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Diabetes Mellitus in the

Pacific:Public Health Issues

Dr. Kimberly OmanFiji School of MedicineDiploma in Medicine

Revised September 2002

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Epidemiology of Type I Diabetes

Country Prevalence per 1000

Finland 2.2

USA 1.0UK 0.7

France 0.24

India 0.060.7China 0.09

Japan 0.03

Tropical Africa 0.03

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II Diabetes age 30-64 (downloaded

WHO 1998)

Country of origin Group %men %womenUSA white 5 7.2

India S India rural 3.7 1.7

S India urban 11.8 11.2

Durban SA 14.4 20.8

Dar es Salam Tanzania Hindu 17.8 13.2

Dar es Salam Tanzania

Muslim

18.0 16.6

Fiji - Indofijian Rural (Sigatoka) 23.0 16.0

Urban (Suva) 23.6 20.3

Fiji - Indigenous Rural (Sigatoka 2.1 1.7

Urban (Suva) 5.2 11.9

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Country of origin Group %men %women

Papua New Guinea Highlanders rural 0 0

Highlands periurban 0 0

Costal rural 2.7 0

Costal periurban 8.2 4.8

New Caledonia 0-2.5 2.3-3.3

Kiribati Rural 4.0 4.6

Urban 15.8 13.4

Nauru 40.6 42.0

Tuvalu Funafuti 1.3 6.3Western Samoa Rural 2.1 4.9

Urban 10.7 10.4

Niue 7.9 10.4

Cook Islands 7.0 10.1

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Complications of DiabetesMellitus

Hypoglycemia Diabetic ketoacidosis / hyperosmolar coma Retinopathy Nephropathy Neuropathy

peripheral neuropathy autonomic neuropathy

Amputations Macrovascular disease (strokes, ischemic

heart disease)

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Diabetes Mellitus:Burden of disease to the individual

Being diagnosed as sick despitefeeling well

Doctor visits Need to take medications

Complications Blindness Amputations Heart attacks and stroke

General unwellness Premature death

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Diabetes Mellitus:Burden of disease to the family

Premature disability (especially strokes,amputations, blindness) Loss of income

Loss of productivity: childcare, domestic duties Need for family to care for unwell individual(loss of employment opportunities)

Transporting patient for clinic visits

Premature death Loss / grief

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Diabetes: Burden to the Nation(1)

Need for clinic visitsfor glycemic control Patient education

Insulin

Oral hypoglycemicagents

Related conditions(CAD, HTN,

hyperlipidemia)

Doctors, nurses, healthcentres, lab support Dieticians, health

educators, TIME Refrigerators, syringes,

Education!! Reliable drug distribution

infrastructure Expensive drugs,

hospitals, Coronary careunits

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Diabetes: Burden to the Nation (2)

Nephropathy Retinopathy

Amputations

Early infirmity

Premature death

Dialysis ($$$$$) Opthamologists,

laser machines Surgeons, hospitals,

antibiotics,prostheses

Loss of taxableincome, need forhome carers,

pensions

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Natural history vs. clinical course ofdisease for Type I Diabetes (1)

Time Disease manifestations

Week one

NATURAL HISTORY

STARTS HERE

Polydipsia, polyphagia, polyuria

DKA: DIAGNOSIS MADE

Insulin started

CLINICAL COURSE STARTS

HERE

Rest of patients life Hypoglycemia (occasional)

Hyperglycemia / DKA (with

intercurrent illness

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Natural history vs. clinical course ofdisease for Type I Diabetes (2)

Natural history = clinical course of dz

Time Disease manifestations

After decades Retinopathy, Nephropathy,

Peripheral Neuropathy,

Cardiovascular Disease

Then Blindness, renal failure,amputations, heart attacks,

strokes

DEATH

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Natural history vs. clinical course ofdisease for Type II Diabetes (1)

Age Manifestations

Age 25 (does natural

history start even earlier?)

Undiagnosed gestational diabetes

Several large infants by c-section

Age 30 Undiagnosed glucose intolerance

Age 35 Takes up a sedentary job

Coworkers bring in sweets everyday

Becomes obese

Age 40 Overt diabetes (by fasting blood

glucose) but no one checked

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Natural history vs.clinical course of disease for Type II Diabetes (2)

Age Manifestations

Age 55 Hospitalized for MI

Raised random blood glucose discovered

Elevated serum creatinine

No one checked fundi

DIAGNOSIS MADE

CLINICAL COURSE STARTS HERE

Age 55-59 Starts diet therapy

Fails to lose weight

Started on oral hypoglycemic agents

Poor compliance

Natural history vs clinical course of disease

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Natural history vs. clinical course of diseasefor Type II Diabetes (3)

Natural history much longer than clinicalcourse

Age Manifestations

Age 60 Congestive heart failure

Foot ulcer leads to amputation

Complains of poor vision

Advanced retinopathy noted

Age 62 DIESof 3rdmyocardial infarction

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Reducing the burden of disease dueto diabetes mellitus

Primary prevention Prevent diabetes from developing

Secondary prevention Early diagnosis Control of blood sugar - does this reducecomplications?

YES! - first demonstrated in 1998 forType 2

Tertiary prevention Recognizing complications at early treatable stage

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Diabetes in the United States

Plenty of doctors and dieticians Plenty of specialists Diabetes educators Many educated and highly motivated patients Self-help groups for patients

Home glucose monitoring is widespread BUT

Many patients not educated about their diabetes Cultural, language and financial barriers Many doctors who communicate poorly Many poorly-controlled diabetics

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Diabetes in Ethiopia

Very impoverished nation

85% live in isolated rural areas

Few drugs, poor access to health clinics

Terrible or nonexistent roads Limited diagnostic capability

Many other serious health problems

75% of diagnosed rural diabetics are Type

One: WHY?

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Type one diabetes in Ethiopia

Most must travel 20km to get insulin supplies(poor or non-existent roads) 1/4 must travel over 100 km (3-5 day journey) Often short supplies - only given 1-2 months

insulin Use minimal insulin to survive (to conserve

supplies) leading to severe wasting Few long-term survivors

Type 2 diabetics: why bother?

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Diabetes in the Pacific

Many diabetics

Limited public awareness of diabetes

Fewer resources

Understaffed, very busy clinics Not enough doctors, dieticians and nurses

Problems with distribution of medicationsand supplies

Problems with remoteness andtransportation

B i i i i

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Basic exercise in economics:A trip to Cost-u-Less

How much does a television cost? a small radio? Which will you buy:

If the bill comes to you? If the bill comes to daddy?

If Daddy has 10 children and they buy expensivethings every week, what will happen whenDaddy goes broke?

No schooling House and car repossessed by the bank No food ETC ETC

H lth i i i

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Health economic issues inDiabetes Mellitus

Should you spend 10x as much for a medication If there is significant benefit? If there is marginal / equivocal benefit? If it is only available in the major centers?

What are the relative costs of health care

worker time compared with medications? If you spend health resources on world-class

care for your own patients, will less be availablefor patients in remote settings?

Is it ethical to spend more health resources on

some patients than others? (ie. the articulate,the educated, the prominent, etc.)

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Approaches to lowering the burden ofdisease due to diabetes

International

Regional (Pacific Islands)

National

Provincial District

Local Hospital

Health Centre

Community

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Medication costs (Fijian $) 1996

Glibenclamide 5 mg Glipizide 5 mg Tolbutamide 500 mg Metformin 850 mg Isophane insulin 10 U Syringes (one) - 1 ml HCTZ 50 mg Atenolol 50 mg Propranolol 40 mg Captopril 12.5 mg Pravastatin 10 mg (BNF-97)

Home glucose monitor Test strips (50)

$0.006 $0.07 $0.01 $0.04 $0.12 $0.10 $0.005 $0.04 $0.01 $0.07 $1.73

$43.00 $35.00

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National level decision making (1) Should all diabetic patients be monitoredwith HbA1C 4 times a year? Cost (1999)

$10 per test (excluding transport costs) 30,000 diabetics in Fiji $10/test x 4 tests per year x 30,000 = 1.2 milliondollars!

Moral issue If transporting lab specimens outside of the majorcenters is a problem, is it ethical to only test atmajor centers?

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p ons or spen ng m on

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p ons or spen ng . m onto lower the disease burden from

Diabetes mellitus (1)

Health care workers $10k/yr($5/hr)

Health care workers $20k/yr($10/hr)

Health care workers $60k/yr($30/hr)

(dieticians, doctors, nurses,community workers, educators)

Overseas expert visits (20 days @

$1000/day) 4-wheel drive vehicles ($50,000) Boats for island visits ($25,000)

120 HCWs 60 HCWs 20 HCWs

30 visits

24 cars 48 boats

m on o ower e sease

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m on o ower e seaseburden from Diabetes mellitus

(2)

Diabetic education and treatment options 120 HCWs x 1940 hours/HCW/yr / 30,000diabetics = 7.8 hrs/diabetic/yr

Television and radio commercials Educational program in the schools

Other community awareness programs

Hemodialysis ($50,000/yr) - 24 patients(which ones???) (???CAPD)

Laser machine to treat retinopathy (?cost)

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National level decision making (3)

How often should diabetic patients seea doctor?

Assumptions: 30,000 diabetics in Fiji

10 minutes per visit Sample calculation: monthly visits 30,000 x 12 visits/yr x 1/6 hr/visit x

1920 hours/yr/doctor (40-hr week) Need 31 doctor full-time equivalents

(FTEs)

National level decision making

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National level decision making(4)

How often should diabetic patients see adoctor? (2) Summary

Monthly visits: 31 doctor FTEs Every 2 months: 16 doctor FTEs

Every 3 months: 10 doctor FTEs OR: see patients monthly for 3 minutes: 10 doctorFTEs

How do you get extra doctor FTEs? Work existing doctors harder for the same pay

(leading to migration, loss to private practice)

Recruit doctors from overseas Train nurses and nurse practitioners

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National level decision making (5)

What is the economic impact of replacingtolbutamide with glipizide?

Assumptions: Tolbutamide 500 mg po tds: $11/yr

Glipizide 5 mg po bd: $51/yr

Assume 10% of diabetics on glipizide

30,000 diabetics in Fiji

Estimated cost to Fiji per year: $112,000

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Yearly $ of ideal diabetic control(Fiji health budget: $26/head)

Metformin 850 mg po tds Isophane Insulin 25U nocte Enalapril 20 mg po daily Lovastatin 10 mg po daily

($8/m) Home glucose monitor (1/5

of total cost per year) Test strips (2x/wk) HbA1C 4x/year PLUS clinic visits, dieticians,

lab tests, specialist servicesfor complications, etc.

$44 $190 $29 (2002) $96 (2002)

$9

$73 $40 Total: $481 ($385

without statins)

i h b d f di

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Lessening the burden of disease atthe national level - resource

allocation (1)

Development of treatment guidelines Based on evidence

Economic analysis Epidemiology (determining # of

diabetics) Education / training of health care

workers Initial training Continuing medical education / in-servicetraining

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Lessening the burden of disease atthe national level - resource

allocation (2)

Hiring more staff

Medications

Equipment

Laboratory support

Transportation Facilities to treat complications

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Lessening the burden of diabetes mellitus at thelocal level

(hospital and/or district level)

More effective clinic visits Evidence-based practice More time with patients

Organize support services Dieticians Diabetic educators

Empower other doctors and health care

workers Teaching Evidence-based guidelines and protocols

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Issues for Fiji (exercises) Metformin is more expensive than

sulphonourea medications. Is it worth the

extra cost?

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Rules: confine your search to: Cochrane Collaboration

New England Journal of Medicine Annals of Internal Medicine ACP Journal Club Lancet British Medical Journal

Journal of the American Medical Association Medical Journal of Australia Journal Watch (General Internal Medicine) No internet surfing (except major guidelines) Recent textbooks including UpToDate

Clinical evidence