Download Edited Proceedings - The Global Alliance for Women`s Health

Diabetes in Asia, Africa, Latin America
and the Caribbean
16 November 2004
Ambassador Paulette A. Bethel:
Diabetes is, at its base, a health-care issue; however, its relation to socio-economic
development is also clear, both as a result of lifestyles and levels of socio-economic
development and the threat it poses to productive capacity and the potential for further
economic development. When these facts are combined with the alarming levels of
diabetes found in women in particular, it becomes clear just how much of a challenge that
we as governments, in partnership with international organizations, medical professionals
and the industry, have to face.
In my own country, The Bahamas, the Ministry of Health has identified diabetes as one
of the most significant health challenges facing our small nation. The 2001 Bahamas
Living Conditions Survey Report indicated that 3.8% of the
Bahamian female population has diabetes, as opposed to 2.7%
of males. Further, 83% of these women are between the ages of
20 and 64, the most productive years. When considered in the
context of the size of the population of The Bahamas,
“… 3.8% of the
Bahamian
female
population has
diabetes, as
opposed to
2.7% of males.”
approximately 310,000 people, these statistics provide a clear
indication as to the magnitude of the health-care challenge we face. More alarming is the
fact that diabetes ranked as the fourth leading cause of death in 2001 among all
Bahamians, and it is estimated that diabetes accounts
for just over 750 potential years of life lost to
premature death in The Bahamas. These statistics are
“Diabetes ranked as the
fourth leading cause of
death in 2001 among all
Bahamians.”
staggering, foremost in terms of the lives lost and
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families broken but also in regard to the loss of productive capacity in our developing
country.
Faced with this challenge, The Bahamas Government has recently enhanced its response
and created the National Chronic Non-communicable Diseases Program in 2003. The
program’s immediate goals are to reduce the risk factors of chronic non-communicable
diseases such as diabetes, including obesity, unhealthy eating habits and lifestyles,
physical inactivity, etc. The long-term goals of the program are ultimately to strengthen
the public health response to the rising problem of these diseases and to examine
community-based approaches to reduce premature death and disability as a result of these
diseases. While situated within the Ministry of Health, the program also involves close
cooperation with all stakeholders, including non-governmental organizations and other
parts of civil society and the wider community. It is the hope of my government that
through programs and partnerships such as these, we will be able to successfully step up
our response to diabetes and enable our citizens to lead healthier, happier and more
productive lives.
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Nicole Johnson Baker:
Diabetes is a disease that simply steals away the body's very potency. It subverts that
most elemental and savoury experience, the enjoyment of food. But that very food, that
very experience that so many of us love, then detonates the body's ability to manage it as
fuel.
Diabetes has become known as a silent, or hidden, killer. For some, as myself, in the
discovery phase it pounces suddenly, in the very prime of life. I was diagnosed as a
teenager. But for others, like my grandmother and soon, if some changes are not made,
my father, it stalks over long years in a slow undoing that gathers speed and then can
overwhelm the very core systems of our cells, our hearts, our eyes, our limbs, all from
that smooth free flow of our blood lines.
Let me set the stage, a stage of two views. The first, a larger one of global consequence;
then the other, a more personal one that plays out inside of me every moment, a tight rope
of balance that permits very, very little ease.
The story of the diabetes threat for all of our nations is first understood by a narrative of
numbers, if you will, numbers that are increasingly unsettling and worrisome.
Worldwide right now, there are 190 million people who have the condition diabetes,
whether they know it or not. This number will grow to over 330 million in the next 20
years, not to mention those affected by the epidemic of pre-diabetes. But still, so many
are unaware of the threat, the signals and the consequences. This lack of knowledge is
both dooming and damning. Dooming to deeper and more severe consequences and
complications, and damning because it just does not have to be that way.
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The ravages of diabetes in so many cases can be avoided. They can be eased, and they
can be overcome. Technology, science, invention have proven themselves. Over the
course of the last 30 years, we have been blessed with glucose monitors, with insulin
pumps, with new forms of insulins and medications, and impressive research, all
supporting life, all searching for answers, and all poised to give great hope to the millions
of people who are suffering. It all leads toward health improvement, but for the lack of
knowledge, on the very simplest of levels, we are paying a staggering price.
Right now, in this country, $1 out of $7 in health-care expenditures is a diabetes dollar.
When you add all of those diabetes dollars on top of each other, the result is
overwhelming, to the tune of $132 billion a year. Worldwide, the numbers are equally as
impressive.
Also, the personal side of this condition, the daily drill of diabetes management – finger
sticks, insulin injections, carbohydrate counting, activity management – is overwhelming
at times even for the most well informed. I consider myself one of those individuals, but
yet even during lunch today, my blood sugar drops low.
Answers are still needed about how to manage this condition. It is not easy. For me, to
date, managing my diabetes has meant 38,000 shots. That is finger sticks, injections,
pump changes combined – 38,000. It is life maintenance survival, and it is all part of my
race against the threat of complications. In addition, there are my psychological and
emotional struggles, the fear, anxiety and worry of what is next.
Next week, I enter my eleventh year of living with type 1 diabetes. It is scary. My
concerns and doubts about the future, about family, about career, about ambition are very
real. The reason for that scare is that over 80 % of people living with diabetes experience
some form of complication, usually a micro-vascular complication. That is four out of
five people with this condition.
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I am doing all I can to be that one out of five that does not experience the complications
and hopefully I will succeed, but I have no real guarantee. I know that because I just live
with this disease, as science has recently told us, I am already considered to have the
same level of risk for cardiovascular disease as someone who has already had a heart
attack.
This means I am waging an intense fight for my life, a fight for information, for tools, for
the magic, if you will, to preserve my health. And I am so glad that there are partners in
this fight against diabetes and its related conditions, and that these partners are rising up
across the globe. Thank you for being part of this organization and this partnership to
fight this condition.
On World Diabetes Day in November of 2004, the focus was on the problem of obesity
and its connection to diabetes. The connection, in my opinion, is that very same lack of
information, lack of awareness, lack of management and care. This connection most
often results and shows itself in the development of one of the micro-vascular
complications.
This problem of obesity is a problem that affects between 30 to 35% of people under the
age of 30 in the Americas. We have our work cut out for us, but I am delighted that in
the sense of partnership, new things are being announced. Recently, the Lions Club
International announced a program, along with the Lilly Partnership in Diabetes, a
program I am involved with, to raise awareness of diabetic eye disease. I cannot imagine
living a life in a world that I cannot see. That frightens me more than any other
complication.
In addition to that partnership, recently the American Diabetes Association teamed up
with the American Heart Association and the American Cancer Society to create greater
awareness of diabetes. Then there are the meetings put together as part of the Global
Alliance for Women's Health’s focus on diabetes. All of this gives me incredible hope,
yet reinforces, in my heart and in my mind, personally and professionally, recognition of
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the incredible needs still to be met: for legislation, policy development, regulatory
change, and for just collecting information around the world.
One of the other needs that I am convinced about, and I urge you to focus on is the need
for
gender
messaging
and
“As daughters, wives and mothers, women are
servicing.
Women play an often the primary decision makers when it comes
to health, but are also a major conduit of
especially important role in this information, one that is underused.”
awareness effort. As daughters, wives and mothers, women are often the primary
decision makers when it comes to health, but are also a major conduit of information, one
that is underused. We need to create safer, more comfortable environments for women
not only to aid in the health management of their loved ones but also for themselves,
something that is forgotten in the daily whirlwind of life. This means more targeted
communication, more programmatic thinking and, of course, more gender-specific
research. It is unbelievable and alarming that the study of women's health is but only
about a decade old. There is so much left to learn, and so much left to do.
When it relates to diabetes specifically, women are at a greater risk for diabetes and heart
disease than men, 60 %. But women do not realize it. Again, we must address this
problem in creative and new ways to break through.
A little over a year ago, I got married, and in the process adopted a ready-made family
with three children, one of them a teenager. My life has changed quite a bit, but I
understand full well how the strains and stresses of health management can be affected by
the flurry of life, schedules, children, and homes. In my own management of diabetes, I
struggle to get the appropriate amount of exercise.
I struggle to manage my level of stress and anxiety, worrying about the future of my
family and their activities. I struggle to eat the right foods, when I am surrounded and
inundated by negative food messages and other inappropriate messages. I struggle to just
test my glucose at the right times when someone is tugging on one arm and another is on
the other arm. Yet I am committed to my good-health regimen because I know that if I
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do not, tragedy and heartbreak could and probably would result. To me this is not
acceptable. I hope that commitment such as mine will be assumed by women all across
this world, those living with diabetes or with other chronic diseases.
It is because the threat of diabetes is ominous that the potential for pain and suffering
related to this condition is so very real. But the beauty in proper care and management,
the fulfilment I experience in seeing others realize the reality of the struggle and
understand the opportunities that do exist for a long life with diabetes, and without
complications, is incredible.
Our charge and our goal is to determine how can we move forward in such a way that
communicates the seriousness of this issue, the consequences that accompany it if not
managed
correctly,
and the optimism that
does and should exist
in the aggressive and
motivated
“Our charge and our goal is to determine how we can move
forward in such a way that communicates the seriousness of
this issue, the consequences that accompany it if not managed
correctly, and the optimism that does and should exist in the
aggressive and motivated patient.”
patient.
For that matter, how do we create more aggressive and motivated patients? The reality
is, anything is possible. My life with diabetes, 11 years, is an incredible achievement. I
was able, despite what people said, to receive an education, become a professional with
an intense schedule (something that individuals say is not a reality for a person with
diabetes) and have the opportunity to stand on a stage and be chosen to represent this
country as Miss America 1999. These are all things that I was told diabetes would keep
me from doing. Today, they are examples of what can happen when we create the right
environment and provide the right tools and access, proof that diabetes patients can
accomplish anything.
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Ambassador Christopher Fitzherbert Hackett:
When we at the Permanent Mission of Barbados were invited by the Global Alliance for
Women's Health to co-sponsor the meeting we readily agreed to do so because I was
aware of the high degree of diabetes in Barbados, and indeed the Caribbean, and the way
in which the disease was negatively affecting or impacting progress in the health sector
and in the overall economic and social development of the countries of the region. I
hoped to share some of the details of this health condition in Barbados and the Caribbean,
about the nature and scale of the problem, the response to date, and how we can
eventually move toward a more concerted response to this public health crisis.
I should explain that I am not a medical doctor myself. You may wonder how I am in a
position to make such an input on this serious health topic. We at the Permanent Mission
of Barbados collaborated with the University of the West Indies in the preparation of the
presentation. At the University, there is a unit called the Chronic Disease Research
Center that actually provided significant substantive input which enabled me to prepare
my presentation.
The increasing global prevalence of diabetes constitutes a major public health concern,
particularly in middle-income countries, and the Caribbean region is one such example.
Barbados is known to have the highest level of diabetes in the English-speaking
Caribbean.
However, the disease does in fact represent one of the greater health
challenges for the region as a whole.
Indeed, diabetes is the third-leading cause of death in Barbados, with numbers projected
to increase if the necessary corrective interventions are
not made. Thus, diabetes is of particular importance to
“… diabetes is the thirdleading cause of death in
Barbados…”
us in Barbados and the region.
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The prevalence rate of diabetes in Barbados is considered to be 17%, whereas in North
America, it is 9.7%, and in Europe, 9.1%. It would
seem that lifestyle changes of reduced physical activity
and increased food consumption as well as the nature of
that food consumption are seen as some of the major
contributing factors. Both type 1 and type 2 diabetes
“The prevalence rate of
diabetes in Barbados is
con considered to be
17%, whereas in North
America, it is 9.7%, and
in Europe, 9.1%.”
are to be found in the Caribbean, although I am advised that in contrast to the European
experience, and to some extent, the North American experience, type 1 diabetes is rare.
There are higher rates of type 2 diabetes, however, and this has been documented already
in the Caribbean, with an estimated overall prevalence of 10% of the type 2 diabetes in
the region. Studies that have been undertaken have consistently shown a higher female
prevalence of diabetes. The diabetes condition as a health crisis, as a health concern in
Barbados and in the Caribbean is a phenomenon that appears to be chiefly influenced by
higher rates of female obesity.
Trends in diabetes rates relate to differing lifestyles and related factors which in turn are
affected by the increased frequency of obesity.
It is also pointed out that while
recognized diabetes risk factors have been reported in Caribbean populations, data
quantifying measures of association between diabetes and other factors have only
recently become available.
One of the disturbing implications of the disease in the region is that approximately up to
15% of diabetics will have an amputation carried out in their lifetime, with the resulting
permanent disability and an adverse effect on the quality of life. Such outcomes are
particularly likely in settings – and this is unfortunately the situation in our region –
where people have limited access to prosthetic devices and rehabilitation services. This
situation is all too common in the Caribbean region.
In addition to the high economic costs to health-care systems, amputations result in
economic hardship for patients as well as their families. Furthermore, amputations often
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coexist with other complications, leading to reduced life expectancy. We have also found
that diabetic foot problems are a significant clinical and public health issue in Barbados
and the Caribbean. Indeed, they account for the majority of hospital admissions as well
as admissions to the general surgical service.
Deficiencies in the provision of care and education uptake by patients have been
documented, and the appropriate interventions, we believe, are really urgently needed.
Indeed, it is established that simple improvements in foot care practices and behaviors
can significantly reduce the likelihood of lower extremity amputation. This, we argue,
must be the challenge for all care providers in the region as one moves forward in trying
to manage this particular health crisis, this particular disease.
Diabetes lower extremity amputation rates in Barbados are among the highest
documented in the world, and it is argued that this is linked to inadequate footwear which
also tends to triple the risk of amputation.
Another phenomenon of the disease found in the Caribbean, and in Barbados in particular
is the ocular complications of diabetes. Data about ocular complications are available
from the Barbados Eye Studies, a nationally representative cohort of adult Barbadians
between the ages of 40 to 84 which was the basis of a study carried out for more than a
decade.
The aim of the research was to document the prevalence, risk factors and the incidence of
the major causes of the visual loss within the population, and there were close to 5,000
persons in the random sample. It was found in the study that 5.9% of the population had
diabetic retinopathy, which also affected another 28.5% of participants with diabetes.
Minimum changes were evident in about 20% and moderate changes were apparent in
another 8%, while severe vascular changes were seen in only about 1%. In addition,
during the survey, it was found that lens opacities were also frequent in the Barbados Eye
Study population, with a rather staggering number of 41% who had some form of lens
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opacity (that is really quite a high percentage) or some history of previous cataract
surgery.
It was also found that persons with diabetes had nearly a twofold increased risk of
cortical opacities, while elevated blood pressure and abdominal obesity were also found
to be other risk actors. While there is a belief that diabetes also has had an impact on
cardiovascular and renal disease in Caribbean populations, there at present no significant
data on this particular point.
Regarding diabetes and survival rates, it has been found that a doubling of the crude
death rate attributable to diabetes has been recorded in the Caribbean during the decade
ending in 1990. Recent information directly evaluating the impact of diabetes on survival
is in fact now available from an evaluation of the Barbados Eye Study. It was pointed
out, or it can be pointed out, that compared to non-diabetics, diabetes was associated with
a 40% increase in mortality over a four-year period. Furthermore, glycated hemoglobin
levels were predictive of increased mortality risk.
This, in our view, signals the need for public health interventions aimed at improving
glycemic control at the population level in order to reduce attributable mortality in
persons with and without overt diabetes.
Regarding the quality of care, there have been a number of studies carried out in the
Caribbean in this particular area. Two, in particular, have explored the quality of care
issues linked to glycemic control. In a comparison of public and private clinic settings in
a number of the Caribbean islands, Barbados, Trinidad, and Tobago, and the British
Virgin Islands, overall blood-glucose control was poor in 50% of the population studied,
while in a comparable Jamaican study, it was poor in 61%. These high percentages
again demonstrate the implications of managing the diabetes health crisis, or
situation, that exists in the region.
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There are in fact also public health and clinical issues which are of particular relevance to
the Caribbean.
Patients from the region with diabetes still have a very poor
understanding of their condition -- at least this is what the studies suggest.
On the other hand, care providers still seem to be more focused on medication rather than
on diet and activity changes, and care is often driven by drug marketing and fashions in
prescribing. Once again, this is what the evidence would seem to suggest, based upon the
studies in the region and in Barbados in particular. We believe that improved education
for both the care provider and patient is therefore a vital step on the path to progress.
In closing, I address the evolving or the additional response being made by the
government of Barbados regarding this health crisis.
The government of Barbados
believes that there is a need for a broader and more strategic approach to the management
and control of diabetes. Any such approach, we further argue, will have to focus much
more on fundamental lifestyle and behavioral changes at both the individual and
community levels through patient education and information.
In addition, the government also intends to establish a holistic primary-care unit under
which the diabetes team would provide care in a single setting, set protocols for
screening, early diagnosis, referral and management and implement aggressive treatment
protocols. The whole idea is to provide a supportive social setting, or environment, that
would provide care for those disabled by diabetes.
The Barbados National Strategic Plan for Health for the period 2002 to 2012 has
identified chronic non-communicable diseases as a priority and has established an overall
goal of reducing the morbidity and mortality associated with those diseases, including
diabetes.
This has meant that a high percentage of the national budget, currently
estimated to be about 14 to 15%, has been allocated to the health sector, with close to
20% of that allocation representing the direct costs of diabetes treatment.
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Thus, the financial cost to the government is high and not really sustainable. We hope
that our approach will bring about a significant reduction in the high incidence of
diabetes cases, thereby reducing the high allocation from the budget that is meant to
address this condition. But at the same time, we also look forward to the support of the
international community in partnering with us in Barbados and in the Caribbean to help
us control the growth of the disease.
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Dr. Alberto Barceló:
The Declaration of the Americas on Diabetes was created in 1996. It was sponsored by
all the governments in the Americas when ministers of health gathered in Puerto Rico
during a Pan American Health Organization (PAHO) Directing Council subscribed to a
declaration advocating for better health for people with diabetes.
DOTA (the Declaration of the Americas on Diabetes) also became an organization, and it
is a coalition between IDF (International Diabetes Federation) and the Pan American
Health Organization. DOTA has four areas of work: epidemiology, children's diabetes,
awareness, and education. During the past eight years, DOTA has sponsored programs all
over Latin America and the Caribbean.
The prevalence of diabetes is increasing in the Americas. It is going to increase from 35
million in 2000 to 64 million in 2025. Yet, it is a well-known fact that type 2 diabetes is a
preventable disease. All the suffering that diabetes causes in those affected could be
avoided by diet and exercise.
The highest prevalence of type 2 diabetes in the region has been found in Barbados
(17%); in some other Caribbean countries and Mexico, the prevalence is over 10%. In
South America the prevalence of type 2 diabetes is between 6% and 7%, while in Central
America recent reports showed prevalence of around 8% in Guatemala and Nicaragua..
The prevalence of pre-diabetes was about 10%. This information comes from surveys
that PAHO is doing in Central America.
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Diabetes represents a high burden for society and those affected. Research in Costa Rica
showed that people with diabetes are
reportedly
less
employed
than
people without diabetes, about 1.5%;
“… People with diabetes are reportedly less
employed … 1.8 % fewer graduated from
college and they have disabilities at a rate 2.6
times higher than people without diabetes.”
also, 1.8% fewer people graduated from college and they have disabilities at a rate 2.6
times higher than people without diabetes.
The cost of diabetes has been estimated at $5 billion in Canada, $132 billion in the US,
and $65 billion in Latin America and the Caribbean. Indirect costs were 84% in Latin
America and the Caribbean. This was due to high premature mortality and high
prevalence of disability: temporary disability, $2.4 million: permanent disability $726
million. Mortality was estimated at 6%. The direct cost of drugs, insulin, hospitalization,
consultations and complications together come to $10 billion. For the different aspects of
health care, complications take 23%, oral medication, 27%, insulin, 18%, while
consultations take 23% and hospitalization, 9%.
The largest part of the
cost of complications
was
due
nephrothapy,
to
and
“The most recent information available indicates that in the US the
cost of diabetes care per year is about $13,000 per person while the
government spends around $4,000 per person on their health care.
In the Spanish-speaking Caribbean, the health expenditure is only
$92 per person, while the cost is more than $1,000.
some of these costs can be avoided by good care. In Latin America and the Caribbean,
more than $600 per year is the cost for just supplies that the person with diabetes has to
have. There is a big gap between government expenditures in health care and the per
capita cost of diabetes care.
This analysis showed that only in Canada are health
expenditures higher than the estimated cost of diabetes care. In the US the gap is huge,
and this is not even based on the most recent information. The most recent information
available indicates that in the US the cost of diabetes care per year is about $13,000 per
person while the government spends around $4,000 per person on their health care. In
the Spanish-speaking Caribbean, the health expenditure is only $92 per person, while the
cost is more than $1,000.
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PAHO promotes various initiatives to tackle the burden of diabetes. DOTA has programs
in education, epidemiology, children with diabetes and awareness. The CAMDI (Central
American Diabetes Initiative) project in Central America promotes diabetes surveys and
is trying to improve quality of care for people with diabetes.
The VIDA (Veracruz Initiative for Diabetes Awareness) project in Mexico was an
intervention to improve diabetes control in five health centers in Veracruz.
This
methodology is now to be applied in many other centers across Latin America and the
Caribbean. IRDC (Institutional Response to Diabetes and Its Complications) is a project
that PAHO has in the Caribbean in participation of various countries.
Research demonstrated that type 2 diabetes can be prevented by diet and physical
exercise, while many long-term complications, such as amputation, terminal renal failure,
blindness and cardiovascular diseases, can be avoided or delayed by diabetes
management and education. In conclusion, diabetes represents a high burden to societies
in the Americas and in the world. Strategies to ensure better care for people with
diabetes should be established in order to avoid the huge burden caused by complications,
disabilities and premature mortality.
Diabetes prevention activities should be
commenced across the Americas.
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Dr. Juliana Chan:
Diabetes as a Silent Killer
The joint statement by the World Health Organization and International Diabetes
Federation states that at this moment in time, 3.1 million deaths are attributable to
diabetes worldwide. One in 20 of all deaths is attributable to diabetes: i.e., six deaths
every minute. Looked at another way, by the time you finish reading this article, quite a
number of people will have died from diabetes around the world.
Young and middle-aged people can be particularly affected by diabetes although diabetic
complications take time to develop. Young people are now experiencing the most rapid
increase in diabetes rates and, in this regard, 75% of people who develop diabetes before
the age of 35 are expected to eventually die as a result of their conditions.
Asia – Where Diabetes Hits the Hardest
Diabetes has now been declared a global epidemic, with twothirds of the affected people coming from Asia. According to
the December 2002 issue of Time Magazine (Fig. 3), diabetes
is presented as the Asian disease and has China and India
leading the world in this global epidemic.
“Diabetes
has now been
declared a
global
epidemic,
with twothirds of the
affected
people
coming from
Asia.”
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Fig. 3 Time Magazine, December 2002
Using China as an example, approximately 20 million people have diabetes (half remain
undiagnosed), a population equivalent to that of Australia, and this number is expected to
increase to 40 million in less than 20 years. One of the proposed reasons for this epidemic
relates to the rapid changes in lifestyle, as we move from a gatherer and hunter lifestyle
characterized by energy scarcity to a sedentary lifestyle with energy abundance. Besides,
it has been suggested that certain thrifty genotypes (or survival genes) which might have
been conducive to survival during times of hardship have become disadvantageous in
modern societies, leading to increased risk of obesity and related diseases such as
diabetes and hypertension. This phenomenon will be most obvious in developing
countries undergoing rapid socioeconomic changes such as those in Asia.
In a Lancet report, using DEXA (dual-energy X-ray
absorptiometry) to measure body composition,
despite having the same body mass index of 23
(kg/m2), the body fat percentage of Professor Yudkin,
a diabetologist from the United Kingdom, was only
9% compared to that of 21% of Professor Yanik from
India, thus emphasizing the increased tendency for
“… Heightened stress
responses leading to high
blood glucose and high blood
pressure can theoretically
improve survival in primitive
societies but may have
adverse health consequences
in modern societies where
competitions are fierce with
many city dwellers under a lot
of psychosocial stress.”
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Asians to deposit fat tissues. Besides, heightened stress responses leading to high blood
glucose and high blood pressure can theoretically improve survival in primitive societies
but may have adverse health consequences in modern societies where competitions are
fierce with many city dwellers under a lot of psychosocial stress.
Using Hong Kong as an example, in less than 100 years Hong Kong has been
transformed from a fishing village to a cosmopolitan city with a highly efficient system
accompanied by both qualitative and quantitative changes in food content as well as
dramatic reduction in physical activity with frequent use of elevators and automobiles
and mass transport systems. Hong Kong, being a window to China, also epitomizes what
China will become in 10 to 20 years. In this respect it is noteworthy that the prevalence of
diabetes among Chinese living in different areas varies from 1 to 2% in rural areas in
China to 6 to 8% in some coastal cities such as Shanghai and Beijing to more than 10% in
Hong Kong where the lifestyle is highly affluent and westernized.
Impact of Aging and Childhood Obesity on Diabetes Epidemics
Apart from lifestyle, there are inevitable changes in our hormonal systems which are
associated with aging that can lead to obesity and metabolic disturbances. In China and
Hong Kong, we are expecting that more than 30% of the population to be over the age of
65 in a few decades. Adding fuel to this epidemic, we are also facing a burgeoning
epidemic of childhood obesity and type 2 diabetes. Large-scale surveys which include
data from Hong Kong, Singapore and China have shown that 10 to 15% of young boys
and girls are either obese or overweight.
Driven by this increasing population of obese children, the
most rapid increase in diabetes rates are found in the youth.
While the overall prevalence of diabetes in China has increased
by two- to threefold in less than 15 years, the major increase is
found in the 25-35 age group, where the prevalence of diabetes
has increased from 0.16 percent to 1.6 percent, a tenfold
increase. Similar trends are also observed in other populations,
“…in contrast to US
and Europe where
the major increase in
diabetic population
is observed in the
elderly population,
in developing
countries such as
those in Asia, the
major increase will
be in the middleaged group which
will have major
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impacts on societal
productivity.”
especially in non-Caucasians. According to the World Health Organization, in contrast to
US and Europe where the major increase in diabetic population is observed in the elderly
population, in developing countries such as those in Asia, the major increase will be in
the middle-aged group which will have major impacts on societal productivity.
Risk Factors for Diabetes and its Complications
Diabetes is a genetic disease which becomes apparent upon interaction with
environmental or lifestyle factors. Apart from age, obesity, family history of diabetes,
other risk factors for diabetes include smoking and gestational diabetes (i.e. high blood
glucose during pregnancy). In a recent analysis involving Chinese women with a history
of gestational diabetes, 90% of them developed diabetes ten years after the index
pregnancy and the majority were not aware of their risk if they had not undergone
screening. It is also important to note that these risk factors interact in a multiplicative
manner to increase risk of diabetes, so that the risk of diabetes was increased by more
than 30-fold in the presence of four risk factors compared to those with only one risk
factor.
It is now clear that diabetes frequently coexists with other risk factors notably high blood
pressure, abnormal blood fat levels, increased protein in the urine and obesity, a
syndrome frequently referred to as metabolic syndrome. These factors also interact to
give rise to heart disease, kidney disease, stroke, and leg amputations. Besides, there is
emerging evidence supporting close associations between diabetes, depression and some
cancers, notably colorectal cancers, although the nature of these associations needs
further clarification. Using Singapore which is a multiethnic society comprising Chinese,
Malays and Indians as an example, Indians are the most at risk population for metabolic
syndrome. Importantly, even in the young age group of less than 30 years, 3% have
metabolic syndrome. This percentage increases 20% in people in the middle-age group to
more than 30% among the 65 year or above group.
20
Diabetic Kidney Disease – Another Silent Epidemic
A particularly important problem in our part of the world is diabetic kidney disease,
which develops very silently but hits suddenly. Based on the US Renal Registry, at this
moment in time nearly a quarter million people are on dialysis in the US, 50% of them as
a result of diabetes. In both developed and developing countries, the number of people
on dialysis is mainly driven by diabetes and hypertension, and in the US this number is
expected to increase to half a million in 10 years.
If we multiply this figure by four, we will have some idea about the number of people
who will need dialysis in China. One of the biggest challenges in this global epidemic is
the silent and “non-urgent” nature of diabetes. Using cancer as typical of a lifethreatening condition, in the US the number of people with kidney disease ranks just
below those with lung cancer and is followed by cancers of the colon, breast and prostate.
Indeed, in the US which has a general decreasing trend of smoking, the number of people
succumbing to lung cancer is expected to decline. On the other hand, with an increasing
rate of diabetes, there will be more people with kidney problems which are associated
with a further increase in the risk of heart disease. Hence although, theoretically, people
on dialysis should not die from kidney failure, 10 to 15% per year of them will eventually
die from heart disease or stroke, thus making diabetic kidney disease likely to be the top
killer in many countries in the years to come. Needless to say, in areas where access to
dialysis is limited due to its high costs, people will have premature death due to kidney
failure.
In this connection, non-white populations, including Asians, Native Americans and
Japanese, are known to be at increased risk of developing kidney disease if they have
diabetes.
In a seven-year multi-center survey conducted by the World Health
Organization, 15 to 20% of deaths in Asian diabetic women were due to kidney disease,
in contrast to less than 5% in Caucasian people. In support of this notion, in a recent
Asian survey involving more than 6,000 diabetic patients recruited from 11 countries,
50% of whom were Chinese, 60% of all these patients had some form of early or severe
kidney damage. Of note: once these diabetic patients develop protein in the urine in a
21
persistent manner, many of them will go into renal failure in five to ten years depending
on how well their risk factors, such as blood pressure, blood glucose or blood fat levels,
are controlled. In a study conducted in Hong Kong, patients who excrete large amounts
of protein in the urine had a 4% death rate every year. In comparison people without
protein in the urine had approximately 1% per year death rate. In a Japanese study
involving patients who developed diabetes before the age of 35, more than 50% have
developed kidney failure after 20 years of the disease, a time when they were only in
their mid 40s to 50s -- during their prime of life.
The Cost of Diabetes
These are some of the facts and figures relating to 6.8 million Chinese in Hong Kong.
One in three people are obese, one in ten have diabetes, 30% of whom have the disease
before the age of 40. Twenty-five percent of elderly people have diabetes. This suggests
that one in four of us might develop diabetes if we live long enough. In Hong Kong every
year approximately 8,000 people die of heart disease or stroke, 30 to 50% due to diabetes.
One in two people with diabetes have early kidney damage. Currently 4,000 people are
on dialysis, with 200 new cases every year, and 50% of them are due to diabetes.
Treatment for end-stage renal disease is extremely costly. Indeed the cost of dialysis has
been predicted to increase exponentially and is projected to be in the region of trillions of
US dollars. Given the increasingly young onset of disease, many companies are seeing
their profits eroded by their increasing health-care expenditures on their young and
middle-aged employees.
According to a recent report in McKinsey Quarterly, the
annualized growth rate of health insurance was 6% per year among the Fortune top 500
companies. This greatly exceeded the average yearly rate of growth of profits of these
companies. Based on these figures, it was projected that in five to ten years, nearly 100%
of the corporate earnings will go into health-care expenditures mainly due to chronic
diseases, notably diabetes.
In China the cost of diabetes has been estimated to be US$2.3 billion which accounted for
only 3 to 4% of the overall health-care expenditures. With increasing awareness and
22
improvement in its health-care system, this percentage is expected to increase as China
continues to modernize. In China, as in most countries, 81% of diabetes costs are spent
on treatment of complications. For diabetic persons with no complication, treatment
costs increase two- to 13-fold depending on the types of complications.
On the other hand, according to the American Quality Assurance Committee, it has been
estimated that if blood glucose levels can be controlled in 95% of diabetics, every year
1,473 lives can be saved and 1.4 million sick days can be avoided for an annual saving of
US$164 million. Indeed, when compared to the costs for treating these devastating
complications, such as revascularization for heart disease, dialysis or kidney
transplantation for kidney failure, rehabilitation for stroke, expenditures for high quality
diabetes care and education programs, weight reduction programs and use of appropriate
drugs are comparatively low and are highly cost effective.
Educations – The Cornerstone in Diabetes Management
I would like to emphasize the importance of education in diabetes management. Our
blood glucose level which represents the fuel substrate of
our body is maintained within a narrow range between 4
mmol/l and 7 mmol/l through a complex set of
interacting hormonal systems.
Once this fine control is
lost, everything that we do, everything that we eat, and
every thought that we have can affect our blood glucose
levels. These factors include our diet (how and what we
eat and how often we eat), body weight, exercise,
emotions, other medications and illnesses. Hence, the key
to successful diabetes management is the patients
themselves who have to learn how to manage their
“…the key to successful
diabetes management is
the patients themselves
who have to learn how
to manage their
condition by
understanding the
disease and its
consequences, adjusting
lifestyles, taking regular
medications and
working closely with
their health-care team to
keep their condition
under optimal control.”
condition by understanding the disease and its consequences, adjusting lifestyles, taking
regular medications and working closely with their health-care team to keep their
condition under optimal control. We have previously shown that diabetic patients who
consulted dieticians, performed self blood glucose monitoring and/or stopped smoking
23
had HbA1c, an index reflecting long-term blood glucose control, were 1% percent lower
than those who did not. This 1% difference in HbA1c can be translated to 20 to 30% risk
reduction in all diabetes-related complications in seven to 10 years.
From Advocacy to Action
Given the complex causes and silent nature of diabetes, the management of diabetes and
obesity represents one of the major therapeutic challenges. In Hong Kong we have
developed a weight-management program using a multidisciplinary and multifaceted
approach. After six months treatment with anti-obesity drugs, subjects who did not have
reinforcement of lifestyle changes regained all the body weight lost previously while
those who had lifestyle modification maintained their weight loss. This emphasizes the
importance of combining pharmacological and non-pharmacological treatment in the
management of obesity, a major risk factor for diabetes.
While there is good evidence showing that the risk of diabetes and its complications can
be reduced by lifestyle modification and various medications in high-risk subjects,
implementation of these programs in a quality-assured manner on a large scale remains a
major challenge. In our hospital we adopted a combination of strategies including risk
stratification, periodic assessments, education and empowerment to help patients change
behavior and improve compliance. In this respect the use of peer pressure and champions
as well as frequent feedback and support are the key components in behavior
modification therapy.
In diabetes management, we are now advocating the importance of achieving the ABC
goals: A for HbA1c (less than 7%), B for blood pressure (less than 130/80 mmHg) and C
for LDL-cholesterol (less than 2.2 mmol/l). Despite a large body of evidence showing
that if these ABC goals are attained, the risk of major complications can be reduced by 50
to 70%, many international audits have shown low adherence rates to the processes of
measuring these parameters regularly and attaining these treatment goals. In a structured
care program which we initiated in our hospital back in the early 1990s, diabetic patients
who were followed up according to a structured protocol by a multidisciplinary team had
24
a yearly death rate of only 1% compared to 4 % for patients who were receiving standard
or usual care.
Similarly, in another structured care program delivered by a pharmacist and a
diabetologist, the risk of developing end-stage renal disease was reduced by 50% for
diabetic patients who had moderate kidney damage.
Fifty percent of them would have
died or required dialysis in two-years time if they received only routine medical care.
However, given the fact that 30% of people in the community are obese and that 10%
have diabetes, there is also a need to perform comprehensive assessment to stratify risk in
order to further increase the cost-effectiveness of these structured care programs.
In closing, I would like to highlight the importance of raising awareness through
education and improving quality of care by action. To this end, the yin-yang logo of the
International Diabetes Federation epitomizes the importance of balance and teamwork in
the successful management of diabetes.
25
Dr. Linda Siminerio:
I would like to relate an experience of mine that occurred when I was 12, quite a while
ago, when my father was diagnosed with diabetes. The morning after his hospital stay,
we were all sitting at the breakfast table – that was in the days when everybody ate meals
together. I watched him as his hand started shaking, then he fell from his chair and had a
seizure.
As young children, we were very frightened and did not understand what had happened.
He was whisked away to the hospital, and we were certain that he had died. We had
never seen anything like this before.
When he came walking in the door hours later, we felt it was a miracle. Well, the miracle
was that he simply was given a glass of orange juice and some glucose intravenously.
I realized at that time education was the key to good health care. We learned that if
someone had simply told my mother that breakfast needed to be ready immediately after
my father took his insulin and that orange juice was a simple treatment for dizziness, my
father’s collapse could have been prevented. At 12, I was astounded that this could
happen, and I am still astounded at what is happening today. Believe it or not, similar
situations still occur in every country in this world because people lack the necessary
education.
I named my speech A Global Renaissance,
Diabetes Education because I got very much
involved in health-care education. My own
background was in nursing, I took that a
“Thirty-two years ago, diabetes
education was simply teaching
people how to administer an
insulin injection and test their
urine for glucose.”
step further by earning a Ph.D. in the field of health-care delivery. Thirty-two years ago,
diabetes education was simply teaching people how to administer an insulin injection and
test their urine for glucose. Since then, I think there is some recognition that diabetes
education is a critical, yes critical, element of diabetes care.
26
I think where we have missed the boat for all people with diabetes, especially women, is
that with all of the societal and genetic changes that have happened in all of our cultures,
we have not been providing the necessary diabetes education along the way.
An epidemiologic and a societal transition has taken place. What used to be a problem of
infectious disease has transitioned into problems with non-communicable diseases,
cardiovascular disease, hypertension and diabetes. And most of these are preventable,
preventable with education.
I would like to concentrate on education, particularly why there is a problem, how we can
help with education, and where education needs to be directed.
Consider the incidence of diabetes in all of the different regions of the world: in 1995, up
to 2000, with projections to 2025. In the Americas, we really have a major epidemic
coming upon us.
80
70
60
50
1995
2000
2025
40
30
20
10
0
Afr
Eur
SEA
W Pa
Amer
E Med
Fig. 1 The prevalence of diabetes in adults (millions of people). WHO World Health Report, 1997
The yellow bars in Fig. 1 show that the developing world is facing an enormous problem.
Another huge concern for all of us, in all of our countries, is the onset of diabetes age
27
difference. Refer to the graph in Fig. 2 and notice the numbers for diabetics between the
ages of 45 and 64. When I started focusing on diabetes 32 years ago, we never saw the
condition in people that age. Also, we never saw diabetes in young children, other than
type 1. Now, our young people are being faced with a problem that is an adult disease.
We are seeing even those 10 to 12 getting this adult disease. What is going to happen to
these children in 10 years?
120
100
80
Developed
60
Developing
40
20
0
20-44
45-64
65+
All ages
Fig. 2 Estimated number of people (in millions) with diabetes. WHO Global Burden of Disease
Women, particularly, are disproportionately affected by diabetes.
To review the
numbers: 9.1 million women have diabetes, and it is two to four times higher in minority
populations – Hispanics, African Americans, Western Pacific and Native Americans.
Women suffer more with coronary heart disease, and once they get coronary artery
disease and coronary heart disease, their prognosis is worse than that for men.
There are higher rates of depression and eating disorders in women with diabetes. Also,
with the rise in this epidemic, we are seeing higher numbers of girls affected than boys.
Many women, during their reproductive age, have diabetes and, sadly, many of them do
not know they have the disease. As you have already heard, when we can identify
women who are at risk, those with gestational diabetes, we need to start targeting them
for educational interventions because these women are at increased risk of developing
more serious diabetes in their lifetimes.
28
Diabetes is the leading cause of death among middle-aged women, and over 4 million
women over the age of 65 have diabetes, and
one-fourth of them do not even know they
have the disease. This is why education is so
critical for women. What is the impact and
why are women so influential in prevention
and treatment efforts? Most of the problem,
other than type 1 diabetes, is a result of
dietary factors.
“Diabetes is the leading
cause of death among
middle-aged women, and
over 4 million women over
the age of 65 have diabetes,
and one-fourth of them do
not even know they have the
disease.”
Although our countries are becoming overnourished, there are still
concerns about women who are undernourished.
People who are undernourished in early life and who then become obese tend to get
diseases such as hypertension, heart disease and diabetes at a higher rate. Reducing
malnutrition in pregnant women will have a great impact in the prevention of obesity and
subsequent diabetes.
Also, women control the family health. Dr. Chan shared this with you in her comments
earlier: women control what happens in the home as far as food and television. Just a few
current statistics: today, the average American family spends 15 minutes preparing meals,
compared to two hours a few years ago, and the rates of obesity in children, as you have
heard from many of our speakers, is increasing.
Women influence many of these
changes. Again, that is why education is so important.
While we should have been doing something about education, we have had to face a lot
of other problems. I know that we are told that we should be self-managing and diabetes
is a lifestyle disease that people should have control of, but there are so many societal
influences that have an impact on us, especially on children. Messages promoting foods
that are not nutritious are directed at our children almost every minute of every day. On
top of that, we have computer and transportation issues that are slowing down activity
and thereby increasing the rates of obesity.
29
Good health education is also a responsibility of governments. So, I implore all of you
who are health ministers, please work with your governments because we need strategies
both to help with marketing and to control marketing. For example, in my country,
companies spend enormous amounts on fast food, confectionary and beverage
advertising. Then think about how much our Centers for Disease Control and our Food
and Drug Administration spend on promoting good nutrition.
You can understand the
disparity: a disproportionate amount of funding goes to advertising that promotes poor
health behaviors.
Health-care dollars, I think, are not spent on prevention. They are spent on treatment.
For example, at my own university, the
University of Pittsburgh, those who are
morbidly obese can have their stomach stapled,
and insurance companies will pay for it at a rate
“Health-care dollars … are
not spent on prevention.
They are spent on
treatment.”
of $30,000 per procedure. Yet, insurance companies will not pay for obese persons to
see a nutrition specialist unless they are diagnosed with a disease. Unless they have
diabetes, or unless they have kidney disease, the cost of seeing a dietitian, $50 an hour, is
an out-of-pocket expense.
I just read in our local newspaper that an entire family -- parents and two teenage children
-- all had their stomachs stapled at a cost of $30,000 per person. Their insurance
companies are paying for this. Also, many of you see in the news every day how much
Americans are spending on weight-loss strategies that have not even been proven to be
effective, such as the Atkins Diet and the South Beach Diet. All these diets have been
marketed and promoted without any science behind them, and the costs to our society are
huge.
Care needs to be improved. Not only do we need to educate our policymakers and our
communities and our environments but also we need to educate providers. Believe it or
not, even in the United States, the expenditures for care of those diagnosed with diabetes
30
are very low. Tests that have been shown to prevent the complications of diabetes are
rarely done. Why? Because with managed care, we have seven minutes with a person
with diabetes.
How in seven minutes do you handle somebody with hypertension or cardiovascular
disease, check for all the complications; then teach the patient how important it is to eat
healthy and undertake a good exercise program? It does not happen in seven minutes,
and that is our problem. The same situation occurs in many of our Latin American
countries. Consequently, care is poor.
We need to have education for providers, for health systems which include physicians,
nurses, the community and health workers. We cannot do this alone. We need to educate
the public, advertisers,
“…science has demonstrated that we can prevent the
policymakers,
health
diabetes complications and we can prevent diabetes from
communities,
progressing if we get people at the earliest stages. We just
systems,
and people who are at
do not do it.
risk for diabetes. We know that science has demonstrated that we can prevent the
diabetes complications and we can prevent diabetes from progressing if we get people at
the earliest stages. We just do not do it.
Our problem in health care is that we have way too many patients, and we do not have
enough providers. Recently I spoke with colleagues about the health-care crisis and the
shortage of health-care providers in specific disciplines. We discussed specifically the
shortage of endocrinologists and nurses in this country. This is the case all over the
world. How are we going to handle the growing number of people affected by the
diabetes epidemic with a limited number of providers?
We keep working in the old way. We need to change the paradigm in our health-care
systems.
We need to spread out the work.
No longer is the work of just an
endocrinologist enough. It should be work for a team, and the team should include all
health professionals, including lay health workers in the community. There have been
31
studies showing that in Hispanic populations and in African American populations
community workers can be important members of the team. They are located where
people live and breathe, not in doctors’ offices.
We need programs that support everyone who can touch people with diabetes. We need
to move away from an acute-care approach. We treat disease; we do not focus on
prevention. Our physicians and our nurses are not trained in prevention methods. And
we need to get away from a paternalistic approach – you should do this, you have to do
this, you must do this – and, instead, make the patient-centered approach and education
the pinnacle of good care.
We used to promote knowledge. Care is not about just giving information. People with
diabetes used to be given a diet sheet. What does that mean? We have to learn to
promote translation of knowledge into behavior change.
These are key points and
strategies.
We have already started doing this. We have had some successful collaborations. The
International Diabetes Federation, with PAHO, has already started doing training
programs for health workers in communities who will really educate people in their
communities about prevention and treatment. Also, there is another aspect: evaluation of
the programs. We have trained people in three communities to be data collectors so that
they could assess the effectiveness of our programs.
In closing, I would like to say that when spiders unite, they can tie-up a lion. And so I
hope that all of us, with all of our groups, working together can help improve the life of
women in the prevention and treatment of diabetes.
32
Dr. Mapoko Mbelenge Ilondo:
Diabetes is an epidemic all over the world.
There seems to be awareness of this
phenomenon in the US, in the Americas in general and in Asia, but in Africa there is little
awareness of diabetes.
In fact, when we look at data from the World Health Organization, the major cause of
mortality in Africa is still infectious diseases. This is a fact. It means that all African
governments still have to concentrate on infectious diseases because this is what most of
their people die from. But does it mean that we do not have a problem with diabetes in
Africa? Actually, the data on cardiovascular disease also applies to diabetes because the
risk factors for diabetes and the cardiovascular diseases are the same.
33
Source: WHO January 2003
If you look at the first world, the highincome economies, around the year 2000,
they are past the peak of the diabetes
epidemic, so they are in a progressive
“… Governments only find the courage
and resources to do the right thing when
business takes the lead.”
Kofi Annan
decline. The economies in transition are now about to reach the peak of the epidemic.
But when it comes to middle and low-income economies, they are still in the increasing
part of the epidemic. They have not reached the peak yet. When we perform studies in
Africa, it does not seem that the problem is there. The problem is coming, but we simply
are not aware of it.
We do not have the kinds of statistics regarding Africa that Dr. Barceló had from Latin
America. But we do have some nice epidemiological studies done in some countries, and
those data are consistent with data that Dr. Barceló cited about Latin America. The
results of our Cameroon study of women show that for those living in rural areas, the
prevalence of diabetes is 2.9%, for those in urban areas it is 3.4%.
However, if you look at impaired fasting glycaemia, which is a condition that can be
considered as a pre-diabetic condition, in the rural areas the prevalence is 4.9%. But, as
you move to big cities like Yaoundé and Douala, the prevalence is 10.5%, especially in
34
women. I am not saying that we have a big problem of diabetes in Africa now. The
prevalence of diabetes in Africa is low, but diabetes is on the rise. We can already see
the preliminary signs. It is coming. When we add the obesity factor on top of what these
statistics regarding the transition from rural to urban cities indicate, we find the
proportion of overweight women in rural Cameroon at 5.8%, in big cities, 13.4%.
Apart from the increase in type 2 diabetes that we are seeing all over the world, and also
in Africa, we have to take into account the obesity factor. While the obesity factor is not
something that we are facing right now, it is something that we will face in the future. So
35
what I am saying is that we already have a problem, and this problem is likely to get
worse in the years to come.
Consider three groups of people. The first one is population from Cameroon’s rural
areas. The second one is from Cameroon’s big cities. The third
consists of people from Cameroon who are living in Manchester,
England, where they get westernized. One of the reasons why the
diabetes epidemic is on the rise in developing countries is the
result of what we call westernization of the lifestyle. When these
people from Cameroon move to Manchester, they get westernized:
they change their food habits and adopt a more sedentary life.
Then the fasting plasma glucose in this population increases. So
instead of having the kind of normal glycaemia they had in their
“One of the
reasons why
the diabetes
epidemic is on
the rise in
developing
countries is
the result of
what we call
westernization
of the
lifestyle.”
own country, they are in almost a pre-diabetic condition. What is happening to people
from Cameroon living in Manchester is similar to what has been observed in Jamaica.
36
We do not have a big problem in Africa yet, but we can see as the economic conditions
improve in our countries, and I hope they will, we will find ourselves in the same
situation that exists in the Caribbean.
The prevalence of diabetes is very low in rural areas, but for African executives, it is
10%.
What I just said about the improvement in economic conditions, we already see
occurring in Tanzania. And for reasons that I do not quite understand, African priests
and African nuns also have a high prevalence of diabetes.
In 1994, there were approximately 5.3 million people with diabetes in Africa. The
projection for 2010 is 18.8 million. This is a major increase. And right now, there is not
much being done about diabetes.
All efforts are being directed to HIV/AIDS,
tuberculosis, and malaria. I am not saying that it is wrong – it is correct, because this is
what most people in Africa die from. But if we do not start doing something about
diabetes now, when diabetes numbers reach 18.8 million, we will have a very, very big
problem.
These are some of the challenges that we meet in our fight against diabetes in Africa.
Diabetes is not a public health priority. As a consequence of inadequate health-care
infrastructure and lack of qualified and trained staff, many people only get diagnosed
when they report to the hospital for the most severe lesions.
Take the case of one patient who did report to a hospital where his wound was treated for
weeks with no improvement. He was not tested for diabetes because lack of awareness
by the health-care professionals there. Then, what most likely happens in Africa is that
the hospital concludes that his disease cannot be treated. So this particular patient left the
health-care system and sought alternative solutions. When, after several months, nothing
happened, he eventually came back to the hospital. His condition was so bad, he was
tested for diabetes and diagnosed.
37
Diagnosis is a major problem in our region. The other problem is that diabetes is a
chronic condition. These people with diabetes have to come to the health center every
day to get their injections. This is an enormous strain on the patient and the health-care
system.
Thus, education is very important, but unfortunately in the health-care systems that we
have in our countries there is no place for diabetes educators. Treatment is the sole focus.
You go to the hospital, you see a nurse and doctor, and that is it. There is nothing else on
the agenda.
38