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Roles of a Community Pharmacy in Management
of Type 2 Diabetes Mellitus (T2DM)
Point Of View of Practicing Community Pharmacists
Tan Kean Chong, Ooi Show Yuen
Good Health Pharmacy, Puchong, Selangor
26th August 2012
Introduction
Type 2 Diabetes Mellitus (T2DM) is a major disease that poses huge- challenge to public,
medical profession & government. In 2006 about 15% of the population above 30 years of age
was reportedly diagnosed with T2DM. Prevalence of the above population was estimated to be
20% or more if we were to refer to recent studies. Base on the prevalence mentioned, 1 in every 5
adults above 30 years of age was a diabetic in Malaysia. The latest figures reported in parliament
revealed that there are 2.6 million diabetic patients among all the population in Malaysia. It is an
epidemic with huge impact to government & society as a whole and undeniably its economic
impact sets to be the most challenging for the government. The 2008 Diabcare Study Malaysia
further shows to have more shocking findings, it was documented that 70 - 80% of diabetic
patients was not well controlled based on the American or international standard. Thus,
Community pharmacy (CP) as part of healthcare profession plays crucial roles in cushioning the
impact. Accessibility is the key factor that drives diabetic patients to CP for services such as
medication refills, getting food supplement , testing for blood glucose and getting advice on
diabetic related matters. However, being accessible is not sufficient in providing the services
mentioned . A complete understanding of the roles of CP help to alleviate the impact of T2DM
and at the same time contribute positively to the profession .
Why Does a CP Has Major Roles?
The main reason is accessibility. Most CPs are located near residential area with convenient &
accommodating business hours. Apart from convenient location & accommodating business
hours , the CP retail environment encourages a hassle free interaction with the pharmacist , be it
over the counter or in a counseling room . In contrast, an encounter with a doctor is more formal
& usually not as casual as in CP. In a candor environment, trust &loyalty will flourish between
CP & diabetic patient .All these factors enhance CP role in T2DM management.
The other reason is the vast medical needs of diabetic patients. Diabetic patient has many medical
needs that can be adequately & readily fulfilled by CP. Diabetic medication refills, blood glucose
& pressure measuring, blood glucose meter accessories refills & nutrition product supply are the
needs that drive diabetic patient to CP. Besides, if there is a diabetic complication, the needs will
be even more profound. For example, a diabetic foot wound need dressing product in large
quantity due to the slow healing process. Hence, a patient with this complication will visit CP
more frequently.
Based on these two reasons, CP is in a good position to play major roles in T2DM management.
What Are The Roles Of CP?
1) As motivator
i.
T2DM is a progressive disease that requires long term medication with medical
supervision from a doctor. Quite often the patient will feel taking long term
medication is a burden & non-compliance will set in as the disease progresses.
Uncontrolled blood sugar makes thing even more daunting to stay motivated &
making visits to a clinic becomes an unpleasant one. Eventually, the patient will
become de-motivated & stop visiting clinic altogether. CP will have to keep
reminding the patient that long term medication & medical supervision are needed as
T2DM is a progressive disease. The regular clinic visit is a routine for better control
of blood glucose. Though, there is no cure for it, but leading a normal life &
avoiding/delaying all the complications is very much achievable. Motivation is the
key factor in adhering to medication & leading a healthy lifestyle.
ii.
How to recognize signs of low motivation?
When patient compliance is low e.g. taking longer duration to refill medication than
the duration of supply . Or if a patient expresses frustration such as “…tired of taking
medication.”, “…..hate taking medication .” , “ …better die than taking medication
.”, “…no matter how hard I control my diet & keep on taking medication , my blood
sugar is still high .”, “ every time I see doctors ,it is still the same .” ,“ I just can’t
afford the new medication” .Any signs of the above mentioned warrants action to be
taken to boost motivation.
iii.
How to re-motivate?
CP must regularly remind patients that DM is a progressive disease & taking
medication continuously will ensure delaying or even avoiding diabetic
complications. Quoting example of severe complication such as diabetic wound
might help for certain patient but not all is receptive towards this scare tactic. Pictures
of wound healing because of better blood glucose control & proper dressing will be
more acceptable than the above. This method is mostly employed by multi- level
marketing company which proves to be effective .Currently, all clinical guidelines
recommend treating diabetic patient to achieve blood glucose target and aggressive
target is set for younger patients . By following these guidelines , drastic change in
diabetic medication will be seen and some patient will become skeptical of the
doctor aggressive approach. The role of CP here is to reassure patients that
aggressive treatment is necessary especially for younger patient to avoid
complications appearing at an early age . With the reassurance , patient will be
motivated to continue with diabetic medication prescribed by his/her doctor . Diet &
lifestyle changes are crucial in controlling blood glucose. Any drastic changes in diet
& lifestyle will backfire. Therefore , CP must always encourage patient to make
small changes in diet or lifestyle to achieve targeted blood glucose & pressure. For
example, the patient is advised to reduce consumption of rice by 2-3 tablespoonful in
each meal. On top of that , patient is encourage to walk more by parking their car
further or using stairs instead of the elevator or escalator on a daily basis . Blood
sugar monitoring should be done regularly when making the small changes to show
improvement in blood glucose control. Encouragement should be given whenever
there is an improvement no matter how small it is. Eventually, the patient will be able
to achieve blood glucose targets by taking small but doable changes.
Whenever a patient complains about the affordability of diabetic medication, CP
should always suggest patient go to the nearest government hospital or clinic to get
proper treatment . In Malaysia , no patient should be deprived of proper diabetic care
due to financial constraint because the patient can always seek treatment from
government clinic or hospital that charge only a nominal fee for good diabetic care .
As for compliance on diabetic medication, the best ways is to suggest once a day
medication to the patient and getting doctor approval is a prerequisite for any
changes. There are many medications that can be administered once a day & readily
available in Malaysia.
All the methods or ways mentioned are not exhaustive , the CP accumulative
experience can become handy in time to come.
2) As screener & reminder in blood glucose monitoring
i) Recurring complaints from normal people
Recurring complaints such as fatigue, poor sex performance or fungal infection on
private part could be the reason for normal people to seek nutrition or herbal supplement
or even some over the counter product at CP. For these people, blood glucose screening
is really advisable even if it is random blood glucose. If the blood glucose level is high,
CP must advise them to seek treatment from medical doctor. The other common
complaint is slow wound healing on the foot which always needs extra attention. If a
person has been buying dressing items for a while, CP should advise him/her to have the
blood glucose test done to make sure this person is free from DM.
ii)
Blood Glucose Monitoring for diabetic patient
i.
Blood glucose testing should be done on patient with diabetic as often
as
required. Each time a patient refills his/her diabetic medication, remind him/her to do
blood glucose test to keep tab on blood glucose control.
ii.
If it is necessary advise patient to have a glucometer at home for selfblood
glucose monitoring. This will be helpful in controlling blood glucose level. Besides,
for elderly patient who is more prone to hypoglycemic events due to improper use of
sulphonylurea (SU), measuring blood sugar during hypoglycemic symptoms will
help in managing these avoidable side effects. When a diabetic patient is on insulin,
glucometer will be very useful to guide doctor in dosage adjustment as well as for
patient to detect hypoglycemic events. Another benefits of doing self- blood glucose
monitoring is measuring blood glucose after a meal will find which type of food that
contribute towards high sugar level .Subsequently ,patient can avoid taking this high
glycemic index food & has better control of blood glucose themselves .
iii.
Patient must be reminded to fast & avoid taking any diabetic medication before
testing for fasting blood glucose (FBG). One common mistake is patient will fast but
without knowingly or even purposely taking diabetic medication before going for the
test. It will definitely alter the blood glucose & interpreting result will be inaccurate.
Doing FBG is to find out whether the diabetic medication taken day before works or
otherwise. Some patients who fast overnight but take oral diabetic medication
intentionally before going for blood glucose testing to avoid being reprimanded by
the doctor for not controlling blood glucose. However, this self-deceiving act will
pose danger to patient if severe hypoglycemia occurs. This is seen mostly in patient
who has been followed up in government hospital or clinic.
3) As advisor on medication , diet & supplement
i.
Medication
a) Side effects of a diabetic medication are always the culprit of non- compliance.
Feeling hungry & hand shivering are signs & symptoms of hypoglycemia caused by
sulphonylurea (SU), a commonly used diabetic medication. It is always
recommended to take SU before or immediately after food. Weight gain is another
major side effect of SU which will lead to non-compliance. Preempting patient on the
side effects will definitely improve compliance & blood glucose control. Metformin,
another commonly used diabetic medication, causes diarrhea or stomach discomfort
which sometimes can be very troublesome. As a result,the patient might sometimes
ask for a change of metformin due to side effects. Besides , long-term metformin use
could cause Vitamin B12 deficiency which can be corrected by taking a Vitamin B12
supplement.
b) CP has a major role to play in insulin administration. Currently ,there are many
patients on insulin , be it from the private hospital or even from the government
hospital. CP must advise patients on proper storage & administration technique
which will ensure efficacy & reduce wastage. Showing a diagram on the correct
injection site will help to prevent scarring due to multiple injections on a same spot.
Although the patient will be given counseling on method of administration the first
time he/she is prescribed with insulin, CP will definitely find some patients not fully
following the correct way of administration if CP care to ask or enquire about how
patient handle insulin injection. Another important message that needs to be
conveyed is recognizing hypoglycemic symptoms such as giddiness, tremor, loss of
consciousness, delirium, thirsty, hunger etc. . . .Any of the above signs & symptoms
warrant immediate action from the patient himself/herself or caretaker to ensure
blood glucose rise back to normal level. Therefore, CP has to remind the patient
about keeping sweet or sugary drink readily available in case of any emergency.
c) Diabetic patient could be on antihypertensive medication that contributes negatively
to blood glucose control. The common combination that has this effect is beta
blocker & thiazide diuretic which were commonly used back in the 90’s or early
2000. Though, they are less seen now, but CP will definitely come across a diabetic
patient who is still on this combination. A CP is duty bound to inform patients about
other available antihypertensive options that are neutral towards blood glucose
&cholesterol control or even has renoprotective properties. Of course changing the
antihypertensive is the prerogative of doctor who clinical judgment is utmost
important. Another most commonly seen medication given inappropriately to
diabetic patient is cough mixture with a syrup simplex base. A tablespoon of it will
cause blood sugar to rise substantially for those who have long been diagnosed with
diabetes. Therefore, CP must remind patient to be extra cautious & inform doctors
that he/she is a diabetic. Due to lack of medication option in a government hospital or
clinic , most of the time patient with cough /cold will be prescribed with cough syrup
that is of sugar based .Consequently , the patient’s blood glucose level will be high &
bringing this level down will take some time.
Ii .
Diet
a) One of the most common misconception on a diet is substituting rice with
noodle, rice vermicelli ( beehoon) or chappati or bread to reduce blood glucose .
The common response will be “ I don’t take rice . I take noodles or bread” or “ I
only take rice once at night , the rest will be bread or beehoon or noodle”
without realizing the carbohydrate content might be higher in noodle or even
bread .Thus , the blood glucose will remain high . In order to rectify the
misconception, a CP must highlight that rice,noodles , white bread , tosai or
chappati are all carbohydrate , replacing one with the other does not give much
of a change in blood glucose . Instead, replacing a portion of the above with
vegetable, fruit or even protein such as chicken or egg will help in reducing
blood glucose. Generally, our Malaysian diet contains excessive carbohydrate.
One good example is Chicken rice which contains high portion of rice with very
small portions of vegetable & a moderate portion of chicken. Replacing a small
portion of rice with vegetable or chicken will definitely reduce the carbohydrate
portion and still able to maintain total calorie intake. By doing so, we can address
the common complaint “ I take less rice , I will feel hungry faster” and
simultaneously reduce blood glucose . Changing diet is a gradual process that
needs a lot of patience & motivation from patient & CP as well. It is always good
to understand the normal daily diet of a patient before any changes are made. For
typical Malaysian breakfast such as nasi lemak , noodle or even roti canai that
contains high carbohydrate, blood glucose will be quite difficult to control .
Replacing a small portion of carbohydrate of the above with vegetable or fish or
even chicken will be the first step of seeing changes in diet & subsequently good
blood glucose control will follow. Perseverance is a must for any success to be
observed in dietary changes. Once patient experience success with changes in
breakfast , replacing a small portion of high carbohydrate food with
fruit/vegetable or egg /chicken during lunch & dinner will be more achievable
.Following this method , calorie intake for a diabetic patient will be contributed
more adequately from fruit/vegetable or even protein instead of depending too
much on starchy food . If the situation permits suggest to the patient to have
small portion of the meal but taking more frequently to avoid fluctuating blood
glucose. As for drink, CP should encourage a diabetic patient to switch to sugar
free drink or use artificial sweeteners such as aspartame to have better control of
blood glucose .A typical Malaysian diet contains excessive starchy food and real
improvement in blood glucose can be observed if positive diet changes can be
implemented by the patient with the help of CP.
b) Read the nutrition label
1. Calories
2. Carbohydrate
3. Sugar
4. Fiber
The educated diabetic patient should be informed of the importance of
reading nutrition label & making a comparison on food product available.
This act of reading & comparing will directly lead to better blood glucose
control. Food that contains low in calories, carbohydrate & sugar content
but high in fiber content should be the choice of every diabetic patient. The
key thing is to compare & then choose the best option. Continual
education is a main factor in changing the habit of choosing food that is
best for diabetic patients.
iii.
Supplement
a) The desire of trying an alternative medicine for reducing blood glucose is
always strong among diabetic patients. It could be due to our cultural
background which makes us think natural or herbal medicine is better.
Sometimes the desire is so strong, CP just has to let the diabetic patient try
alternative medicine with close monitoring of blood glucose. Any intention
to change or substitute diabetic medication must be discouraged unless with
prior consent from a doctor. The most commonly used supplements are
product derived from bitter gourd, chromium or vanadium. Any
recommendation of these products must be done as a supplement to diet,
exercise & medication. Patient must not take the recommendation as a
replacement without doctor consent.
b) Though not much been documented but it has been accepted that vitamin B
1, B6 & B12 should be used by diabetic patient with neuropathy symptoms.
CP should recommend this supplement whenever it is indicated. As for
patient on long term metformin, Vitamin B12 is advisable to replenish
depleted storage due to long term use of metformin.
4) As a collaborator with medical doctors in managing & preventing complications
i.
Diabetic Wound
a. It is the most common diabetic complication that drives patients to CP. Initially,
patients will visit the clinic for daily dressing. Once the condition improves, the
patient might opt to do the dressing himself or herself & getting the dressing
supplies from CP. The role of CP is to remind patients of the importance of
monitoring wound progress. If the wound healing is slow, patient must be
advised to visit a clinic & debridement must be done if necessary.
ii.
Prevention
a. Any adult customer with in- grown nail on the toes that buys antibiotic ointment
or antiseptic lotion should be informed that if he/she is a diabetic, doctor’s
consultation is a must. No self-treatment is allowed for diabetic patients with ingrown nail on the toes.
b. The first question for an adult with Corn/Callus/Warts on his/her feet who needs
salicylic solution is “Are you a diabetic?” If the answer is yes, please inform the
patient that doctor’s consultation is really important before treating
herself/himself.
5) As myth buster
i) Alternative or traditional medicine is able to cure DM.
Every diabetic patient has to be informed that DM is a progressive disease with no cure at
the moment. However, leading a normal life without complications is achievable. This is
the key message that CP must find ways to drum it into patient mind & if possible rooted
deeply in the mind. Otherwise there will be a lot opportunist who will convince a diabetic
patient that alternative medication or treatment can cure DM.
ii) Insulin administration equals severe stage of DM
Most patients are afraid of insulin injection and even the educated one has the same fear.
With new development in DM treatment, insulin is given much earlier than patient’s
expectation. The main thing of giving insulin at an early stage is to preserve whatever
pancreatic function left in diabetic patient & provide good blood glucose control. Some
patient might need insulin at very early stage base on clinical judgments of doctors eg.
when a patient is critically ill. From a patient point of view , insulin is the most dreaded
treatment for diabetic patient .CP must change this stigma .Actually , CP must inform
patient that insulin is the only treatment that is able to lower blood sugar unlimitedly &
control blood sugar effectively with proper usage .Ask any of diabetic patient about
starting on insulin & most likely the answer will be “ I am not that bad or serious , let me
really control my diet & exercise regularly first before starting on insulin ” or “ I don’t
want , I would rather take more medicine than injecting myself with insulin” or “ I feel
shy using insulin in public place .” CP must always encourage patients to use insulin if it
has been advised by doctor.
iii) Diabetic medication will cause damage to the kidney.
The fact is kidney damage is caused by long term uncontrolled blood glucose. High blood
glucose will cause nephropathy. Even educated patient sometimes has the idea that taking
long term diabetic medications will have detrimental effect on kidney. It is so
unfortunate for these patients .CP must inform patients that if diabetic medication is truly
harmful, no government or doctor with a sane mind will prescribe diabetic medication so
freely. The true culprit that damages the kidney is uncontrolled high blood glucose.
Therefore, CP must reiterate that uncontrolled blood glucose is the true culprit that
damages the kidney & no diabetic medication has been proven to cause kidney to fail.
6) As Diet & Exercise (D&E) Advocate
i.
A CP must realize that medication alone without changes in diet & exercise causes
uncontrolled blood glucose. All the clinical guidelines available emphasize on
healthy diet & exercise before starting on the medication. This shows the important
of D&E . Some desperate patient will enquire about the best or latest diabetic
medication, some even request to be given insulin for controlling their blood glucose.
However, CP must drive into patient mind that changes in diet & doing exercise are
very important in diabetic treatment. In fact diet, exercise & medication are the 3
pillars in treating DM. A treatment plan that is lack of any one of the pillars is
deemed to be heading for definite failure.
ii.
Convenience seeking patient will definitely request for good diabetic medication
without compromising on their excessive appetite or sedentary lifestyle. This must be
rectified with good communication skill from CP. Driving home the message of
proper diet, adequate exercise & strict medication compliance must be achieved if
any improvement were to be seen.
iii.
If a patient intends to take up the sport, he/she has to be informed that proper sporting
gear is very important to prevent injury. If an injury happens such as osteoarthritis on
the knee, it will affect the exercise program & subsequently patient blood glucose
will become difficult to control . Moreover, the proper sporting shoe will avoid injury
on foot which might develop into diabetic foot .Swimming & brisk walking are
sports that less likely to cause injury which are suitable for diabetic patient. The latest
guideline on the duration of exercise is 150 minutes per week. It is quite a task for
those who have sedentary lifestyle all the while. In order to overcome the beginning
stage inertia, CP should advise patient to start slow like 30 minutes each session for 3
days & gradually improve to 5 days .The patient has to be informed that any exercise
is better than no exercise at all. Even muscle strengthening exercise has proven to
reduce high blood glucose.
THE CHALLENGES
i)Profitability Vs Professionalism
CP must not diagnose, change medication & dosage of a diabetic patient. A medical doctor is the
best profession to carry out the above. Even if the patient complains about the service or attitude
of his/her doctor. The only best thing CP can do is recommending a good doctor with a strong
interest in treating DM. The true responsibility of CP is medication refills, advice on diet &
exercise, alert patient of possible side effects of medication, guide patient in taking of medication.
Monitoring of blood sugar is also beneficial to the patient which could fall under the
responsibility of CP. CP must have a clear mind on what falls under his or her responsibility &
avoid crossing the border of responsibility with doctor due to temptation to increase sales or
profitability .
CP should focus on professionalism. However, it is a difficult task especially for a new CP .The
temptation to increase or even maintain profit is hard to overcome. At the end of the day,
balancing between profitability & professionalism will be a difficult but doable. The basis of
professionalism is to provide up to date & accurate information without being selective on patient
& with patient interest in CP mind. Soon profit will follow. The 1 million Ringgit question will
be how soon? If it is too soon, professionalism surely will be jeopardized. If it is too late, there
will be no opportunity for professionalism to take place. It is really up to the person who runs the
CP .
ii)Staff & Training
1)Hiring a pharmacist who has an interest in DM is time-consuming . A pharmacist must show
interest in self-educating if he/she wants to play a role in T2DM management. In an everchanging world of medicine, once a pharmacist ceases from gaining new knowledge , that is the
time he/she will turn into a professional retailer .Currently , pharmacist with an interest in DM is
still very few and far between .But fortunately , if CP tries hard enough to look for pharmacist
with an interest in DM , eventually CP will find one to join the journey of uplifting CP
profession . Training a pharmacist with an interest in DM is easy & really rewarding. Just allocate
a project on DM to a passionate pharmacist, it will be considered done even at the early stage.
2)Training of pharmacy assistant (PA) on basic of DM , simple diet & exercise tips , blood
glucose target of a diabetic patient is time- consuming & sometimes challenging . Worst still if
the turnover of pharmacy assistant is high. Overcoming these challenges could be done by using a
simple chart on DM, target blood glucose, diet & exercise tips & always help PA when he/she is
doing blood glucose testing.
3) Remuneration package based on performance will be beneficial for CP & PA. Developing a
fair & yet rewarding package must be discussed thoroughly & openly between both parties to
address high turnover in CP. Performance based incentive can be incorporated into a basic salary
package of pharmacist and even PA . By doing so, a pharmacist or PA will be more loyal and less
likely to be lured by other CP or chain pharmacy.
iii)Space & Privacy
One of the major constraints in CP growth is floor space. Allocating a room for counseling will
be very ideal in providing comfort & privacy to the patient but at the expense of optimal use of
floor space. In retail, efficient use of floor space will enhance revenue or even profitability. In
other words, the more product that can be displayed per square feet, the more sales can be
generated per square feet .CP must balance between providing comfort & privacy and efficient
use of floor space. As mentioned earlier, casualness will be sacrificed if counseling is done in a
room as some experience seen in the doctor’s room. CP must find ways to address this issue in
order to gain …. first trust & then loyalty of patient.
iv)Time
Time constraints will be a major hindrance for CP to play a major role in T2DM management. At
an early stage of growth of a CP, time is not an issue. However, as CP grows, time will become
difficult to come by. Sufficient time must be made available to have a good & effective
counseling. Precise information must flow between CP & diabetic patient. With limited time,
precise flow of information will be hard to achieve. As a result, it will hinder a CP in rectifying or
improving patient condition. There are many ways a CP can address the time constraints issue &
one of it is to employ extra pharmacist who will immediately address this issue but CP must be
wary of the extra cost incurred. At the end of the day, an investment of an extra headcount has to
have a fair return at the bottom line. Another way of addressing this issue is by informing a
diabetic patient who needs extra attention to come in the afternoon when CP is less busy or even
during the weekend. Thus, patient will get the attention needed whereas a CP will efficiently use
the limited time available for patient counseling.
v)Education background
Education background of a patient will determine the level of communication involved. Those
who are less educated might need more time & creativity in conveying the message across.
Whereas for those who are educated needs less time in conveying a message. Using a chart or
picture will be helpful in communicating with a patient who is less educated. A patient’s
motivation to control blood glucose is influenced by patient awareness of diabetic complications
and it is regardless of patient’s education background .The higher the awareness, the higher the
motivation. A patient could be holding a degree but leading an unhealthy lifestyle without any
remorse or regret. Once complications set in, any remedial action taken will be futile in reversing
the condition.
vi)Price Competition
Currently, price competition is very bloody among CPs. Price undercutting becomes a norm in
CP daily practice. Though, many CPs know exactly the consequences of price undercutting but
resolving this issue seems to be very remote. CP has sometimes been too engrossed in this bloody
war & unknowingly neglecting patient interest. Hence, the role of CP in T2DM management will
be jeopardized. A CP will be demotivated to see his/her effort in playing the role in T2DM
management goes down the drain when patient hopping around for the lowest priced medication.
A CP must stay focus & have a heart of steel together with a continuous flow of creativity to
overcome the price competition issue. It will be a tough but rewarding if CP is able to divert
patient attention from price oriented to service oriented.
vii) Recognition
The role of a community pharmacist in playing a role in managing T2DM is not being
recognized by other medical professions . Dietician , diabetic counselor and diabetic foot nurse
supporting roles has been rightly or deservingly recognized by medical doctors . However , CP
may not gain much recognition in playing a role of supporting medical doctor in managing
T2DM . Questions have to be asked on how CP can gain recognition or respect from other
medical professions . Inward looking into the professionalism of CP is the way to go before any
progress can be made .From the current situation , the journey towards gaining recognition from
other medical professions is still far away but within reach if CPs & relevant authorities begin to
look into ways of rectify any shortcomings in the profession holistically .
CONCLUSION
If CP involvement could reduce uncontrolled diabetic by 1 %, it will translate into 26000 patients
that will likely to be free of diabetic complication. Existing diabetic care system is not sufficient
in handling the diabetic epidemic as reported in 2008 Diabcare Study .Hence; there is a room for
CP involvement to support the existing diabetic care system. There are many areas a CP can be
involved as discussed but personal interest of individual CP will determine the direction to be
taken by CP. Though the challenges are daunting but if CP really strives to carry the
responsibility, the return will not only be rewarding but also will uplift CP profession. The role of
CP in T2DM management will only grow with time as a result of ever growing diabetic
population in Malaysia. Therefore, CP must be ready to grab the opportunity arises & turn the
profession into a well- respected one in the eye of the community.