrocketed as large numbers of displaced people arrive daily with no resources whatsoever.

Complications in the south – but care continues In southern Mali, care has remained accessible, despite strong concerns about large displaced populations and the increasing frequency of diabetes complications. Diabetes consultations are still running in all state structures in the region but resources are severely stretched.

At Mopti regional hospital and the Hospital of Mali in Bamako, care needs have skyrocketed with the daily arrival of large numbers of displaced people coming from the north with no resources whatsoever. With the physical and social hardships of being displaced and the tremendous stress provoked by the crisis, there has been a marked increase in the frequency of diabetesrelated coma and diabetic foot problems. The period of economic embargo

DiabetesVoice 41

Diabetes in society

has also profoundly affected the capacity of state structures, hospitals and central pharmacies to source monitoring equipment and drugs.

A quick response to address the humanitarian emergency Santé Diabète, in close partnership with the Ministry of Health, the Department of Endocrinology-Diabetology, the Hospital of Mali and the National Federation of Malian People Diabetes (FENADIM), has launched an emergency response on two levels.

Diabète Santé has partnered with NGOs like Médecins Sans Frontières and Médecins du Monde to improve and expand care.

Humanitarian intervention in the north Emergency donations of insulin, syringes and oral blood glucose-lowering medications have been transported in the regions of Kidal, Timbuktu, Gao and Douentza in order to cover the needs of hundreds of people with type 2 diabetes.

Specific supplies also have been sent to the two children mentioned above living in Timbuktu and Douentza. These donations will allow all those people with diabetes to maintain a reserve for several months of treatment.

Meanwhile, emergency kits have been prepared for the management of people in coma. Collaborations have arisen with the Médecins Sans Frontières team in Timbuktu, who took care of two people who were in a critical condition. Other partnerships have been forged with Médecins du Monde and other NGOs to provide further coma and foot kits on a larger scale to other northern regions.

42

DiabetesVoice

Santé Diabète provides support in difficult conditions.

Structural intervention in the south Donations have helped secure domestic supply of insulin at the central pharmacy of Mali. In parallel, kits for the management of emergencies, including coma and foot complications, have been distributed in the national and regional hospitals closest to the refugee camps and displaced populations.

Humanitarian corridors of hope As soon as humanitarian corridors through the devastated regions are open and secure, doctors from Santé Diabète, in collaboration with the Endocrinology and Diabetology service of the Hospital of Mali, will hold weeks of free consultations in Douentza, Timbuktu and Gao. These missions will be complemented by training sessions for onsite doctors working with emergency NGOs on monitoring people with diabetes.

Donate and protect In this major humanitarian crisis, the emergency response coordinated by Santé Diabète and its partners continues

to offer support to hundreds of people with diabetes who had lost all access to healthcare. The intervention has saved countless lives. It would not have been possible without financial support or donations from private individual donors, the Sanofi Foundation, Insulin Zum Leben, Novo Nordisk and Sanofi Aventis.

Stéphane Besançon and Sidibe Assa Traore Stéphane Besançon is the CEO of the NGO Santé Diabète (www.santediabete.org).

Sidibe Assa Traore is the head of service of endocrinology and diabetology of the Mali Hospital, Bamako, Mali.

July 2012 • Volume 57 • Issue 2

The right education

for all

Diabetes: protect our future w w w. w o r l d d i a b e t e s d a y. o rg

early Register from to benefit fees reduced rential and prefe tes. hotel ra

Don’t miss the chance to help shape the future of diabetes. www.worlddiabetescongress.org