Diabetes: no time to lose

An urgency needs to be shown in dealing with diabetes mellitus

Diabetes mellitus (DM), a life-long condition in which insulin, a hormone that lowers blood glucose is either deficient, i.e., Type 2 diabetes (T2DM) or completely absent as in Type 1 diabetes (T1DM). Consequently, insulin is needed from the outside and is vital for all Type 1 diabetics.

Of all cases of diabetes, a vast majority (90 percent) have Type 2 diabetes. People with T2 DM almost always have pre-diabetes first, a condition where blood sugar levels are higher than normal but not high enough to be labelled as ‘diabetes’. In Pakistan, the prevalence of pre-diabetes is 11.4 percent and of diabetes 15 percent according to a meta-analysis published in the Pakistan Journal of Medical Sciences (2019). Being overweight or obese is the most prominent factor in the development of diabetes. Type 2 diabetics who are overweight find it hard to control their glucose levels.

In a clinical trial approximately 88 percent T2DM patients who followed intensive dietary intervention went into remission after losing or maintaining >15kg body weight. Other contributing factors are: lack of exercise or sedentary lifestyle. Similarly, regularly consuming high glycaemic index foods, which increase your blood glucose can rapidly put you at a high risk of developing diabetes. These include: sugar, sugary foods, fizzy drinks, rice and potatoes etc. Having a family history of diabetes or diabetes during pregnancy (gestational diabetes) also increases the likelihood of having diabetes later in life.

Why is it important to keep blood sugars within normal range? Diabetes mellitus is a complex and heterogenous disease. If undiagnosed or left untreated, it leads to complications affecting many systems of our body. Multiple organs can be harmed by persistently raised blood glucose but the most vulnerable are: heart, brain, eyes and kidneys.

In a low-middle income country lacking comprehensive health coverage, problems due to severe and uncontrolled diabetes like kidney failure leading to dialysis, blindness and diabetes-related amputations not only lead to immense burden on the family due to out-of-pocket medical expenditure but also stretch the resource-constrained economy.

In order to minimise such complications, adequate management is of paramount importance. In addition to maintaining a healthy lifestyle, like incorporating regular exercise and eating healthy, there are two main treatment categories: oral medications (tablets) and injectables. The mainstay of therapy for T1DM is insulin whereas T2DM can have both: tablets and insulin. As insulin is needed for both main types, its availability remains a challenge, particularly in resource-limited settings like ours.

Patients requiring insulin not only need injectable medication (insulin) but also related products like glucometer, test strips, needles and a sharps container. The barriers can be categorised broadly into these four domains: health system related, factors associated with patients, physicians-related and private sector (pharmaceuticals). With the abysmally low healthcare expenditure, currently $43 per capita, a number of medications, including essential drugs are not obtainable.

Insulin and related products are no exemption, particularly when dealing with over 19 million people with diabetes in the country (International Diabetes Federation). In a publicly-funded healthcare facility insulin is available to diabetic patients who are either admitted in hospitals or presenting in emergency rooms. Those who attend out-patient clinics do not get it.

Among the non-affording patients, Type 1 diabetics are worst affected. Meethi Zindagi, a not-for-profit organisation founded by Sana Ajmal in 2018, has 140 children currently enrolled with it. Their capacity is to support up to a maximum of 3,000 case - a drop in the ocean. Abaseen Institute of Medical Sciences (AIMS) in Peshawar, a volunteer-run organisation, has 30,000 registered diabetic patients and around 300 registered juvenile diabetic patients. For non-affording patients, the hospital covers the cost of Rs 7,000 ($45) per month. It includes consultation fee, blood tests, medication and checks for other diabetes-related conditions like retinal (eye) screenings.

We are all in it together. It is everyone’s responsibility. Both public and private sectors have a role to play. It is a well-known fact that any chronic disease can be effectively managed through patient-engagement and holistic care. This can be achieved through a well-established primary care system. Urgent attention is needed by the government to address the paucity of trained general practitioners and lack of availability of full array of services (e.g. eye care, foot care) to the defined population.

Primary care transformation initiatives are a must to deal with the huge burden of this non-communicable disease. Continuing medical educational (CMEs) activities arranged by the private sector (pharmaceuticals) must focus on evidence-based medicine, encourage general practitioners/family physicians to be patient advocates and provide medications/related products at a discounted rate, especially in the Covid-19 times when a significant number of families have been affected by job losses. It is time we realise the gravity of the situation and act fast. There is no time to lose.

The writer is an assistant professor in family medicine at the University of Health Sciences Lahore

Diabetes: no time to lose