WHAT P.N.G SHOULD BE DOING IF WE ARE TO AVOID BEING OVERWHELMED BY THE DEVASTATING COMPLICATIONS OF DIABETES
I recently enrolled in an online diploma program in diabetes which has been a real eye opener for me.
What I am learning is allowing me to reassess my own practice and apply what I am learning to better care for my patients as a GP.
The knowledge about diabetes: pathogenesis, natural history and response to various modes of and approaches to treatment has come a long way over recent years thanks to several major landmark studies that have define how we think about and how we clinically manage diabetes. As we find out more and more about this condition our approach to treatment of individuals and our public health approach is also changing.
I’d like to highlight some of these landmark studies and how the results of these studies have influence modern diabetes care as I have come to understand it.
Diabetes research goes back a long way however let us start this story with one of the important modern studies into diabetes, the United Kingdom Prospective Study (UKPDS).
This study was one of the biggest prospective, multicentre studies spanning from the year 1977 to 1997 and was designed and conducted two gentlemen the late Professors Robert Turner and the late Professor Rury Holman, The Diabetes Trial Unit (2016)
In essence the study involved the follow up of about 4000 newly diagnosed diabetics who were randomly allocated into two treatment pathway arms. The the clinical outcomes of the people allocated to the two different arms were then analysed and compared.
Management Pathway 1 – The patients’ glucose control was intensively managed to achieve glucose levels as near to normal as possible using appropriately indicated pharmacological treatment. The target for this “intensively managed” arm of the treatment pathway was a HbA1c level equal to or below 7%.
Management Pathway 2 –This less intensely managed arm of the two pathways involved; initially diet and exercise regimes alone and as and when the individual’s general blood glucose control worsen (as decided when fasting plasma glucose levels reached 15mmol/L and above) pharmacological agents were added.
The main conclusions from this landmark study according to the Diabetes Trials Unit (DTU), which is a part of the Univeristy of Oxford’s Radcliff Department of Medicine was:
Reducing glucose exposure (HbA1c 7.0 % (intensive arm) versus 7.9 % (less intensive arm) over median 10.0 years), with sulphonylurea or insulin therapy,reduced the risk of “any diabetes-related endpoint” by 12% and microvascular disease by 25%, with a 16% trend to a reduced risk of myocardial infarction (P=0.052). DTU (2016??)
For insulin and sulphonyluria treatment for type 2 diabetics the UKPDS as cited by DTU (2016) showed that “though neither of these therapies impaired quality of life, both increased risk of hypoglycaemia and weight gain”. These two aspects of these treatment must be well communicated to patients so that they understand from the outset of treatment.
The intensive treatment arm included appropriate blood pressure treatment to also control it to as near normal as possible using again appropriately indicated lifestyle and pharmacological interventions.
Some of the main conclusions that the UKPDS researchers arrived at as summarised below by the Diabetes Teaching Center at the University of California, San Francisco (2016):
Intensive blood glucose control & management of hypertension resulted in fewer diabetes related complications, and approximately
20% decrease in death related to diabetes
40% decrease in eye, kidney, and nerve diabetes complications
40% decrease in blockage of the blood vessels to the lower limbs
15% decrease in heart attack
Despite all this high level evidence of the benefits of intensive treatment of diabetes, it was recognised that the optimal targets in regards to glycaemic control, blood cholesterol levels, and blood pressure that translated to these benefits were not being met by the vast majority of diabetics.
According to Saaddine et al (2006), analysing data from National Health and Nutrition Examination Surveys (1988-1994 and 1999-2002) in the USA:
· 2 in 5 persons with diabetes still had poor LDL cholesterol control
· 1 in 3 persons still had poor blood pressure control
· 1 in 5 persons still had poor glycemic control with HbA1c levels of 9% or above
· Only 42% of adults had HbA1c values < 7%
These findings triggered a lot of question about the way diabetes care was being delivered and a new surge of research arose to answer the question – why was it that even in the USA, a country with one of the most developed healthcare systems in the world these life prolonging target were not being reached. The DAWN study which was the topic of my last blog post was another landmark study that came about because of these questions
The Papua New Guinea Perspective
If these are the finding in the USA then the figures in Papua New Guinea (PNG) if we had any credible statistics into the issue would be even more staggering. It is very hard to say what the actual situation is like in however it would be a very safe bet that it is grim
The vast majority of people do not even know what diabetes is, let alone the treatment needed and the targets need to be reached to see a prolongation of their lives. The majority of diabetics in PNG find out for the first time that they are diabetic when they fall ill with one of the complications of diabetes – they may have an early heart attack, visual impairment or blindness, chronic kidney disease or failure, a serious gangrenous lower limb which needs to be amputated or some other serious infection.
Even if a person is diagnosed with diabetes the services available to them is of such low quality and so under resourced that any hope of reaching these life prolonging targets would be quite low.
As an example, the biggest hospital in the country the Port Moresby General Hospital despite being very busy, does not have the appropriate number of qualified staff and does not have a reliable and continuous laboratory support. Even tests that should be considered basic essential test for a diabetes clinic like HbA1c, Lipids profile and urinary micro-albuminuria are not always available. The bewildering thing is that the Governments own official Diabetes Clinical Practice Guideline recommends that these tests be available in all the district level hospitals. I think this is overly ambitious however it would be fair to expect that all provincial hospitals at least should have the capacity to do HbA1c, Urinary microalbuminuria and lipids. The cost involved in ensuring this is not anywhere close to what the PNG government has seen fit to spend on other infrastructure however the benefits of having these tests available on an ongoing basis would be tremendous.
This grim picture in PNG is likely to get grimmer unless the PNG Government takes the issue seriously and make appropriate investments into improving and sustaining the provision of diabetes care in the country.
There needs to be specific investments into developing the pool of expertise within the country including, diabetes educators, podiatrists, diabetes nurses, doctors with a higher diploma in diabetes. And to support these experts there needs to be investments into appropriate equipment to assist them to do their jobs more effectively.
From a wider societal point of view and especially in the urban centres where dwellers there are becomming to sedentary there needs to be investments into more accessible, family friendly and “wallet friendly” exercise facilities. The built up infrastructure must also be developed to cater for the vast majority of citizens who do not have vehicle. Good standard footpaths have to be made safe so people can walk or bike ride with comfort and safety.