Prevention of diabetes complications in developing countries: time to intensify self-management education

Abstract

The IDF report has indicated that about 80% of four million diabetes-related deaths that occur every year comes from the developing world. The IDF report suggests the need to focus more on preventing diabetes complications in poor countries. Thus, considering the economic constraints in combating the explosion of diabetes complications in the developing regions of the world, it appears that exploring culturally adaptable educational intervention programmes for specific regions would be the appropriate strategy. We believe that diabetes-related deaths could be reduced in developing countries through intensified diabetes self-management education.

Keywords::

• Type 2 diabetes
• diabetes complications
• self-management education
• developing countries

The 2009 Atlas Report of the International Diabetes Federation (IDF) on the global prevalence rates of diabetes showed that diabetes prevalence is much more prominent in the developing regions of the world and more than 438 million people will be living with diabetes by the year 2030 (Sicree et al., 2009). Unfortunately, the statistics suggests that the intense campaign on the prevention of diabetes by the IDF and affiliated organizations around the world has not matched the epidemic development of diabetes in poor-resource countries and indeed the entire world (Sicree et al., 2009). The reports of increasing prevalence of type 2 diabetes in young adults in both the developing and developed nations poses yet more challenges for the campaign for prevention of diabetes and its complications (Vivian et al., 2011). As childhood type 2 diabetes is associated with obesity and sedentary lifestyle, management of both obesity and diabetes in adolescents will demand robust treatment paradigm and more challenging in the developing world (Scollan-Koliopoulos et al., 2011). In developing countries, childhood type 2 diabetes may be associated with additional risk factors such as intra-uterine environment and birth weight (Singh et al., 2004), factors which, with appropriate interventions, could be stemmed.

That 70% of world diabetes cases are resident in the developing countries is unacceptable considering the regional and world campaign initiatives to prevent diabetes on the entire globe (IDF, 2004, 2006; WHO, 2000). With the escalation of the prevalence rates of diabetes in the poor countries, it would appear that the burden of diabetes has shifted more to diabetes complications. For instance, it is known that about four million diabetes-related deaths take place every year and 80% of this is in the developing countries (Roglic & Unwin, 2009). Thus, it becomes reasonable to argue that there is an urgent need to focus more on preventing diabetes complications in populations that do not have the economic resources to combat the potential explosion. In India, for example, the national budgetary allocation for healthcare in 2010 was US$4.5 billion whereas the annual direct and indirect costs for diabetes care in the same year was estimated as US$31.9 billion (Tharkar et al., 2010). Thus, faced with the daunting task of combating both communicable and non-communicable diseases, it is time to explore culturally appropriate educational intervention on prevention of diabetes complications in the developing countries. The gap in health inequalities in developed and developing countries is so wide that not stemming diabetes complications in poor countries is not an option. Rawal et al. (2011) recently reviewed studies on non-pharmacological intervention to prevent diabetes and its complications in the developing countries. The summary of the review suggests that non-pharmacological educational intervention in patients with type 2 diabetes could be effective in preventing diabetes complications if the intervention tools are sustained and optimized (Kim, 2007, 2008; Sun et al., 2008; Wattana et al., 2007). It should be noted that studies in developed countries have confirmed that non-pharmacological interventions assisted in controlling glycaemia in type 2 diabetes patients and subsequently prevent diabetes complications (Davis et al., 2007; Eriksson & Lindgarde, 1991; Tuomilehto et al., 2001). It is also expected that more culturally adaptable non-pharmacological intervention studies are conducted in developing countries to seek outcomes similar to those of the developed world (Simmons et al. 2009). Type 2 diabetes is a condition, both in developed and in developing countries, that if poorly controlled is associated with diabetes co-morbidities and complications and eventually diabetes-related mortality (DCCT, 1993; UKPDS, 1998a, b). Thus, because of the peculiar limited economic resources available in the developing countries, diabetes co-morbidity and mortality rates are higher and more devastating in poor countries (Roglic & Unwin, 2009).

Even with the limited research output from the developing countries, reports of high prevalence rates of cardiovascular risk factors in patients with type 2 diabetes are abundant in the medical literature (Ezenwaka et al., 2007, 2009). Similarly, research on social and economic impact of diabetes have shown that the economic impact of diabetes and diabetes-related mortality rates are greater in poorer countries in the developing regions of the world (Roglic & Unwin, 2009; Tharkar et al. 2010). These reports suggest that there is the urgent need for more intense diabetes education tailored for prevention of diabetes complications. Poor glycaemic control and obesity are the central risk factors for cardiovascular disease in type 2 diabetes patients in the developing countries (Ezenwaka et al., 2007, 2009). Previous non-pharmacological intervention studies in the developing countries targeting exercise, dietary modification or increased blood glucose monitoring have shown both relative risk reduction in the incidence of type 2 diabetes (Li et al., 2008; Ramachandran et al., 2006) and improved CHD risk profile in the patients studied (Ezenwaka et al., 2011; Sun et al., 2008). Indeed, it could be argued that the risk of diabetes complications could be improved through empowerment of the patients for diabetes self-management. The management of type 2 diabetes is mostly glucocentric, warranting that the major target in self-management of type 2 diabetes should be self blood glucose monitoring. The issue of cost-effectiveness of self-monitoring of blood glucose in persons living with type 2 diabetes has been contentious (Allen et al., 1990; Ezenwaka et al., 2011; Davidson, 2005; Jansen, 2006; Welschen et al., 2005). While some authors argue that it is a waste of scarce resources and time (Davidson, 2005; Allen et al., 1990), others have reported immense benefits of self-monitoring of blood glucose (Ezenwaka et al., 2011; Jansen 2006, Welschen et al. 2005). Although it is important that cost-effectiveness analysis must be considered before prescribing self-monitoring of blood glucose in type 2 diabetes patients in developing countries, the cost should not be allowed to constitute a barrier to patients’ empowerment education. For instance, despite the claimed high cost of glucose test strips, the overwhelming majority of Caribbean type 2 diabetes patients who practice self-monitoring of blood glucose considered glucose self-monitoring as beneficial and useful in blood glucose control (Ezenwaka et al. 2011). Indeed, in advocating for patients’ self-management education to prevent diabetes complications, the patients, the healthcare system and the healthcare providers must collaborate as partners. It is only when these three stakeholders show sufficient commitment, interest and willingness to be part of the team for self-management education that the outcome will be beneficial for everybody.

Acknowledgement

Prof Ezenwaka received a Re-invitation Scholarship to visit German Diabetes Center Dusseldorf from Deutscher akademischer Austauschdienst (DAAD) of the Federal Republic of Germany and a travel grant from the University of the West Indies, Trinidad and Tobago.

Declaration of interest

The authors state no conflict of interest associated with this paper.