Diabetes Interventions: Divergent Perspectives on a Common Cause

Starting Project HOPE’s research in April, I never anticipated how unbelievably fragmented the perspectives are on the future of diabetes care. At first, this really surprised me. Not only do approaches vary by physician role, geography, and level of experience, but the fundamental priorities and mechanisms for piloting interventions are also quite disparate.

I was first approached by Larry Ellingson in early April to help me understand and coordinate among the varied and established perspectives in the diabetes world. Larry Ellingson is the current CEO of Protemix Corporation and previous Chair of the American Diabetes Association (ADA) with years of experience working on the international task forces with the ADA and International Diabetes Federation (IDF). Larry is also a registered pharmacist and spent most of his career as a leader of global diabetes care for Eli Lilly. After being introduced by Dr. Howe, Project HOPE’s CEO, Larry kindly offered to speak with me and learn more about Project HOPE’s mission in diabetes and other chronic diseases. I was humbled by his offer. I will be the first to recognize that there is a steep learning curve here with many leaders who have been leading the way to address issues related to diabetes for many years. However, we had a pivotal discussion in terms of the fact that that, as he indicated (and encouraged), there is a lot left to be done.

One of my takeaways from our discussion is that fragmentation in the today’s global approaches creates potentially the largest challenge to coordinating among them. Some of this has to do with the fact that the needs, culture, healthcare environment, and policies are very different in every country. I can attest to this even within regions – they are far more dissimilar than I would have thought originally. However, Larry made a point that has stuck with me throughout my research, “the strategy is universal, but the implementation is local.” The IDF has been the communicating and coordinating body for diabetes, but for the larger chronic diseases there isn’t really any resource I could work with who has insights across multiple countries and regions.

Another key point (and something I’ve since seen with my own eyes) is that many of the current leaders in diabetes have been doing truly amazing things to help the patients in their communities. Their efforts are incredibly inspiring and undoubtedly leading the way for developing outcomes-based interventions that “work”. However, it’s important to point out that these efforts are largely focused on implementation vs. strategy – mostly because the patient needs are very urgent and require local and immediate action. My hypothesis is that this focus on local implementation, in many ways, has lead to the segmentation of thought for diabetes interventions globally.

Below are some selected perspectives from global thought-leaders in diabetes and chronic disease efforts provided through Dr. Ellingson and Project HOPE contacts.

Interview Excerpts: (click to read)

Dr. Richard Bergenstal – President Medicine & Science, American Diabetes Association and Executive Director of the International Diabetes Center

Dr. Gojka Roglic – Department of Chronic Diseases and Health Promotion, World Health Organization

Dr. K.M. Venkat Narayan – Hubert Professor of Global Health, and Professor of Medicine & Epidemiology

Dr. Shaukat Sadikot – a Vice-President of the International Diabetes Federation and President of DiabetesIndia

Eliana Tameirão – Senior Director Corporate Activities, Genzyme Brazil

Dr. Li,jianxin, Director of Cardiovascular Diseases Prevention Department, Shanghai Center for Disease Control and Prevention

Dr. Hj. Titi Renawati, Director Diabetes Programs, Ministry of Health of Indonesia

This is why umbrella organizations like IDF (for diabetes) and WHO (for multiple diseases) have such an important role. Larry stressed that for chronic diseases, it’s important to recognize the priorities that exist and work together to leverage assets in the community. It can't just be a diabetes solution, it has to be chronic disease solutions. Not only is it more efficient, but it can be more effective. I’ve noticed that health professionals working in diabetes already see a good cross-section of chronic diseases in their patients: diabetes is where many chronic conditions intersect. For example 95% of diabetes cases are Type 2, obesity-driven insulin resistance (note – this means a BMI just greater than 25 for most Asian countries). According to the IDF 50% of deaths annually are due to cardiovascular disease (CVD which include complications from hypertension, high blood pressure, and obesity. Sever clinical depression is also prevalent in about 15-20% of cases and a good portion have COPD either through obesity, genetics, smoking or all of the above. “This is where 1+1=3,” Larry mentioned. If we can collectively prevent the common causes (nutrition and exercise habits, obesity, smoking) the co-morbidities and mortalities will all go down.

I do believe that Project HOPE can serve as an “innovation engine,” as I described previously, for piloting and tracking outcomes to identify successful and replicable interventions. I met earlier this week with the Director General of the Ministry of Health in Indonesia. As the highest official governing all health programs and policies, he described to me an interesting evolution of their office. Just three years ago they created their division for non-communicable diseases (in addition to the infectious disease and environmental health divisions). They have a lead on diabetes and have spent countless hours developing physician guidelines, educational materials, and health promotion tools. Indicating the level of effort, I asked them who they worked with over the past two years to develop these materials. To my surprise, these were all insular activities or performed “organically” to put it in business terms. I was shocked. To me this is like building a car without consulting an engineering manual – how would you know it’s going to work?

It is clear that a global cohesive strategy is very much needed. Although not necessarily in scope for our research and strategy-setting with Project HOPE, I am hopeful that we can help work with larger umbrella organizations to create, embrace, and fund efforts that are coordinated and communicated globally. In the case of Indonesia’s MOH, they desperately would have wanted some guidance in developing their diabetes programs. I mentioned the opportunity to share “best practices” or a “menu” of programs across countries so they could at least have access to information and contacts on what others are doing. Their eyes lit up. They assumed that because they couldn’t afford to travel and attend international conferences that they wouldn’t have access to this information. They are asking me for help.

Countries can learn a lot from each other regardless of how “developed” their healthcare programs or policies. This week I was elated to find an article in Jakarta newspaper about the US looking to Iraq for innovative ways to provide primary care (see article here). This is wonderful! I am an advocate for breaking away from traditional health models (especially when they are clearly not working) and looking for solutions in unlikely places. Health programs in many resource-constrained areas are perhaps the most interesting, and if they generate strong outcomes can be applied to health systems in a number of countries to reduce the increasing cost and consumption of healthcare resources. This reinforces the point that idea-sharing across borders can be extremely mutually beneficial for both developing and developed countries. In addition, 90% of all chronic disease care (and diabetes care) is provided in the primary care setting. 90%! This creates a lot of room for disruptive models in care that can revolutionize the people, processes, and technologies used to deliver chronic care globally.

As one can infer, the debates surrounding chronic care and diabetes efforts are remarkably complex. For me, Dr. Roglic’s point further explains the reason for the diversity of perspectives here: there is no “tried and true” method. This is extremely frustrating. As emphasized by Dr. Venkat, outcomes are critical to moving forward with any global effort. So what do you do when there aren’t any? Would you risk developing and hedging your bets on strategies that are directionally correct, but potentially incomplete or inaccurate? If the outcomes are good, how do you know they are replicable? Could diabetes educators or peer educators produce better outcomes than the current physician-based systems in many countries? Are physicians’ outcomes being measured in the first place? As Dr. Bergenstal reinforced, if you have $1, how do you prioritize controlling the current population vs. focusing on prevention efforts? Which is more effective?

As we work towards establishing global strategies for chronic care prevention and treatment, it’s imperative to keep a close eye on which programs and policies are working and more importantly, which are not working. This requires a portfolio management that is strategic by nature, but flexible enough to pick-up and drive successful models and quickly adapt less effective models – all based on outcomes. Which outcomes are important is an entirely separate matter. I asked Dr. Roglic about this during our discussion, and she was very clear that there is not one example of interventions that show convincing outcomes. My understanding is that these are still in development and debate globally. At some point we will have to get the right people in the same room to align and drive towards these outcomes. This will facilitate the “strategy” we need to guide global portfolios in chronic disease care!