A Diabetes ‘Epidemic’ in Hawke’s Bay?

A Diabetes ‘Epidemic’ in Hawke’s Bay?
By Elizabeth Sisson

Today, there are 6,755 known cases of diabetes in Hawke’s Bay. Based on national statistics, there could be at least 1,000 more people with undiagnosed diabetes here. The repercussions are huge … and growing.

Diabetes is an increasingly common disease which, untreated, can lead to serious complications and death. Diagnosed early, it can be controlled. Chronic, complex and, to date, incurable, diabetes can develop at any age. Numbers of people with diabetes are rising here and worldwide. In response, the NZ Ministry of Health (MoH) has made diabetes a national health-services priority, setting treatment targets for all district health boards.

The MoH says diabetes is the major preventable cause of renal (kidney) failure and dialysis, lower-limb amputation and avoidable blindness in working-age adults and it’s a major risk factor for cardiovascular disease.

The MoH also reports that diabetes contributes to inequalities in life expectancy for Maori, Pacific people and Asians in New Zealand. The incidence rates for Maori and Pacific people are more than three times higher than the European rates and Maori and Pacific people are more than five times as likely to die from undiagnosed diabetes.

Based on statistics, the MoH expects the prevalence of diabetes to increase at an accelerating rate. The Ministry has charged health boards to identify and treat people with diabetes who have yet to be diagnosed.

Locally, the Hawke’s Bay District Health Board (DHB) is working to respond to the MoH requirement and the anticipated increase of diabetes cases. The DHB’s own stocktake (November 2010 Board Paper) notes that diabetes services have “tended to exist or be developed in silos,” and points to a scarcity of up to date information for both health professionals and people with diabetes, less than optimal referrals, and unequal access to available services.

In addition to the very human toll diabetes takes on individuals, families and communities, it can be very expensive. For example, the DHB cost of dialysis per individual per year is $40,000-$70,000, depending on where and how patients receive that treatment. Fifty people currently receive dialysis at the Hastings hospital, at least half of them as a result of diabetes. The DHB’s current budget specifically for diabetes treatment is $1.2 million. This does not include costs for dialysis, which are covered in the renal service budget, or for services such as ophthalmology and vascular surgery.

It is in everyone’s interest, first, to be familiar with the symptoms of diabetes; second, to understand what can help prevent its development and progress; and third, what services are available to help.

Graeme Norton was very familiar with diabetes: his father had it for more than 40 years. A competitive cyclist, Graeme thought his own healthy, active lifestyle would prevent diabetes. He was wrong. Failing to recover after a cycle race four years ago, he went to a GP who diagnosed him with Type 2 diabetes, gave him a prescription for pills and sent him home.

When the pills failed to help, Graeme was referred to Dr Janet Titchener, a GP with a special interest in diabetes who arrived in Hawke’s Bay about five years ago. Janet diagnosed him with Type 1 diabetes, prescribed insulin injections and, with him, worked out a regime of care.

“She empowered me to learn enough to become an expert on my own condition,” Graeme said. “I learnt more in a few weeks than I had in years previously.”

“Each person is unique and has a very different experience of the illness,” Janet said. “They are the experts on their life, their culture, family and work demands, their belief system. If the patient does not participate meaningfully in choosing what they want to do for their management, they’re not going to be compliant with a treatment plan.”

The impact of diabetes on Graeme’s life was considerable. “When you get diabetes, your whole family gets it,” he said. “The responsibility is with you and the family or whanau around you. Providers need to explain to all of them what’s happening — but, at the end of the day, the only person who manages your condition is yourself.” He sees education and access to coordinated diabetes health services as essential to the successful treatment of diabetes.

“What worries me is that those who are articulate and involved get over-serviced and those who are not don’t get access. I’d rather see more spent on prevention and early intervention, which saves money in the long run.  I also want to see more emphasis on outcomes. Our health system is designed around activities, not outcomes. We should ask: has this intervention achieved a measurable result? If not, we should be doing something else.”

Dr Titchener trained as a primary care physician in the US, and diabetes ultimately became her major focus. Based on data collected in her patient-centred practise, she reports measurable outcomes in the treatment of diabetes. Essentially, she tracks HbA1c, the measure of a patient’s average blood sugar over three-month periods. Research indicates that if a person can reduce their HbA1c count by one percentage point, then they will have reduced their risk of a heart attack or stroke by 27% and their risk of retinal disease and renal disease by 22%.

“Our average reduction across the board – Maori, Pacific, pakeha, etc. — in HbA1c is two percentage points,” Janet said. “But what is very exciting is that the patients are maintaining this two percentage point reduction for two years after they have been discharged from the service. And, based on the US literature, for every one percentage point reduction in HbA1c you save about 30 percent of expected health-care dollars.”

Graeme, whose HbA1c had been higher than 11 – out of control – brought it down to under seven. In his case, the more he learnt about his disease, the more control he took over it, especially by changing his eating regime. One book he recalls: How to Think Like a Pancreas!

In 2010, the Hawke’s Bay PHO and the HBDHB jointly established the Diabetes Service Development Group. They recruited Graeme and other users of diabetes services, Janet and a host of other GPs, medical specialists, community and practise nurses, a DHB planner and representatives of special interests, such as Diabetes Hawke’s Bay and the local Iwi, to be members of the group, charging them to review diabetes services and make recommendations for improvement and integration.

What emerged is a proposal for an integrated service approach to diabetes with an emphasis on patient participation and self-management, and education. So how might that work?

Sharon Rye and Caroline Malan, both members of the group, are nurses with Te Kupenga Hauora-Ahuriri in Napier, a community health service that sends nurses into local homes. Te Taiwhenua o Heretaunga in Hastings provides similar community-based services.

Sharon and Caroline say the service already provides education and support to people with diabetes and their families. “We have registered nurses and community support workers who can describe diabetes in lay terms,” Sharon said. “We have to give information to people in a way that is meaningful to them.”

Visiting nurses can identify new cases of diabetes. “When we’re in a home we can check on everyone there.” With a holistic, case-management approach, they can refer the people they see for services as needed.

Current nurses employed by Te Kupenga Hauora – Ahuriri work with a significant number of clients diagnosed with diabetes. To carry out the Ministry of Health’s charge to identify undiagnosed people with diabetes, they claim they would need to recruit more staff trained in
this area.

That brings us to funding. The development group presented their proposal for diabetes services to the DHB at the Board’s November meeting. The recommendations are all you might wish: emphasis on reducing inequalities: patient-centred care and self-management; creation of a diabetes information service centre; a steering committee that includes people with diabetes; a monitoring and accountability framework.

Two members of the development group, Dianne Keip, portfolio manager with DHB Planning and Performance, and Trish Freer, service development manager with Hawke’s Bay PHO, now are working on the final stage of the group’s concept: a detailed implementation plan that will include costs, timelines and outcome measures.  This will be delivered at the DHB’s March meeting.

“The central philosophy is patient-centred, family-centred, community-based care,” Dianne said. “People need to be able to manage themselves, especially as the diagnosed numbers of diabetics grow.”

WHAT IS DIABETES?

According to the Southern Cross Medical Library (www.southerncross.co.nz), diabetes is a metabolic disorder, which means a problem with the process by which food is digested and used as energy by the body. It is a chronic (long-term) condition characterised by high levels of glucose in the blood.

If not treated it can cause long-term complications such as heart disease, kidney damage, stroke, circulatory problems and damaged vision.

Here’s a more detailed description: During digestion most foods are converted into a sugar called glucose. Glucose is a simple sugar that is the main fuel source for the body. Once food has been converted to glucose, it moves into the bloodstream, where it is circulated around the body. It then passes into the body’s cells to be used as energy.

For glucose to pass from the bloodstream into the cells, insulin is required. Insulin is a hormone produced in the pancreas, a large gland behind the stomach. In people with diabetes, there is a problem with the production of insulin or with the body’s ability to use it.

There are several types of diabetes. Type 2 accounts for 90% of all diagnoses. In Type 2, the pancreas produces insulin, but possibly not enough to meet the body’s needs — or the cells can’t use it properly. Type 2 diabetes is often described as “adult onset diabetes.” It can develop at any age, but most commonly after age 40.

There is a strong hereditary component to Type 2 diabetes and it also is related strongly to obesity. The more overweight a person is, the more likely they will develop diabetes.

Type 1 diabetes is most common in children and is a condition in which the pancreas produces little or no insulin.  Often it is described as “juvenile onset diabetes.” The causes of Type 1 diabetes are unclear, but it is believed that certain viruses or environmental factors as well as genetic factors are involved. Some evidence suggests diet and stress play a part in development of Type 1 diabetes.

KNOW THE SYMPTOMS OF DIABETES

The symptoms of Type 2 diabetes develop gradually and can go unnoticed. The common symptoms are:

• Weight loss
• Excessive thirst
• Excessive urination
• Fatigue
• Nausea
• Irritability
• Yeast infections
• Blurry vision
• Skin wounds that are slow to heal
• Numbness and tingling in the feet

If you or someone in your family seems to have some of these symptoms, visit your general practitioner for a check-up.