Diabetes management in low resource setting-Final

1. Management of diabetes in Low Resource Settings Dr Shahjada Selim Associate Professor Department of Endocrinology, BSMMU Visiting Professor in Endocrinology, Texila American University, USA Website: shahjadaselim.com

2. I have nothing to disclose.

3. Presentation Flow • Introduction • Prevalence • Challenges • Management • What can be done

4. Introduction • Management of T2DM in the resource limited settings is suboptimal, often because of challenges with access to medications (globally, patients typically pay ‘out of pocket’).1 • Additionally, increased co-morbid disorders associated with diabetes and a growing population of patients for whom resources must be distributed mean that medications are severely limited.2 • T1DM can still be a death sentence for some patients if they, or their family, are unable to purchase insulin. 1. 2. Forging paths to improve diabetes care in low-income settings. Lancet Diabetes Endocrinol. 2017;5:565. International Diabetes Federation. Access to medicines and supplies for people with diabetes.

5. Introduction…… • In rural Mozambique, for example, the life expectancy of a child who is diagnosed with T1DM has been estimated to be as short as 7 months, equal to that in Britain in the pre-insulin era, 100 years ago.1 • Africa is facing a rapidly growing chronic non-communicable disease burden, while at the same time experiencing continual high rates of infectious disease. • Diabetes has been associated with a three-fold incident risk of tuberculosis, and it is hypothesized that tuberculosis might also increase the risk of developing diabetes. 1. Clinical Medicine 2013, Vol 13, No 1: 27–31

6. Introduction…. • A major barrier to optimal care is the delivery system, which is often fragmented, lacks clinical information and capabilities, and is poorly designed for the coordinated delivery of chronic care. • Implementation of optimal diabetes management requires an organized systematic approach and the involvement of a coordinated and dedicated team, which can often be lacking in clinical practice.1 • Importantly, there are also often delays in diagnosis, creating a greater burden of disease after onset of complications.2 1. Improving care and promoting health in populations: standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42(suppl 1):S7–12. Gopalan A, Mishra P, Alexeeff SE, et al. Prevalence and predictors of delayed clinical diagnosis of type 2 diabetes: a longitudinal cohort study. Diabet Med. 2018;35:1655–62. 2.

7. 4 in 5adults with diabeteslive in low- and middle-income countries 4 in 5adults with diabeteslive in low- and middle-income countries 4 in 5adults with diabeteslive in low- and middle-income countries Prevalence1 4 in 5 Adults with Diabetes live in low and middle-income countries 537 Million adults are living with diabetes (1 in 10) ✓Number of diabetic patients will reach 643 million by 2030 and 784 million by 2045. ✓Diabetes is responsible for 6.7 million deaths in 2021 - 1 every 5 seconds. ✓541 million adults have Impaired Glucose Tolerance (IGT), which places them at high risk of type 2 diabetes.. 2. IDF Diabetes Atlas 10e 2021

8. IDF Diabetes Atlas, 10th edn. Brussels, Belgium 2021. https://www.diabetesatlas.org

9. IDF Diabetes Atlas, 10th edn. Brussels, Belgium 2021. https://www.diabetesatlas.org

10. IDF Diabetes Atlas, 10th edn. Brussels, Belgium 2021.https://www.diabetesatlas.org

11. IDF Diabetes Atlas, 10th edn. Brussels, Belgium 2021.https://www.diabetesatlas.org

12. Bangladesh Update The overall age-standardized prevalence • Diabetes-12.8% (95%CI 11.2-14.3) (men: 12.8%, women: 12.7%), and • Prediabetes-14.0% (95%CI 12.6-15.4) (men: 12.1%, women: 16.5%). • Among people with diabetes, 61.5% were unaware that they had the condition Rakibul M et al 2021. Prevalence of diabetes and prediabetes among Bangladeshi adults and associated factors: Evidence from the Demographic and Health Survey, 2017-18. medRxiv 2021.01.26.21250519; doi: https://doi.org/10.1101/2021.01.26.21250519

13. Plausible etiological factors responsible for the increased propensity to develop T2DM1 Environmental risk factors Genetic and acquired factors Urbanization and modernization Globalization and industrialization Genetic factors (familial aggregations) Ethnic susceptibility Adverse gene–environment interaction (i.e., epigenetics, metabolic maladaptations) Lower threshold for diabetogenic risk factors (i.e., age, BMI, central adiposity) Low muscle mass Increased insulin resistance Decreased β-cell compensation insulin insensitivity Presence of metabolic obesity Increased inflammatory response Environmental risk factors Urbanization and modernization Globalization and industrialization Unhealthy behavioral habits (sedentary consumption of energy- tobacco chewing, consumption) lifestyle, dense food, smoking, and excessive alcohol Sleep disturbances Psychological stress disproportionate to Societal factors Cultural and religious taboos Psychosocial factors Lack of universal health coverage 1. Arun N et al. Diabetes Care Mar 2016, 39 (3) 472-485; DOI: 10.2337/dc15-1536

14. Glycemic Control US 2018 A1C • 50.0% had an A1C value of 7.0% or higher. Specifically: » 22.3% had an A1C value of 7.0% to 7.9%. » 13.2% had an A1C value of 8.0% to 9.0%. » 14.6% had an A1C value higher than 9.0%. • 16.3% of adults aged 18–44 years had A1C levels of 10% or higher, compared to 12.7% of those aged 45–64 years and 4.3% of those aged 65 years or older (Appendix Table 9). https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

15. Bangladesh Update Glycemic Control Table Selim S et al 2018. The challenge of proper glycemic control among Patients with type 2 diabetes in Bangladesh. SJDEM. 6(2). 1-5: DOI: 10.4038/sjdem.v6i2.7310

16. Practical problems in diabetes management • In most developing world settings, especially sub-Saharan Africa, the management of diabetes is suboptimal ► • Few diabetes disease specialists • Limited training of dedicated nurses • Absence of standardized management guidelines and protocols • Frequent fluctuations in the availability of medications • No register or database of health records • Health education is often under resourced and • Health-related behaviors can be complex and difficult to change. Clinical Medicine 2013, Vol13, No 1: 27–31

17. Practical problems with diabetes management in resource-poor settings Access Quality Context Type 1 diabetes management Problems accessing and affording insulin Access to glucometers for the self-monitoring of blood glucose Storage of insulin (refrigeration) Breaks in treatment and the risk of diabetic ketoacidosis Cultural issues regarding self-injection Type 2 diabetes management Problems accessing oral hypoglycemic agents Access to health education Education and understanding around lifestyle and dietary modification Appropriate up- titration of medications Compliance and understanding of the need for chronic therapy Clinical Medicine 2013, Vol13, No 1: 27–31

18. Practical problems in diabetes management • Lifestyle • Health education • Lack of diabetologists and drugs Clinical Medicine 2013, Vol13, No 1: 27–31

19. Lifestyle • People with diabetes are often advised, not only to control their diet, but also to exercise and lose weight; choices that may seem anathema to many in the developing world • In Botswana, for example, a marker of social success is an elevated body mass index (BMI) as in Sri Lanka, Cameroon, Bangladesh? • Acute metabolic complications commonly develop in those with diabetes and these are associated with high mortality: ▪ About 10–30% in DKA and ▪ up to 41% in HHS • These mortality rates are often caused by lack of insulin and delayed presentation. Clinical Medicine 2013, Vol13, No 1: 27–31

20. Health education • Healthcare in developing countries primarily focuses on acute disease, relying little on laboratory services, and offers limited patient follow-up. • By contrast, chronic disease management requires sustainable laboratory services, training of the healthcare workforce, the availability of appropriate drugs, and patient education in nutrition and self-care. • Lack of resources, poor infrastructure and the loss of healthcare workers to developed countries have all slowed progress in these areas • The costs of patient education need not be great: this is one of the least expensive diabetes treatments and is a major and effective part of all of the currently described care-delivery packages Clinical Medicine 2013, Vol13, No 1: 27–31

21. Lack of Diabetologists and Drugs • In the developing world, sub-standard care is frequent and the complications of diabetes are often not screened for, recognized or treated. • It could be argued that generic forms of OADs such as metformin and glibenclamide are relatively cheap and affordable, but interruptions to the supply of essential drugs are all too common. • Unstructured and unmonitored clinical care is unfortunately the norm and there is little in the way of reliable information about treatment outcomes, morbidity and mortality. • There is little doubt that the prevalence of micro- and macrovascular complications has increased in keeping with the rising occurrence of diabetes. • This is likely to strain the health budgets of resource-poor countries Clinical Medicine 2013, Vol13, No 1: 27–31

22. Suggestions as to how these practical difficulties might be overcome • Diabetes register to ensure that patients are tracked over time and to allow population level data to be collected and analyzed; • Standardized assessment checklist to enable optimal screening; • Increased training for specialist diabetes nurses, educators and pharmacists who not only could provide diabetes-related information but who would also be able to undertake most aspects of the diabetes review; • An agreed management protocol to allow escalation of glycemic treatments when there is failure to achieve tailored targets; and • An improved, reliable supply of essential drugs through closer liaison with the local pharmacy Clinical Medicine 2013, Vol13, No 1: 27–31

23. The problem with insulin • Insulin is a difficult medication to replace, store or circumvent. • It is relatively expensive, available only to those who can afford it and presents problems in terms of storage and delivery. • Some insulins have slightly different storage needs; they need to be kept at temperatures below 25oC and insulin that is not being used needs to be refrigerated. • It might be possible to obtain insulin in vials or the like, but the chronic need for consumables such as clean needles and insulin syringes often represents an unsolvable problem Clinical Medicine 2013, Vol13, No 1: 27–31

25. Diagnosis and management of Diagnosis and management of type 2 diabetes in primary health type 2 diabetes in primary health care in low care in low- -resource settings resource settings

26. Recommendations • Point of care devices can be used in diagnosing diabetes if laboratory services are not available. • Advise overweight patients to reduce weight by reducing their food intake. • Advise all patients to give preference to low GI foods (beans, lentils, oats and unsweetened fruit) as the source of carbohydrates in their diet.

27. Recommendations… • Advise all patients to practice regular daily physical activity appropriate for their physical capabilities (e.g walking). • Metformin can be used as a first-line oral hypoglycemic agent in patients with type 2 diabetes who are not controlled by diet only and who do not have renal insufficiency, liver disease or hypoxia. • Give sulfonylurea to patients who have contraindications to metformin or in whom metformin does not improve glycemic control.

28. Recommendations… • Give a statin to all patients with type 2 diabetes aged ≥ 40 years. • The target value for diastolic blood pressure in diabetic patients is ≤80mmHg. • The target value for systolic blood pressure in diabetic patients is <130mmHg • Low-dose thiazides (12.5 mg hydrochlorothiazide or equivalent) or ACE inhibitors are recommended as first-line treatment of hypertension in diabetic patients. They can be combined. • Beta blockers are not recommended for initial management of hypertension in diabetic patients, but can be used if thiazides or ACE inhibitors are unavailable or contraindicated. • Give patients health education of patients on foot hygiene, nail cutting, treatment of calluses, appropriate footwear

29. Recommendations… • Educate health care workers on assessment of feet at risk of ulcers using simple methods (inspection, pin-prick sensation) • Persons with type 2 diabetes should be screened for diabetic retinopathy by an ophthalmologist when diabetes is diagnosed and every two years thereafter, or as recommended by the ophthalmologist. • Unconscious diabetic patients on hypoglycemic agents and/or blood glucose ≤2.8 should be given hypertonic glucose intravenously. Food should be provided as soon as the patient can ingest food safely.

31. Summary • Diabetes management in a resource-poor setting faces a number of diverse problems. • Some of the barriers to effective treatment are practical, but there are also the political, cultural and social issues that must be attended to. • We must work towards a local solution to a globalised problem — one that diabetologists should be at the forefront of responding to.

32. Summary • Newer agents certainly have a role to play in the management of T2DM and may be appropriate as add-on treatments in certain subpopulations, such as those at higher risk of cardiovascular events and where accessibility and cost allow. However, a pragmatic approach is required in regions where resources are limited. • Sulfonylureas are recommended as the treatment of choice for T2DM when metformin alone is inadequate to achieve glucose targets.

33. Thank You