Diabetes: Treat to target

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Prescribing insulin as soon as HbA1C levels top 7% sounds like a relatively simple thing to do, but not in a country like the UAE, says Dr Ezzedin, where there's a cultural phobia of insulin injections.

"There is a fear of injections. Nobody likes injections, and then there are people who do not really like to bother about keeping insulin in a cool place, and it needs to be looked after. It does present us with a problem."

This is just one aspect of the patient-related problems facing clinicians in the region.

Another is the resistance from the general population to accept lifestyle modification to reduce the risk of developing diabetes, says Dr Abdulrazzaq Al Madani, head of the Emirates Diabetes Society (EDS). He likens the attitude of high-risk patients here to that of a speeding driver.

"The majority of people are aware of this but what happens is they think it will never happen to them," he says. "It's like driving fast - they know it will cause an accident, they see that every day, but they think it will never happen to them."

The EDS, along with groups such as the Emirates Nursing Association, run regular mall-based campaigns where they screen shoppers for obesity, hypertension and diabetes.

The Association also runs weekly lectures for primary care doctors and nurses on diabetes management and patient education in line with IDF recommendations, Dr Madani adds.

Ideally, the society would like to see a national prevention programme advertised through the media, aimed at encouraging lifestyle change and screening for high-risk people, he explains. "The Ministry of Health should come out with a unified protocol for diabetes prevention. I hope this will happen and am optimistic."

Lifelong care

Countries with more developed healthcare systems boast national strategies for diabetes care. Standards, such as the UK's National Service Framework for Diabetes, set out a comprehensive plan for service provision, workforce and disease management standards, alongside a timetable of targets to push providers into improving the delivery of care.

Lack of a countrywide overview has resulted in patchy specialist services, and a dearth of specialist professionals in the UAE, says Dr Ezzedin. "There are no paediatric endocrinologists in the private sector, and few podiatrists. Most specialist doctors are at SKMC or other government hospitals and centres."

Boley agrees that specialist care is poor. "I had retinopathy screening, and they had only the most basic idea of what to do. It was done with a big magnifying glass in a dark room with the doctor looking at the back of my eye, rather than using high-resolution digital photograph, and that worries me a little."

But certain facilities are making progress. A number of centres of excellence have sprung up across the country.

The diabetes units at SKMC, Dubai Hospital, Tawam Hospital in Al Ain and Imperial College of London Diabetes Centre (ICLDC) in Abu Dhabi, all offer international levels of service, Dr Madani says.

But the paucity of these units means a relatively small number of diabetic patients are treated in them. Consequently, full training of primary care physicians and nurses is essential. It is one of the four pillars of work that ICLDC is undertaking, according to its medical and research director Dr Maha Taysir Barakat, by running free monthly lectures and occasional workshops on diabetes management and its complications.

‘You will find doctors treating diabetes in primary, secondary and tertiary care," she says. "We share our knowledge as one centre is not enough for all the diabetes patients in the Emirates."

The EDS runs regular sessions for primary care staff, alongside courses aimed at training nurses to become diabetes educators, Dr Madani reveals.

The association has also teamed up with the drug company Johnson & Johnson to open a new education centre for young people with diabetes in Dubai Healthcare City. Patients, their families and healthcare professionals can visit to learn more about the disease.

Education is the most important aspect to diabetes management, Dr Madani adds, for in a largely self-managed disease, patient empowerment is the only way to prevent the development of complications.

"It's a chronic illness and it will stay with the patient for life so the best way to treat it is like an enemy," he says. "And the best way to combat an enemy is to know him - to protect yourself, you need to know your illness."

Action all governments

The UAE's three health ministries are taking strategic steps to address the epidemic. Abu Dhabi Health Authority [HA-AD] is expected to launch a diabetes register this month, where doctors will have to record all their diabetic patients and their treatment regimens.

The move should help coordinate and monitor treatment, as well as plug gaps in data on the actual numbers of people in the country with diabetes, ICLDC's Dr Barakat acknowledges.

"It is important to have this because there is no objective record of how much diabetes there is - we do not actually know."

Another move to aid earlier detection, treatment and improve long-term management is the introduction of diabetic screening in HA-AD's mandatory health insurance scheme for nationals. Introduced in May, the scheme requires all registrants to undergo basic health screens, including blood tests for diabetes.

A similar scheme is expected to be introduced by Dubai Health Authority, as part of its plan for every resident to register with a primary care centre by January 2009.

The initiatives are also targeting the younger generation. A health check scheme for all school children in Abu Dhabi, launched this summer, includes checks for diabetes and obesity alongside educational programmes on diet and exercise. It follows a Ministry of Health study in 2005 that showed by 14 years, UAE children were twice as likely to be obese than those in other countries around the world.

"It is never to early to start talking about diet and exercise," stresses Dr Barakat. "They are intelligent enough to understand the concept and if it's done in a fun way they can end up winning the battle for the rest if their lives."

Medical thinking

Alongside a change in the public's attitude, a shift in thinking is needed from the medical community. A large part of America's success, claims Dr Buse, has been in changing the attitude of medical staff to thinking of diabetes as a disease ‘bad people' get.

"In the US, over the last 10 to 15 years the impression of doctors has changed from one that saw people with diabetes as bringing the disease on themselves by being slovenly and glutinous, to recognising this is a social and environmentally determined disease," Dr Buse tells MT.

"Now it is acceptable for them to say these are not bad people, this disease happens to good people. The fatalistic idea that if you have diabetes bad stuff will happen to you has gone."

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