Official Journal Of The Trinidad & Tobago Medical - the Trinidad and ...

Caribbean Medical Journal
Health Care Initiatives
Development of a Nationwide T&T Diabetes Outreach
Program
Part 1: Overview
Christopher D. Saudek, MD
From the Division of Endocrinology & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Introduction
Health care professionals, the people of Trinidad and Tobago
(T&T), and its government have known for many decades that
diabetes mellitus is an enormous, and growing, crisis. Poon-
King published a classic study in 19681 , describing the impact
of cardiovascular disease and diabetes. Miller, Byam, et al
tracked cardiovascular mortality related to diabetes in the
1980s2, 3. The late Dr. D. Mahabir and colleagues, in the 1980s,
documented the extent of the problem in the St. James district
of Port of Spain4 . Thus, T&T was one of the first countries
in the world, certainly the first in the Caribbean region, to
recognize the burden of diabetes with a detailed populationbased
epidemiologic survey. Since then, the problem has only
worsened.
In 2003, the World Health Organization (WHO) estimated that
diabetes cost US $812 million in the English Caribbean, and
an excess health care cost of 329% in T&T. The annual cost
of primary care for diabetes in T&T was US $577 per person
5, much less than the cost of complications. In general, health
care expenditures for diabetics are US $10 more per month than
people without diabetes (Diabetics $37 per month, ranging from
$2-833, compared with non-diabetics $US 27 per month, ranging
from US $7-567)4 . Again, the wide range depends largely
upon the extent of diabetic complications. Annual costs for
complications, for example, are $US 138 for retinopathy, $US
2,245 for nephropathy, and $US 69 for neuropathy. (Estimates
for Trinidad and Tobago were extrapolated from Chilean data
cited by the WHO5).
One reason for the high prevalence of diabetes in T&T is the
ethnic makeup of the population. Both African and Asian
Indian ethnicities are known to have high rates of type 2 diabetes.
In people of African descent, the cause is not clear, although
there are indications of genetic variants specific to African
ethnicity 6. In Asian Indians, the evidence is that central
(abdominal) adiposity predisposes to insulin resistance and to
diabetes even in adults of apparently normal weight7 .
The effect of this epidemic of diabetes is both personal and
economic. Complete data are not available to quantify the
morbidity and mortality caused by diabetes in T&T, but in the
United States, diabetes is the leading cause of end stage renal
disease (44% of cases), working-age blindness (12,000-24,000
new cases annually), preventable amputations (>60% of nontraumatic
lower-limb amputations), and neuropathy (60-70%
of people with diabetes have nerve disease) (NIDDK data;
http://diabetes.niddk.nih.gov/DM/PUBS/statistics; accessed 15
February 2010).
There is incontrovertible evidence that management of diabetes
can reduce its morbidity and mortality. Thus, the Diabetes
Control and Complications Trial8 and the United Kingdom
16
Prospective Diabetes Study9 demonstrated long-term reductions
of microvascular complications even 10 years after a limited 3-
5 year period of intensive glycemic control. The Steno-2 study10
and other trials have demonstrated that multiple risk factor
intervention (including lipid and blood pressure management)
reduces cardiovascular disease. There is recent controversy
surrounding exactly what glycemic targets should be set in what
patients, but the consensus is clearly that diabetes management
works.
These considerations prompted the leaders of the Caribbean
nations and their health ministers to gather in Port of Spain in
September, 2007, and to write what became known as the Port
of Spain Declaration. It calls for each nation to have a plan in
place to reduce the effects of chronic diseases including diabetes.
The Trinidad and Tobago Health Sciences Initiative (TTHSI)
is a partnership between the government of T&T, the University
of Trinidad and Tobago, and Johns Hopkins University. Within
TTHSI, the Diabetes Outreach Program was developed in
response to a request by the Government of T&T noting the
burden of diabetes on the twin islands. This manuscript outlines
the Diabetes Outreach Program, developed as a major part of
the TTHSI.
Prevention and Diabetes: 3 Stages
The best approach, of course, would be to prevent diabetes
primarily. The magnitude of that challenge should not be
underestimated, however. We know of no nation in the world
that has actually reduced the prevalence of diabetes, much less
prevented it, by public health action. On the contrary, diabetes
is increasing virtually everywhere in the world, with the fastest
increase being in developing nations (International Diabetes
Foundation data). To be sure, the Diabetes Prevention Program
(DPP), for which we have been a clinical center for the past 13
years, has shown that intensive (and expensive) lifestyle
intervention can reduce the incidence of diabetes by 58%, and
metformin can reduce it by 31% in high risk individuals11.
Primary prevention is a goal worth aspiring to, as indicated in
the U.S. by Michelle Obama’s recent announcement of an antiobesity
campaign. Success, however, would be long term, and
the effort would require nothing less than a change in national
diet and activity patterns.
There are, however, not one but three stages at which the
morbidity and mortality of diabetes can be prevented (Figure
1). Secondary prevention is the goal of good diabetes care:
helping people with diabetes to prevent the occurrence of
complications such as eye, nerve, heart, or kidney disease.
Tertiary prevention requires screening for and treating established
complications of diabetes, to keep them from becoming disabling
or causing premature death. This is also highly effective. For
example, laser photocoagulation, applied at the right time, can