Diabetes: Treat to target

As the international community focuses its attention on diabetes this month, MT takes an in-depth look at how the disease is being tackled in the UAE.

For all its new hospitals and glitzy technology, the United Arab Emirates' (UAE) healthcare system has acknowledged failings when it comes to grassroots care.

For patients with diabetes mellitus, a chronic and potentially disabling disease, it's all too easy to fall through the gaps.

"I'd be terrified if I was actually diagnosed here," says James Boley, a British expatriate living in Dubai who has had type 1 diabetes for 10 years. "There's no call back, no patient follow-up and no mandatory screening for retinopathy or kidney disease."

The decision to move to the UAE was a tough one for Boley, largely because of his concerns over the quality of care on offer for his condition. His diabetes is self-managed, with up to eight injections a day of basal and bolus insulin, administered in response to pre-injection blood sugar tests.

Boley's main bone of contention, however, lies with his health insurance cover. Exclusions mean he spends a hefty AED700 (US$190) per month of his own money to manage his disease.

He can claim money back for the cost of insulin prescriptions, doctors visits and blood tests, which he has every three months, but has to pay the first AED100 of each of these. He also has foot the bill for the blood testing strips he buys, at a cost of around AED500 per month.

"I have quite a few arguments with the insurance company over this, because if they do not sort this out, in the long run they will pay more," Boley reasons.

Limited health insurance plans are a major obstacle to high quality and continuous disease management, agrees Dr Huda Ezzedin who heads the diabetes centre at Sheikh Khalifa Medical City (SKMC) in Abu Dhabi.

Some insurance companies make no provision for diabetes education or consultation with dieticians and lifestyle advisers either, which are all major planks of a comprehensive diabetes care plan.

"They are not included, patients have to pay for it out of their own money and very few do," Dr Ezzedin reveals.

"I cannot work alone, I can give advice but I can't teach patients how to perform blood tests or sugar testing, and how to have a good diet and do more exercise. I can not do all that in a consultation, so we depend on diabetes educators and dieticians."

Patchy insurance coverage is just the tip of the iceberg, however, when it comes to the obstacles clinicians face in trying to improve the detection and management of diabetes - and improvements are sorely needed.

Figures presented by Dr Ezzedin at a conference in Paris in April this year, in partnership with the American Diabetes Association (ADA), showed that less than 30% of patients with type 2 diabetes in the UAE achieve the recommended HbA1c level of less than 7%.

The average blood sugar level among this group is 8.1%: far higher than the normal level of 6% in the non-diabetic population.

It's alarming news for a country that sits second only to a small island in the Pacific Ocean in world rankings for diabetes.

An estimated 20% of the UAE's population is affected by diabetes, a figure that is expected to rise to 22% by 2025, according to data published by the International Diabetes Federation (IDF) in 2007.

A wealthy disease

Type 2 diabetes is a disease of affluence; and one the UAE is increasingly susceptible to. The combination of an ageing population and the country's major social changes - including urbanisation, westernisation and significant economic growth - has been a key driver in the disease's growth.

Type 1 diabetes, the genetically linked form of the disease, is also on the rise. The Arab populations has proved more predisposed to this condition than other demographics.

The widely held hypothesis about the diabetes epidemic, according to Dr John Buse, president of the ADA, is that it has been brought on following radical changes in the quantity, quality and types of foods humans eat, coupled with a reduction in physical activity during the past two hundred years.

"These changes in America have happened over a generation or two but it has happened even faster in the Middle East," he tells MT. "It has been hundreds of years but most environmental changes occur over millions of years. So the ability of humans to adapt to this change, from a genetic point of view, is still lacking."

It has taken the US 15 years to see the impact of aggressive diabetes management. The policy was introduced in the late 1990s after three landmark studies showed that intensive treatment to reduce HbA1C levels to 7% or less dramatically cut the risk of diabetes-related complications such as retinopathy, neuropathy, renal and macrovascular disease.

"Fifteen years ago most patients were quite well controlled, but not perfectly. We used to have a lobby full of people with missing arms and legs or on dialysis," Dr Buse confides. "But now I go months between seeing patients who are blind or with amputations - things are changing."

Treat to target

Latest advice from the ADA and the European Association for the Study of Diabetes states that insulin should be used at the earliest opportunity for people with type 2 diabetes, once their HbA1C level rises above 7%. An amended version of the algorithm has been developed for the Arab population.

Professor Julio Rosenstock, director of the Dallas Diabetes and Endocrine Centre and a clinical professor of medicine, says ‘treat to target' is the essential message for both physicians and patients.

"We are trying to teach doctors that you need to start insulin injections at 7%, even if patients are using oral pills, to get the lowest HbA1C possible without low blood sugars."

This is a departure from traditional care guidance that first asked patients to change their lifestyles, then prescribed oral medication, a combination of oral medications and finally insulin for the most resistant patients, says Profession Rosenstock.

"The problem is over the years doctors have used insulin as a threat, ‘if you don't exercise or improve your diet I'll put you on insulin,'" he says. "Because of that it takes 10 years for insulin to be started. And during those 10 years patients have high blood sugar levels and there is damage to the major blood vessels."

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