Below are a few snapshots of interviews that portray a range of current perspectives on priorities in diabetes interventions. Some are global, national, and community-level leads, but all have extensive and relevant experience which I’ve tried to illustrate through the following excerpts:
Priority #1: Control the Current Patient Population
Dr. Richard Bergenstal – President Medicine & Science, American Diabetes Association and Executive Director of the International Diabetes Center
Dr. Bergenstal is the current President of the American Diabetes Association and International Diabetes Center. He and I had a very lively discussion on their current efforts with the ADA and global initiatives to expand the capacity and quality of diabetes offerings globally. Their programs are centered on “teaming” approaches for delivering diabetes care – among endocrinologists, primary care physicians, nurses, diabetes educators, families, and patients. Since 90% of care is performed in the primary care setting – expanding the awareness and skill sets of general practitioners is very important (both for referrals, early detection and long-term care). Team care, he believes, is also a critical factor for patient empowerment – which I found extremely interesting. He also reiterated Dr. Ellingson’s points around the need to engage local leadership in country and the need for the “process of customization” in implementing programs.
We spoke openly about his perspectives on priorities for investments in diabetes care. His sentiments are that it is better to address a broken system first to control the current population and then establish long-term systems for prevention. And he has a point. If WHO projects the prevalence rates are going to double, prevention is only addressing half the problem and addressing current needs may best help the group with the most opportunity for change: the high-risk or pre-diabetic population. Increasing patient empowerment and quality of care for the current population also has the ability to increase awareness among high-risk and healthy individuals. Would this accomplish some of the prevention goals as well?
Dr. Bergenstal also mentioned that his daughter is working in public health and debates with him often on this point. From what I hear she leans towards the prevention side on the issue (as many “pure” public health thought leaders would agree). But this just goes to show that in a healthy environment, it’s ok to discuss the pro’s, con’s, and potential intersections of both. Generations later, public health will undoubtedly win on prevention, but focusing on the current population and systemic needs can be an enabler and improve the quality of life of millions in the process.
Priority #2: Promote Public Awareness for Prevention
Dr. Gojka Roglic – Department of Chronic Diseases and Health Promotion, World Health Organization
Dr. Roglic was kind enough to take some time to speak with me about the World Health Organization’s perspective on new programs in diabetes and chronic diseases more largely. Before our discussion, she made it clear that the WHO is more interested in efforts that address government policies and public programs within the country vs. corporate objectives in market. As Project HOPE is primarily funded by corporate giving, I wanted to make it clear that the current diabetes/chronic disease effort is driven by a comprehensive needs assessment that will first set a strategy based on needs, then find funding to fill gaps not met by current government and corporate sectors. Currently (as I’ve mentioned before), 99% of funding for public health programs are focused on infectious disease, women and children, and environmental health causes – which is largely why Project HOPE has mostly corporate funds to work with at the moment.
Within the first 2 minutes of our discussion Dr. Roglic conveyed to me WHO’s priorities very clearly, “prevention.” New programs, new policies, new solutions should all focus on targeting the healthy and at-risk populations. These conditions are ”perceived as diseases of affluence,” but they’re not. It’s time to advocate for education, awareness, and early screening. The right messages have not been communicated in country, for example, many people have no idea that diabetes is preventable (and I’ve seen this over and over again).
She broke down primary prevention into three segments of programs and policies: urban planning, transportation, and food. Dr. Roglic believes that solutions in public health are largely contingent on the options patients have available for food (cheap fruits, vegetables), exercise (parks, sidewalks), and transportation (can they walk or ride a bike safely?). I agree with her entirely on the importance of these topics and discussed the “city gym” and “adult playground” concepts in Brazil and China respectively. Philip’s latest efforts on certifying healthy cities may also be an interesting step in the right direction, although corporate driven. I asked her about Dr. Venkat’s perspective on the fact that clinical trials suggest it is better to focus on high-risk populations vs. the general public. She responded that there are no clinical trials present in obese or overweight populations to demonstrate otherwise. Fair point. I will have to do some research as well and compare what is really available, but even then outcomes that are “significant” are also debatable (as are the study approach, selected population, trial protocol/variables, and methods for statistical analysis).
The key question I had towards the end of our discussion was around lifestyle change. What do you do when people have access to cheap healthy foods, but choose to eat junk food instead? I recalled my experience in India with the popularity of fast food restaurants like McDonald’s and Cinnabon – fruits and vegetables are very cheap and accessible here but many overweight (children especially!) can be seen waiting in line for the more expensive, greasy alternative. In the US many cities have options for facilitated exercise, yet we have one of the highest obesity rates in the world. Is it just about providing choices or do you have to influence how people make decisions?
This may be where the public promotion and prevention efforts come in (coupled with good options) to help change decision-making at the individual, family, and community level. Still, she made it clear that there are no strong examples of lifestyle intervention with convincing outcomes. “It has to be something self-sustaining; conditions that can be replicated.”
Priority #3: Model Interventions Based on Clinical Trial Outcomes
Dr. K.M. Venkat Narayan – Hubert Professor of Global Health, and Professor of Medicine & Epidemiology at Emory University, Previous Chief of the Diabetes Epidemiology, US Centers for Disease Control and Prevention (CDC)
Dr. Narayan and I had a brief initial discussion, but his perspective is worth noting here because of his expertise working with the CDC and experience in the US and Indian healthcare systems. Dr. Narayan has been involved in a number of large-scale diabetes efforts including the Diabetes Prevention Program (DPP), which is probably the largest and most impactful clinical trial in diabetes to date.
His perspective is that clinical trials demonstrate that diabetes and lifestyle interventions are most effective when a person has been screened for either being diabetic or high-risk for diabetes. Therefore, as priorities are concerned screening for early detection and following lifestyle interventions should be the prime focus for investments. These interventions must also have the sufficient intensity (several months) to have a long-term impact; one or two or several touch points are not enough. I mentioned Project HOPE’s programs in Mexico with a 3 month patient education course to get his feedback on that model or intervention.
Dr. Narayan and I are planning another discussion to dive deeper into his experiences with the CDC, DPP, and programs in India in more detail. I’m curious to learn more on his perspectives for increasing the screening rates (e.g. training PCPs, community outreach?), which medical / lifestyle interventions he believes are most successful (how they can be adapted to resource-constrained healthcare systems?), and what outcomes are most valuable in his eyes as a physician-leader in diabetes care globally.
National Leaders & Priorities:
Dr. Shaukat Sadikot – a Vice-President of the International Diabetes Federation and President of DiabetesIndia
Dr. Sadikot has done some inspiring work in India to help increase awareness and empower physicians for better detection and treatment of patients with diabetes. I’ve referenced our discussion earlier, but with respect to investment priorities we also discussed the tradeoffs involved with deciding where to invest educational efforts: patients or healthcare workers? His effort is multi-tiered. DiabetesIndia, of which he is president, focuses on educating healthcare through a network of about 10,000-20,000 physicians. They also perform preventive programs through elementary school efforts. Dr. Sadikot illustrated the need in the medical profession for diabetes training: six years ago he did a conference on diabetes and received 73,000 emails as follow-up.
He also emphasized the importance of bringing together global thought leaders in diabetes to discuss best practices and solutions that could be replicable for multiple regions. Although I have only five countries’ perspectives at his point, sharing ideas across borders could be extremely beneficial to the countries (vs. expensive trial and error methods) and the patients in their respective communities.
Eliana Tameiṛo РSenior Director Corporate Activities, Genzyme Brazil
Eliana is extremely passionate about improving diabetes options for patients in Brazil. Relaying stories to us about her father who has Type 2 diabetes and her grandmother who passed away from its complications (blindness and then amputation), she describes this cause as one that is very “close to her heart.” Eliana spoke about patient empowerments as a key to a successful lifestyle intervention in diabetes. It can’t be a theoretical model – a program has to change people.
The power of a peer community and network was central to her key points. Brazilians are “ready to accept peer-to-peer education.” Group educational sessions offer multiple benefits: effective use of people resources and the ability to allow patients to learn from each other’s experiences. This is very progressive from a diabetes programming standpoint, but over time we may have outcomes that support her hypotheses.
She also mentioned the importance of cheap and accessible early detection (e.g. urine strips). Using the PSF primary care network in Brazil would be a good place to start to help push people into the system.
Dr. Li,jianxin, Director of Cardiovascular Diseases Prevention Department, Shanghai Center for Disease Control and Prevention
China has done a lot to increase its spending in public health efforts and I was very curious to understand their priorities as they relate to diabetes and other chronic diseases. We met with the head of the China CDC for Shanghai (many policies are done by city or province), which is considered a leader among provinces for initiating policies that will be adopted nationally.
China’s CDC is largely focused on awareness and prevention among the larger population (somewhat similar to the WHO priorities). In 2000, they initiated a long-term strategic plan for chronic disease. In addition to public awareness, however, most of their investments have been centered on new technologies and resources for physicians in the hospital and community center setting. They have not yet developed sophisticated chronic disease management models (CDM) to address the current population and are concerned that as more people enter the system, they will be less equipped to handle them.
Dr. Hj. Titi Renawati, Director Diabetes Programs, Ministry of Health of Indonesia
Dr. Titi Renawati started Indonesia’s public health efforts on diabetes just two years ago. Developing a program with Indonesia’s leading experts in the field of endocrinology, HIV/AIDs, primary care, nutrition, and diabetes education they have developed efforts focused on (1) general awareness and (2) physician education materials in the primary care setting. This program is still a pilot being conducted in three districts in Indonesia.
As a country with 17,000 islands 33 provinces, Indonesia is prone to logistical challenges with any national programs. How do you promote a program nationally when the culture and geography is so fragmented? With the government focused on prevention (similar to HIV/AIDs efforts), Dr. Renawati asked if Project HOPE could help with capacity building both at the primary care and community levels.
I could relate to Dr. Renawati’s internal struggle in the nascent years of developing her office on diabetes. At the end of the day, both prevention / promotion and healthcare capacity building have to occur. So how does the government decide what role it takes? For Project HOPE, understanding the local priorities and investments can clarify where they as an organization can have the largest impact. Operationally, best practices across countries can help us determine (when we know our priorities) how to most effectively spend and track our investments over time.
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