Global perspectives on diabetes Volume 57 – July 2012
The right environment f o ra l
World ay Diabetes D poster inside
Diabetes: protect our future www.worlddiabetesday.org
6/6/2012 2:27:39 PM Jamie Oliver
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27 DiabetesVoice 33 Contents
Diabetes Views 4 International Diabetes Federation Promoting diabetes care, prevention and a cure worldwide News in Brief 6 Diabetes Voice is published quarterly and is freely available online at www.diabetesvoice.org. THE GLOBAL CAMPAIGN This publication is also available in French and Spanish.
Building capacity for care and prevention in Malawi 12 Timothy Ntambalika Editor-in-Chief: Stephanie A Amiel, UK Managing Editor: Olivier Jacqmain, [email protected] health delivery Editor: Tim Nolan, [email protected] Advisory group: Pablo Aschner (Colombia), How to protect the children of the Food Revolution – Ruth Colagiuri (Australia), Patricia Fokumlah (Cameroon),
Interview with Jamie Oliver 14 Attila József (Hungary), Viswanathan Mohan (India). Layout and printing: Luc Vandensteene, Ex Nihilo, Belgium, World Diabetes Day 2012 – expanding the circle of influence 17 www.exnihilo.be Isabella Platon Diabetes and climate change: two interconnected All correspondence and advertising enquiries should be addressed to the Managing Editor: global challenges 25 Katie Dain and Lucy Hadley International Diabetes Federation, Chaussée de La Hulpe 166, 1170 Brussels, Belgium Creating a network to tackle diabetes and Phone: +32-2-5431626 – Fax: +32-2-5385114 – [email protected]
NCDs in Latin America 27 Noël Barengo and Ruby Trejo © International Diabetes Federation, 2012 – All rights reserved. CLINICAL CARE No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permis- IDF breaking new ground – building BRIDGES around the world 30 sion of the International Diabetes Federation (IDF). Requests Ronan L’Heveder to reproduce or translate IDF publications should be addressed to the IDF Communications Unit, Chaussée de la Hulpe 166, 33 Exploring ethnicity in people with type 2 diabetes in Australia B-1170 Brussels, by fax +32-2-5385114, or by e-mail Margaret McGill and Stephen Twigg at [email protected]. DIABETES IN SOCIETY The information in this magazine is for information purposes only.
Haiti fights for a brighter future 36 IDF makes no representations or warranties about the accuracy and Philippe Larco and Nancy Charles Larco reliability of any content in the magazine. Any opinions expressed are those of their authors, and do not necessarily represent the views of IDF. IDF shall not be liable for any loss or damage in connection Civil society facing down the diabetes emergency in Mali 40 with your use of this magazine. Through this magazine, you may Stephan Besançon and Sidibe Assa Traore link to third-party websites, which are not under IDF’s control. The inclusion of such links does not imply a recommendation or an endorsement by IDF of any material, information, products and services advertised on third-party websites, and IDF disclaims any liability with regard to your access of such linked websites and use of any products or services advertised there. While some information in Diabetes Voice is about medical issues, it is not medical advice and should not be construed as such.
ISSN: 1437-4064 Cover photo : Jamie Oliver © Jamie Oliver
July 2012 • Volume 57 • Issue 2 DiabetesVoice 3 Diabetes views
At the recent Rio+20 sum- mit, the world leaders and experts came together to Widening IDF's find effective solutions to the many deep fissures that are weakening the very fabric of human societal development – driven by the inexorable implosion of an inherently flawed and unjust financial footprint system. Unfortunately, the event will change very little. During the first quarter of this year, we began to see the impact and The dismal results prove that there is still much work to be done results of the alliances and partnerships forged over the previous in changing the mentality of governments and decision-makers 12 months. We are seeing the increasing strength and influence worldwide. Diabetes is a real health issue with critical links to the of IDF’s Member Associations, amplified through global alliances environment and economic growth of countries. which underline our external focus. Diabetes is a complex condition – from its multi-pronged aetiology and relentless disease path to the multifaceted approach required to manage diabetes on a daily basis. Moreover, the world is waking up to the interplay between the multiplicities of interconnected external factors whose influ- ence is exacerbating the global rise in NCD numbers. In today’s world of intricately interwoven economies and globalized means of production and retail, diabetes appears to have found danger- ously fertile ground – particularly among poor and underserved people in low- and middle-income countries. Diabetes and other NCDs are stealthily engulfing even those communities that were previously considered low-risk.
It is far from coincidence, then, that the launch of the World Diabetes Day 2012 campaign also aims to expand our circle of influence beyond the borders of diabetes, while remaining focused on our core disciplines, including the development, publication and distribution of clinical guidelines. We are all part of the solution to this diabetes epidemic. Therefore, we are convening the different stakeholders and catalyzing dialogue. Our aim is to change the way people think of diabetes on two levels. Our target audience is those who refuse to accept that diabetes is any of their business, those already affected and those at risk. We are engaging these groups by drawing the direct links between diabetes and global health issues.
A good example is the climate change event at the recent World Health Assembly in Switzerland – a groundbreaking collabora- tion with a sector that is new to the all-of-society campaign be- ing mounted by IDF against the current pandemic of NCDs and diabetes. The private health company, Bupa, was IDF’s joint host at the expert dialogue on diabetes and climate, where health and climate sectors gathered to discuss how jointly to tackle these serious challenges. The event brought type 2 diabetes and climate change into the spotlight, as two of the most urgent challenges of the 21st century. Highlighted the connections between climate change and type 2 diabetes that are repeatedly overlooked in Jean Claude Mbanya is IDF President for global policy dialogue. the period 2009 to 2012. He is Professor A promising victory emerged from the 2011 UN High-Level of endocrinology at the University of Meeting on NCDs in New York: the target-25% by 2025. I would like Yaounde, Cameroon, and Chief of the to take this opportunity to acknowledge IDF Member Associations for their role in these achievements. However, we still have to fight Endocrinology and Metabolic Diseases for the other targets to be passed. Unit at the Hospital Central in Yaounde.
4 DiabetesVoice July 2012 • Volume 57 • Issue 2 Diabetes views
Diabetes is, depress- ingly, coming of age – as has been forewarned incessantly in these Phoenix rising: pages over the past decade by a succession of IDF presidents, editors and expert authors. The paradox of the modern world offsets the potential benefits of globalization and rising prosperity (for some) with the personal and economic costs of the rising tide of diabetes a better and other costly chronic diseases – adding to the con- stellation of other serious socioeconomic and health challenges facing the world. Geography, poverty, social re-structuring, under-developed infrastruc- future for ture and disruption by war and civil un- rest threaten the lives of people with type 1 diabetes care? diabetes and feed the rising number of people with type 2 diabetes. end of a dangerously long queue for aid and life-sustaining medication. Although insulin is classified by the World Health Organization as Growing wealth in some sections of society bring about lifestyle an essential medicine, people with diabetes in Port au Prince faced change by revolution, not evolution, driving the diabetes pandemic agonizing periods without insulin in the aftermath of the earth- by mechanisms that remain unsuspected until after the event – and quakes that struck Haiti in 2010. We have recorded in earlier issues with unexpected side effects. In this issue, we learn that the obesity how civil society in Haiti, in the form of another small but highly pandemic now may be a threat to the very processes that created motivated diabetes NGO, the Haitian Foundation for Diabetes and it in the first place (like those obscure biochemistry formulae that Cardiovascular Diseases (FHADIMAC), strove to plug those gaps describe reactions that can go in either direction in textbooks with in care provision. An update from Haiti in this issue reports on the two arrows pointing in opposite ways) through a little-discussed situation in Haiti two years on. FHADIMAC has become a reference impact on climate change (page 25). But initiatives are underway of the government’s plans to tackle diabetes. From the ashes of failing that offer reason for optimism. healthcare systems, new and sustainable structures might arise to improve previous provisions of care for diabetes and beyond. Santé Diabète was created in Mali some 20 years ago as the first development-related NGO to focus on protecting people with dia- New initiatives look not just at treatment for existing diabetes but betes. It was a tiny outfit operating in a country facing multiple social also at its prevention. Noël Barengo’s article describes the develop- and economic difficulties, including an epidemic of HIV/AIDS. Two ment of a network for diabetes prevention under construction in decades later, with about half the population subsisting on USD 1.25 Latin America; IDF’s Bridges projects develop and test deceptively per day and multiple societal challenges – including political unrest simple interventions in both treatment and prevention. and recent military activity in some regions – further complicating life in Mali, the activities of Santé Diabète have become crucial to Meanwhile, Diabetes Voice is pleased to include a contribution from the survival of people with diabetes. The group’s founder provides us an English celebrity chef, Jamie Oliver, who has given prominence with an update on the situation in Mali and brings a message of hope. to the axiom that if you want to change a society you start with the children. Mr Oliver makes clear that in terms of healthy food and Another report from one of our Member Associations describes how to prepare it, the developed world has much to learn from the the challenges facing people with diabetes and their healthcare developing world – those biochemistry arrows again! They can and providers in Malawi, the ‘Warm Heart of Africa’. Malawi too is should go in both directions and one of the political imperatives drinking from the poisoned chalice of development. As its economy must be the recognition that the developed world does not have improves (Malawi has become a net exporter of food), more and all the answers. The Phoenix has her work cut out, but we at IDF more Malawians living in rural areas are drawn to the many op- are there to give her a flying start! portunities – for employment, health and social care – offered by life in the cities. As we have seen elsewhere, that rapid urbanization brings with it a sharp increase in risk factors for type 2 diabetes. Public awareness of the risks from diabetes to individual health has grown exponentially over the past decade – partly because Stephanie A Amiel is the RD Lawrence there appears to be no one left these days who either does not have Professor of Diabetic Medicine at diabetes or does not know someone with the disease! King's College London and Consultant
When any country is affected by extreme circumstances and multiple physician to diabetes services at health challenges, people with diabetes tend to find themselves at the King's College Hospital, UK.
July 2012 • Volume 57 • Issue 2 DiabetesVoice 5 News in brief
More evidence on environmental factors driving up diabetes
An international team of research- by behaviour that promotes obesity. To assess the properties of these spatial ers has studied the spatial patterns However, lead researcher Hernán Makse arrangements, the researchers studied relating to the spread of obesity and concluded that genetics are unlikely to population density, prevalence of adult diabetes. Their findings suggest that play a major role in the obesity epidemic obesity and diabetes, cancer mortality overweight, a key risk factor for type 2 and that the spread of this major risk rates and economic activity. At criti- diabetes, may have more to do with col- factor for type 2 diabetes cannot be tack- cal points, long-range correlations ap- lective behaviour than genetics or indi- led by focusing on individual behaviour. pear, which may signal the emergence vidual choices after all (Scientific Reports of “strong critical fluctuations in the 2012. 454 doi:10.1038/srep00454). The prevalence of NCDs appears to de- spreading of obesity and diabetes”. Moreover, the research exposed rela- velop in clusters, and the spread of obe- tionship between the geography of the sity has been seen to be affected by global The team of investigators believed that obesity epidemic and patterns of food economic drivers. The researchers used the correlations of fluctuations in the marketing and distribution. For exam- microdata provided by the US Centers prevalence of obesity might be linked to ple, a relationship was seen between the for Disease Control Behavior Risk Factor demographic and economic variables. prevalence of obesity and the growth of Surveillance Systems from between 2004 To test their hypothesis, they compared ‘the supermarket economy’. and 2008 to investigate spatial corre- the spatial characteristics of industries lations for specific years. According to involved in food production and points The study did not look at causality – their spatial map of obesity in the USA, of sale – supermarkets, shops selling whether market forces are driving obe- neighbouring areas tend to have similar food and soft drinks, restaurants and sity or the market is being influenced levels of obesity and type 2 diabetes. bars – with other sectors of the economy. Areas with above-average concentra- tions of food-related businesses had high-than-normal prevalence of obesity and diabetes. Professor Makse’s conclu- sions lend credence to the premise that environmental factors are influencing the virus-like spread of NCDs, and wrest importance from genetics, arguing that were it genetics alone that determined obesity, the team would not have seen the correlations.
6 DiabetesVoice July 2012 • Volume 57 • Issue 2 News in brief
Obesity a major threat to food security
The UN predicts that by 2050 there could be 2.3 billion more regional differences, which also point to different stages in the people living on our already crowded planet. Concerns over development of the obesity epidemic that is fuelling the global the demand for natural resources and the effects of over- diabetes emergency. Across Europe, for instance, the average population on the environment and national economies weight was 70.8 kg, compared to 57.7 kg in Asia. More than have prompted some observers to call for measures to con- half (55.6%) the people living in Europe are overweight while trol birth rates – particularly among women in developing only 24.2% of Asians are overweight; staggeringly, almost 75% countries. However, researchers in the USA warned recently of people living in North America are overweight. of a concomitant and comparable threat: the impact on the environment of the flabby bodies of people in the developed Very serious concerns have been raised by the researchers’ countries, the USA in particular. projection of the effect on our planet of a global population equivalent in terms of body weight to that of the USA. They This groundbreaking research, undertaken by scientists at predicted that if all people had the same average body mass the London School of Tropical Medicine (UK), looked at the index as people in the USA, the total human biomass would average weight of adults around the world and found that put on another 58 million tonnes, which would impact heavily increasing population fatness could have implications for on the energy requirements of our species. world food energy demands similar to an extra one billion people on Earth. Put together, the adult population currently Professor Ian Roberts, who led the research, said: "Everyone weighs some 287 million tonnes. A staggering 15 million accepts that population growth threatens global environmen- tonnes of this is due to overweight, with 3.5 million tonnes tal sustainability - our study shows that population fatness due to obesity. is also a major threat. Unless we tackle both population and fatness, our chances are slim." Using data from the UN and WHO, the researchers found that the average US adult weighs 81 kg, almost 20 kg more than For more on the links between diabetes and environmental the global average adult, 62 kg. They found other interesting issues, see the article on page 25 of this issue.
July 2012 • Volume 57 • Issue 2 DiabetesVoice 7 News in brief
Brands finding new ways to market to children
A recent study has exposed the range of advertising tools employed Approximately 16% of the 1678 food references identified were to market potentially harmful food and drink products in children's portrayals of branded food products (or food brands). However, magazines in Australia (Pediatr Obes 2012; 7: 220-9). According to only 83 of these 269 were clearly identified as advertisements. Of the authors, children's magazines ‘blur the lines’ between editorial the 269 branded food references, 86% were for non-core (broadly, content and advertising, and have escaped calls for government less healthy) foods, including all but seven of the advertisements. restrictions that are currently associated with food advertisements aired during children's television programming. The aim of this The researchers concluded that the recent reductions in televised study was to address gaps in the evidence base in relation to com- promotions for non-core foods, and industry initiatives to reduce mercial food messages in children's magazines by investigating the targeting of children, have not carried through to magazine the nature and extent of food advertising and promotions over a advertising. They wrote that their study adds to the evidence base 12-month period. The research team collected and examined for that the marketing of unhealthy food to children is widespread, and references to foods or beverages all issues of Australian children's often covert, and supports public health calls for the strengthening magazines published in 2009. of advertising regulation.
Photograph a famous face for World Diabetes Day
Join the global campaign Go to the IDF website (www.idf.org) and The blue circle is the universal symbol for click on the World Diabetes Day links to view diabetes awareness and this year IDF wants the Pin a Personality gallery of famous faces. to make sure that want everybody knows it. You can help. Join the World Diabetes Day Beat the deadline Pin a Personality campaign. The aim is to Upload your photos before November 14 to photograph a well-known person wearing the World Diabetes Day Facebook page or a blue circle pin. on Twitter using #WDDPin. Make sure you include a couple of lines telling the world Choosing a person to pin why you chose that person. Your personality should be someone you think will catch people’s eye and draw their Whom you would like to portray with a pin attention to the blue circle badge. Or some- for diabetes? When you are ready to take one who contributes to IDF’s mission to on the Pin a Personality Challenge, email promote diabetes care, prevention and a the World Diabetes Day team at wdd@idf. cure worldwide. He or she might be some- org and we will send you a pack of blue one from the entertainment world or an circle pins. athlete or politician. Or they could be a local diabetes hero – like a nurse, a volunteer, a See the report on page 17 of this issue for more teacher or trainer. Good luck and happy snapping! on this year’s World Diabetes Day campaigns.
8 DiabetesVoice July 2012 • Volume 57 • Issue 2 News in brief
IDF recently launched a new advocacy IDF launches programme, Diabetes Roadmap to the Future Development Agenda (The Diabetes Roadmap Roadmap).
to the Future Following in the footsteps of the landmark IDF Diabetes Roadmap Development Agenda Programme that was dedicated to secur- ing strong diabetes outcomes from the UN Summit on NCDs, IDF has designed a successor programme for the period 2012-15. The opportunities for change during this period are immense. For the first time we have political agree- ment on diabetes and NCDs with the unanimously adopted UN Political Declaration on NCD Prevention and Control; for the first time the global dia- the international diabetes federation’s betes community has a clear vision and solutions for the next decade in IDF’s the internationaldiabetes diabetes federation’s roadmap to Global Diabetes Plan 2011-2021; and agenda for the first time since 2000 the world the futurediabetes development roadmap to a2012-2015genda will discuss and define what comes uture development after the end date of the Millennium the f 2012-2015 Development Goals (MDGs) in 2015.
The Roadmap will build on the achieve- ments of our UN Summit campaign and maximize this unique opportunity to integrate diabetes and NCDs into the future development agenda. IDF has always given our full support to the MDGs, but the absence of diabetes and NCDs in the MDGs has been a major obstacle to mobilizing leadership and resources. Now is our chance to change this. The door is open to catalyze a para- digm shift in the global development agenda that would benefit the millions of people with diabetes worldwide.
Continuing with our twin track ap-
IDF’S DIABETES ROADMAP FUTURE DEVELOPMENT AGENDA 2012-2015 1 proach of working both for diabetes and influencing NCD level work through the FUTURE DEVELOPMENT AGENDA 2012-2015 1 IDF’S DIABETES ROADMAP NCD Alliance, IDF will drive forward an ambitious and comprehensive pro- gramme of work to achieve our aims.
July 2012 • Volume 57 • Issue 2 DiabetesVoice 9 News in brief
Industry fury at New York initiative Diabetes, fructose against potentially harmful drinks and liver risk
The decision taken recently by the mayor of New York to ban the sale of sugary Researchers at the US Johns Hopkins drinks over 470 ml (and 25 kcal/100 ml) at restaurants, cinemas, sports venues University suspected that high con- and on public transport provoked a strong negative reaction by the food and sumption of fructose might provoke beverage industry. The lobby group Center for Consumer Freedom ran a full-page liver damage, so they looked closely at advertisement in the New York Times featuring a digitally edited photograph of data from the Look Ahead Fatty Liver mayor Bloomberg as a nanny with the tagline, "New Yorkers need a mayor, not a Ancillary Study, an observational, nanny." Center for Consumer Freedom was founded to oppose bans of smoking cross-sectional study involving people in restaurants and bars. in the USA. Obese people with type 2 diabetes who reported high daily con- Formerly called the Guest Choice Network, the group’s advisory board is comprised sumption of fructose experienced re- largely of representatives from the restaurant, meat and alcoholic beverage industries. duced levels of adenosine triphosphate It organizes media campaigns opposing the efforts of scientists, doctors, health ad- in the liver – reflecting impaired liver vocates and environmentalists, and its reaction to this initiative, which is designed to function – compared with those who protect health, was echoed by others in the industry. A spokesperson for McDonalds consumed less (Hepatology doi: 10.1002/ commented in the New York Times called the ban narrowly focused and misguided. hep.25741). The investigators also deter- mined that elevated uric acid may serve Meanwhile, the Director of the Rudd Center for Food Policy and Obesity at Yale as a marker of impaired liver function University, Professor Kelly Brownell, com- following consumption of fructose in mented that, "There's very strong scien- people with type 2 diabetes. tific evidence that when people are served more they eat more, or in 244 adults with type 2 diabetes aged this case drink more. The Mayor's between 45 and 76 years completed a proposed ban will affect enough questionnaire on their daily fructose people in a strong enough way consumption. The researchers also to create a pretty significant recorded levels of uric acid and meas- public health benefit." ured hepatic adenosine triphosphate. In their conclusion, they underlined the urgent need for increased public awareness of the risks related to high fructose consumption.
10 DiabetesVoice July 2012 • Volume 57 • Issue 2 News in brief
Questions over drug trials in developing countries
A paper in the British Medical Journal by an emeritus professor of diabetes in the UK has accused producers of insulin and other medications of carry- ing out drug trials to increase sales in developing countries. Although not required by licensing authorities, post-marketing studies are often carried out in order to determine the performance of a medication in the real world – without the regular, close monitoring of the clinical trial. Edwin Gale’s article questioned the purpose and usefulness of such trials.
Gale looked at post-marketing trials of analogue insulins, which are markedly more expensive than the conventional human insulin – al- though according to England’s National Institute for Health and Clinical Excellence, analogues do not offer significant benefits for most people with diabetes.
According to the report, since 2005, nearly 400,000 people have been recruited into post-marketing trials of analogue insulins, mostly in middle- or lower-income countries. Gale pointed to the unnecessary cost burden placed on people with diabetes and healthcare systems in the developing countries hosting the post-marketing trials: “The patient or healthcare system pays for a more expensive agent instead of one that is cheaper and equally effective, and the public is offered misleading claims of comparative merit based on studies of limited scientific value.”
July 2012 • Volume 57 • Issue 2 DiabetesVoice 11 The global campaign Building capacity for care and prevention in Malawi
Timothy Ntambalika
A impromptu meeting of people with diabetes at the Queen Elizabeth population growth, particularly now Central Hospital in the country’s capital, Blantyre, generated the impetus in urban areas, is driving an increase to establish the Diabetes Association of Malawi. The author of this report in lifestyle diseases that are established among the urban poor living in post- was among those founding voices to call upon other people with diabetes industrial countries. The obesity that is to come together to form an organization that would advocate for the being unleashed upon young people in health rights of people with the disease. Although diabetes awareness and Mexico and increasingly elsewhere in knowledge were generally low among people with diabetes, as well as the Latin America, or the diabetes-related wider public, in Malawi, people with diabetes in the country are only too stroke and heart disease epidemics that aware of the very serious shortfalls in the provision of care, and the often- are sweeping South-East Asia are ap- difficult access to essential medications. With type 2 diabetes emerging pearing in Malawi. Malawi has been striving to overcome the impact of a as a major health concern in the country, the Diabetes Association of growing HIV/AIDS problem, which Malawi is working hard to warn the health authorities, political leaders kills tens of thousands of Malawians and the general population of the grave threat to development, as well as every year. The increase in risk fac- health and wellbeing, posed by an epidemic of type 2 diabetes. Timothy tors for non-communicable diseases Ntambalika reports from Malawi. (NCDs), including type 2 diabetes, is severely compounding the country’s More than half the population of Malawi situations provoked by climatic extremes already considerable disease burden. lives below the poverty line and the ma- from drought to heavy rains. This forces jority of Malawians live in rural com- Malawi to rely on international food aid The outlook for many Malawians is un- munities, farming a small plot of land. and limits people’s diets to imported certain. Maize meal prices climbed by In recent years, the country has made industrially processed foods – and, of more than 60% in the last four months progress towards achieving economic course, places further strain on Malawi’s of 2011.2 The prices of many basic items growth. Healthcare, education and en- already stretched healthcare services. have gone up by as much as 50%.3 The vironmental conditions have improved.1 USAID-funded Famine Early Warning But Malawi’s food supply is precarious Malawi is one of the most densely popu- Networks (FEWS NET) in its latest re- and the country is prone to disaster lated countries in the world1 and rapid port has warned that price rises in the
12 DiabetesVoice July 2012 • Volume 57 • Issue 2 the global campaign
south may accelerate, worsening the engage in preventative efforts at both monitor and supervise the project and nutritional levels of the urban poor.3 It community and national levels. evaluate its performance against the is people living in towns and cities on intended objectives. This will be a sus- a low income, without access to fresh, It is against this background of impend- tainable project involving Association nutritious foods or, indeed, a healthful ing threat, not only to our health ser- member volunteers. environment, who are at increased risk vices but also to our socioeconomic de- for type 2 diabetes and other NCDs. velopment, that we launched the Malawi Protecting our future Our main objectives Awareness project. The UN summit on As an Association, the severe lack of funds NCDs in 2011 gave diabetes the high- is our principal challenge. Applications are to provide diabetes level political recognition it needed rise have been made to the World Diabetes education and sensitize up the agenda of national governments Foundation and we receive valuable sup- the general public to the worldwide. In Malawi, the government port from IDF but as the burden from has engaged the Diabetes Association of diabetes and other NCDs increases, so threat from diabetes. Malawi to discuss the nation’s response do the needs of people with and with- The main objectives of the Diabetes to diabetes. out a diagnosis of diabetes in Malawi. Association of Malawi are two-fold: to Currently, we have an urgent need to provide diabetes education to those with The status of diabetes in Malawi provide formal training for at least five the disease; and sensitize the general From our experience on the ground, of our diabetes educators. public, via public awareness campaigns we know that diabetes is a serious and and community events, to the threat growing problem in Malawi. While the The Diabetes Association of Malawi is from diabetes and the ways it affects World Health Organization estimates young and diabetes in today’s numbers individuals, communities and even the the prevalence among adults to be 5.6%, is new to our country. We have grown economic wellbeing of the country. we put that figure at around 15% of the quickly and are hoping to develop into adult population. It is imperative that we a strong, well-resourced organization, A survey conducted by doctors from get a clear picture of the status of dia- capable of rising to the challenges ahead. the Blantyre College of Medicine found betes in order to measure and prepare diabetes awareness among people the required response. We have always diagnosed with the condition was low, faced a lack of resources to conduct a Timothy Ntambalika Timothy Ntambalika is President of the and diabetes care in most of the referral countrywide survey. Efforts are under- Diabetes Association Of Malawi. hospitals – even in district hospitals way to secure funding for this and other – to be sub-standard. Meanwhile, the initiatives, such as a diabetes education disease profile of Malawi continues programme among schoolteachers. to worsen, with diagnoses of diabetes and diabetes-related deaths growing In Malawi, the every month. The immediate impact government has of diabetes is felt by people with the engaged the Diabetes condition and their family – in terms Association of Malawi References both of the emotional strain and the 1 Central Intelligence Agency. The World Fact economic burden – but diabetes is set to discuss the nation’s Book. www.cia.gov/library/publications/ also to have serious effects on economic response to diabetes. the-world-factbook/geos/mi.html activities in Malawi. Risk factors for 2 The World Bank. Food Price Watch January diabetes are already accumulating Training the trainers 2012. http://siteresources.worldbank.org/ EXTPOVERTY/Resources/336991-1311966520397/ among people of working age. Those We hope to receive backing to organize FoodPriceWatchJanuary2012.htm who go on to develop the disease are and conduct workshops throughout the very likely to lose working days, leaving country, teaching the basics of diabetes 3 UN Office for the Coordination of Humanitarian Affairs. MALAWI: Rising them out of pocket and representing to teachers in order to create a ripple prices and looming maize shortages. www. a loss to their employers, unless the effect of broadening diabetes aware- irinnews.org/Report/94825/MALAWI-Rising- prices-and-looming-maize-shortages government and society as a whole ness. The role of Association will be to
July 2012 • Volume 57 • Issue 2 DiabetesVoice 13 Health Delivery
How to protect the children of the Food Revolution Interview with Jamie Oliver
English chef and restaurateur Jamie Oliver’s television programmes are shown in more than 40 countries around the world and Oliver has become a global media personality. But it is his relentless campaigning on food issues that has increasingly become the focus of his work. In the UK, his campaign against the use of processed foods in schools has had a lasting effect on the nation’s diet and its psyche. Oliver is committed to changing the public’s approach to food and dietary health, particularly among young people. His latest campaign, Food Revolution Day, attempts to transform the way people eat by educating all children about food, giving families the skills and knowledge they need to cook and motivating people to “stand up for their rights to better food”. He took time out recently from his busy schedule and preparations for Food Revolution Day to speak to Diabetes Voice.
14 DiabetesVoice July 2012 • Volume 57 • Issue 2 Health delivery
Diabetes Voice: Why are you so passion- fast food every day. So it is no wonder or something where the news media ate about fighting childhood obesity? we have a situation where both adult is all over it; it is something that is get- Jamie Oliver: I am passionate about food and child obesity are spiralling out of ting worse every single day, but because education for everyone, but I think it’s control. Something has got to be done it is happening slowly, it gets ignored. crucial for children to learn about food – and there are hardly any governments And yet, if you walked down the street where it comes from, how it affects their in the world who are currently really 40 years ago and then suddenly rolled bodies and how you can cook incredible, tackling the problem. time forwards to today, the difference nutritious meals with fresh ingredients. I in people’s body size would shock you. worry that we are in danger of losing the DV: You have previously highlighted basic life skill of cooking; three genera- the connection between obesity and How can we reverse this trend? Well, tions ago, pretty much every household the exploding numbers of children be- first of all, I do not have all the an- had someone who knew how to cook ing diagnosed with diabetes. How can swers! It is a massive problem and it and ready meals were unheard of. And we reverse this potentially disastrous will take a number of measures – some now, just 30 or 40 years later we have kids trend? Why do you think this health of them unpopular – to really make a and young families growing up without issue remained neglected for so long? dent in the situation. But I do believe the knowledge or skills to cook even the JO: It is not a sexy subject so it is hard that food education from an early age most basic of things, and so they have no for the mainstream media to get excited is the key. In the UK, I have two pilot choice but to live off reheated meals with about it. This is not like war, a high- schools with kitchen gardens, where loads of additives and, in many cases, profile shooting, a major earthquake the kids are growing their own food
July 2012 • Volume 57 • Issue 2 DiabetesVoice 15 Health Delivery
and then cooking it. The feedback I re- focused during cooking classes because ceive from the teachers and parents is it clearly interests and inspires them. amazing. They have said that the kids are so engaged, are already learning an DV: What is the vision for your Food incredible amount, and are completely Revolution Campaign and your Kitchen loving every minute of their time in the Garden Project? garden and the kitchen – which is bril- JO: Via the Kitchen Garden Project, liant, and exactly what this is all about. which has only just started in the UK, I All kids need, and should be armed with, would like to reach a place where every those all-important life skills. We also child in primary school has access to DV: You have consistently shown that have kids in high schools in the UK and a garden where they can help to grow there is a dissonance between people Australia doing cooking classes, and food and then cook it. Clearly, that is and the food they eat, where ingredi- again all the reports back are saying that a huge ask. But I believe it really will ents come from and how to eat season- these young people – some of whom make a difference. When I started work- ally. How can we improve this lack of cannot pay attention in other classes, ing in schools, both in the UK and the knowledge and awareness? How can like maths and geography – are 100% USA, I was very shocked by the fact we make healthier food accessible to that children could not identify basic everyone, rich or poor, regardless of vegetables – some as common as car- where they live? rots or potatoes. In my mind, this is not JO: It comes down to food education acceptable. In California, one teenager every time. When I hear people say that thought that honey came from bears! it is too expensive to eat fresh food, I This is an outrage. know it is wrong because I have been to some of the poorest parts of Europe So for Food Revolution, it is really a and I have been to townships in South change for people all over the world to Africa and I have seen people with stand up and say: “We don’t accept the very little money cooking and eating way things are. We don’t accept that our wonderful food, simply because they children leave school without knowing have the knowledge. They can make how to take care of themselves. We don’t bread with a bit of flour and water. They accept all those nasty ingredients that can create a delicious stew using some the big food companies add to our food cheaper cuts of meat and some root that we shouldn’t be eating, and we stand vegetables. They can use leftovers to get up for change.” an extra two or three meals out of, say, a roast chicken. So I think educating DV: How will you measure the Food our children is key, but also educating Revolution Day campaign? What will our adults, which is already happen- need to happen to make is a success? ing at the Food Revolution Centres and JO: I think it is already a success because Truck in the USA and at the Ministry of even in this first year, Food Revolution Food Centres in the US and Australia, Day is on the map with media coverage, is important too. social media, support from businesses and celebrities, and not forgetting all the incredible people all over the world who are giving their time and energy to take Find out more… Food Revolution Day into communities http://www.jamieoliver.com/ everywhere. The last time I looked there kitchen-garden-project/ was something happening in 36 coun- http://www.jamieoliver.com/us/foundation/ jamies-food-revolution/home tries. For a first year, that is amazing!
16 DiabetesVoice July 2012 • Volume 57 • Issue 2 health delivery World Diabetes Day 2012 – expanding the circle of influence
Isabella Platon
World Diabetes Day unites the world against diabetes by celebrating Social media platforms, such as people who are touched by diabetes every day and raising public aware- Facebook and Twitter, link millions and ness of this killer epidemic. International Diabetes Federation leads millions of people from all walks of life this global grassroots campaign inspiring advocates, organisations and and across all continents. The global accessibility of web-based social media individuals to come together on November 14 to put the spotlight on and the immediacy of the communica- diabetes. Together with its member associations, IDF put diabetes on tions they facilitate are transforming the global health agenda by securing the 2006 UN resolution, making communications strategies worldwide. WDD an official UN Day. We salute those who work to make a life with Facebook and Twitter in particular have diabetes like any other life, and those who strive to make diabetes a become essential tools for any organiza- thing of the past – like insulin pioneer, Frederick Banting, whose birth- tion – from the mighty multinational day provides the date – 14 November. Every year, World Diabetes Day company to the local community ac- generates more momentum, makes more noise and shines more light tion group – with a message it wants to deliver to as many people as possible, as on diabetes than it did the year before. In fact, the celebration that was quickly as possible. They have becomes established in partnership with the World Health Organization in 1991 the tools of our trade. to highlight the risks from diabetes has developed into an ambitious five-year-long campaign implemented across multiple media worldwide. IDF is engaged in conversations with IDF’s head of communications Isabella Platon reports. huge numbers of people via Facebook
July 2012 • Volume 57 • Issue 2 DiabetesVoice 17 Health Delivery
and Twitter – and those numbers are growing every day. Our communica- tions strategy is a blueprint for mas- sive mass communication, broadcast- ing advocacy messages to audiences worldwide, disseminating diabetes data (from IDF’s Diabetes Atlas and Guidelines) and highlighting essential reading for an informed and effective response to diabetes. In essence, IDF’s online campaign is playing a principal role in resolving one of the Federation’s historic challenges: to explore and en- gage the enormous reserves of sup- port lying untapped within a global audience, while remaining relevant, accessible and useful for IDF’s Member Associations.
A case in point was the online storm of activity that was sparked last year by the intervention of IDF President, Jean Claude Mbanya in a web-based forum with the online diabetes community in the USA – which includes diabetes blog- gers, collectively the ‘diablogosphere’, individual diabetes advocates and oth- ers. Mbanya highlighted the human rights issues that underpin access to essential medications, like insulin. He did not mince his words when referring to IDF’s Life for Child Programme and the injustice that leaves millions vulner- Racing car driver, Miguel Paludo, Blue Circle Champion able to the deadliest aspects of diabetes. And he touched a nerve in the USA in particular when he laid out IDF’s conviction that “accidents of geography soon developed into a global discussion organizations, bloggers and other online should not decide whether a child with involving people affected by diabetes advocates, that meaningful dialogue diabetes lives or dies.” around the globe. Posts and tweets rained was underway. The social media in from all sides echoing the heart-felt platforms facilitate open and blink- This stark reality put the diabetes chal- outrage sparked by the depressing statis- of-an-eye, two-way communications. lenge in a different context for the US- tics on children with type 1 diabetes in This enables IDF to hear – through real based bloggers. A nationwide debate fol- developing countries. That conversation comments and opinions of real people lowed with contributors from all over with the world was a turning point in affected by diabetes and real diabetes the country showing their shock and IDF’s social media presence. health professionals – about the needs indignation at the fate of the kids and and wishes of the myriad groups that adults who continue to die just because No sooner had IDF begun engaging form the global diabetes community. they cannot afford to pay for insulin. This via Facebook and Twitter with key And we are listening and learning.
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The online community in the USA is show that where there is internet, there for generations to come, basic knowl- an interesting one for a number of rea- is Facebook. IDF’s presence there will edge on the prevention and optimal sons. Firstly, it is huge and very noisy! allow people in low- and middle-income management of diabetes must reach the Prolific bloggers and frequent tweeters countries, where 80% of deaths attrib- hands of people with diabetes, those at count their followers in the hundreds of utable to non-communicable diseases risk from the disease and our healthcare thousands. Indeed, the US-based com- (NCDs) occur, to receive early warning providers. Policy makers must be made munity is the most mature in terms of of the threat to their health and wellbe- aware of the socioeconomic benefits of its experience with social media and ing posed by diabetes. our messages and spurred into action has shown itself to be proactive as well The links are explained by an informed general public. as responsive. between the risk Young people will be the driving force Active listening for a customized factors for diabetes behind activities to promote and dis- response and the state of the seminate educational and preventive IDF’s role in the conversation reflects a messages. In 2012, WDD will warn the sophisticated and highly audience-sen- planet’s health. world about the dangers of diabetes and sitive approach to maximize every mo- WDD 2012 – educate, protect, enjoy inspire communities to fight back and ment and every movement online. We This year’s World Diabetes Day cam- think of the future. Our messages are believe that listening is the cornerstone paign is a worldwide clarion call to clear and simple and powerful, and go to any open conversation – and we listen action to protect the health of our fu- out to individuals, communities and ‘actively’ so that any internet-mediated ture generations. The campaign aims civil society, as well as the private sec- communication from IDF is appropriate to convey the urgency with which the tor that plays such a fundamental role to its intended audience. This means diabetes epidemic must be approached. in moulding our environment: use your that every message is tailored specifi- Uniquely for a global campaign of any power to protect and take the right steps cally to the needs and sensitivities of an kind, WDD exposes and explains the to health. Together, we can reduce the audience that we know and understand. links between the epidemic of risk risks for everyone and protect the health factors for diabetes and the worsening of the world. A principal concern of the Federation state of the planet’s health. Even more has always been to gather and catalogue importantly, WDD focuses on the ways Protect our future! data on its global constituency in order in which health-protective changes in The campaign focuses the attention of to be able to deliver relevant messages our behaviour, from the individual to the world on the urgent need to address and real-world solutions to millions of the multinational-corporation level, three pillars of concern for the diabetes people living in a myriad different socio- will help us to protect the future of in- community – burning issues that are cultural and economic conditions. This dividuals, communities and, indeed, an having a closely related and concomitant simple approach is working, as reflected entire species. impact on wider society. in the better-than-anticipated numbers ■ Access to education is a basic human so far: by the time of writing, IDF had Knowledge in the right hands can bring right. seen a 65% increase in its followers on power to those how are most in need. ■ The way we live puts our health at risk. Twitter and a 25% increase on Facebook Simply put, in order to reduce the impact ■ People with diabetes face stigma and over the previous 18 months. of diabetes, and thus protect ourselves discrimination.
Thinking very big Communications via the social media allow us to think big. The relevant tech- nology is almost universally available. People have power to protect and Internet connections reach thousands of previously unconnected families and take the simple steps to health. communities every single day through- out the developing world – and figures
July 2012 • Volume 57 • Issue 2 DiabetesVoice 19 Health Delivery
This year, with children and adolescents at the centre of its slogan, IDF is iden- tifying individuals and organizations based outside the diabetes community who are active in promoting health and a healthy future among this key demo- graphic. Diabetes has come a long way in terms of public awareness, particu- larly since the 2006 UN ‘World Diabetes Day’ Resolution, and the successful UN High-Level Meeting on NCDs last year – where diabetes and IDF were notable protagonists. This year, we are count- ing on your help to make diabetes a mainstream issue where it is not one already – and make sure it stays that way where it is!
IDF is partnering beyond the diabetes community with very active organiza- sustainability as a way of life for young Shine a light! tions that share our goals and values in people of school age. Visit the WDD World Diabetes Day has earned its place order to get diabetes included on every- website by following the links at www. among the key dates on the world’s cam- one’s wellness and nutrition agenda. For idf.org for more on these and other paign calendar. Each year, it generates instance, celebrity chef, restaurateur and WDD Champions and to access the more noise and more hope that the last. food activists, Jamie Oliver, has created wealth of information and freely avail- The groundbreaking Blue Monument the Food Revolution, which aims to able campaign resources. Campaign, which last year saw nearly return us to traditional, healthful and, 700 landmark buildings and monuments very importantly, sustainable ways of Pin a Personality bathed in diabetes blue, is a firm favourite cooking and eating. (Read what Oliver Other initiatives this year include the of the diablogosphere and beyond, and has to say about the Food Revolution Pin a Personality Campaign, which a beautiful way to leave a very serious on page 14 of this issue in an exclusive was launched to increase the profile of mark on the night sky. There is room for interview with Diabetes Voice). the blue circle (the globally recognized everyone on the WDD train this year. symbol of diabetes). We encourage Visit our website. Follow us on Twitter. World Diabetes Day Champions anyone and everyone to photograph ‘Friend us’ on Facebook. Together, we World Diabetes Day Champions are be- a well-known person wearing a blue can help protect the health of the world. ing recognized in this year’s campaign circle pin and post it on Facebook for their efforts to improve and protect (see News in Brief for more on this Stay in touch with WDD health. Jamie Oliver’s Food Revolution campaign). The campaign is already Day was a recent champion. A group proving to be popular across the IDF Visit the website called Wellness in the Schools is an- on-line community, not to mention www.idf.org/worlddiabetesday other recent Champion that focuses on its effect on the burgeoning interna- Join us on Facebook healthy eating. A non-profit, communi- tional diabetes paparazzi! The Pin a World Diabetes Day ty-based organization, it was founded in Personality gallery, which you can view Follow us on Twitter 2005 to help improve the environment, on our website, is already filling-up http://twitter.com/#!/wdd food and fitness in public schools in with international personalities like the USA. In collaboration with Save former UN Secretary General, Kofi Isabella Platon the Children, Wellness in the Schools Annan, French DJ, Quentin Mosimann, Isabella Platon is IDF head of communications. promotes healthy eating, fitness, and and Olympic gold medallist Gary Hall.
20 DiabetesVoice July 2012 • Volume 57 • Issue 2
The right environment f o r a l l
Diabetes: protect our future
www.worlddiabetesday.org
Untitled-1 1 6/6/2012 2:27:39 PM The right environment f o r a l l
Diabetes: protect our future
www.worlddiabetesday.org
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health delivery Diabetes and climate change: two interconnected global challenges
Katie Dain and Lucy Hadley
Against the backdrop of the 65th World Health Assembly in Geneva, the and opportunities for physical activity International Diabetes Federation (IDF) and the private health insurance are curtailed. Starvation among pregnant company, Bupa, convened an expert dialogue on two of the most urgent women may even set the scene for type 2 challenges of the 21st century: the global diabetes epidemic and climate diabetes in their children. Meanwhile, change. Both are global phenomena, and have been identified separately people with established diabetes suffer as threatening to derail human development and economic growth; both adverse health outcomes or are left without access to essential medicines are rapidly accelerating and are fuelled by changes in the way we live and because of weakened health systems. work; both are impacting on all countries – with no government having these challenges under control; and both will have intergenerational The indirect connections refer to the effects on the health, wellbeing and security of future generations. common global forces and trends that are fuelling both of these disasters. For Recognition of the sheer size and impact connections between the two issues, and example, patterns of rapid urbaniza- of both challenges has been increasing. A approaches capable of jointly mitigating tion and fast-changing demographics, new sense of urgency to act has resulted their risks and repercussions, has been and global food industry practices are in a number of political commitments missing from policy dialogue. contributing to high-carbon obesogenic for each challenge. The UN Resolution environments. Combined, the direct on diabetes in 2006 was followed by the Where are the links? and indirect links form a rationale for landmark UN Political Declaration on Type 2 diabetes and climate change are an aligned policy agenda. NCD prevention and control last year, directly and indirectly interconnected. and the UN Climate Change Conference The direct connections refer to how Collaborating with Bupa advanced the international communi- type 2 diabetes and climate change With support from Bupa, IDF has de- ty’s response to climate change mitiga- adversely impact on each other. For veloped a pioneering policy report that tion with the adoption of the Durban example, climatic extremes such as will bring these two challenges together. Platform for Enhanced Action. However, drought, disasters and long periods It outlines the interconnections between despite growing political recognition of of extreme heat increase people’s climate change and diabetes; establishes the urgent need to prevent type 2 diabetes exposure to diabetes risk factors because the benefits of combating two global and climate change, recognition of the traditional food supplies are damaged risks in an integrated policy agenda;
July 2012 • Volume 57 • Issue 2 DiabetesVoice 25 Mapping the interconnections: type 2 diabetes and climate change
Direct Impact
Climate Change Global Diabetes Epidemic Carbon-intensive Greenhouse gas emissions are expected to grow by 52% Today there are 366 million people with diabetes, and by 2030 health systems by 2050, raising the earth’s temperature to exceed the safe that number will reach half a billion. Globallydiabetes kills 4.6 threshold. There is now unequivocal evidence for human in- million people a year, it is among the top causes of disability, duced climate change. While high-income countries contribute and costs the world USD 465 billion in healthcare expenditure almost all emissions, it is the poorest countries that suffer every year. Four out of five people with diabetes now live in low- Food insecurity the greatest consequences. If nothing is done, climate change and middle-income countries. Diabetes impoverishes families, will cost 5–20% of the world GDP every year,3 and will impact hampers labour productivity and overwhelms health systems. Weakened on malnutrition, increased infectious and non-communicable health systems diseases (NCDs), poverty and inequity.
Pathways Animal source food production Ageing populations Mechanised transportation Industrial food processing Depleting natural resources Poor urban design and slum growth Global food and agriculture trade Sedentary lifestyles Unhealthy diets and consumption patterns
Global Vectors
opulation Demographics Globalised Food System Rapid Urbanisation Fast-Changing P st By 2050 the world’s population will have grown The 21 century food system is framed by glo- Over half of the world’s population live in cities balisation, liberalisation and industrialisation. today. By 2030, an estimated 5 billion of the from 7 billion to 9 billion, and the biggest in- crease will be in Asia and Africa. Overall global While the benefits of a globalised food system world’s 8.1 billion people will live in cities, and 2 are apparent, industrial food production, pro- billion of them will live in slums. The speed and population is ageing, but many developing countries will witness increasingly young cessing, trade, marketing and retailing are a scale of urbanisation globally is impacting upon major stressor to the planet and contribute to climate change, and in developing countries populations. These changing demographic trends place a strain on already insufficient the nutrition and epidemiological transitions and for socially disadvantaged populations it taking place in developing countries. is compromising human and planetary health. resources, aggravate environmental problems, and contribute to shifting disease patterns.
eport, June 2012 International Diabetes Federation, Diabetes and Climate Change R
and informs the broader global discus- the world on these two urgent issues. At IDF, we believe in protecting and pro- sion on health and sustainable develop- Consequently, we launched our policy moting health through effective mutu- ment. The report has been developed report around the UN Conference on ally beneficial policies, working through with support from an informal advisory Sustainable Development – also known strategic alliances and partnerships. Our group including experts in the field of as Rio+20 – as we believe it provides a report on diabetes and climate change is health and the environment. It was this useful lens for understanding the broad- further evidence for the end of the era piece of work that provided the basis er interconnections between health and of fragmentation between health and for the expert dialogue at WHA. The environment. Moreover, it supports the environment, which has prevented us event was co-hosted by Bupa Chairman case that health must be at the heart of from tackling the root causes driving Alexander Leitch and IDF President- sustainable development. Health is not diabetes and climate change. Our world Elect Michael Hirst, and included only a critical outcome of sustainable is interconnected and only joint action respected panellists, Ruth Colagiuri, development; it is a vital precondition to will prevent human suffering and envi- IDF Vice President, George Alleyne, achieving progress across the three pillars ronmental disaster. Business as usual is Director-Emeritus of PAHO, Maria of sustainable development - social, eco- no longer an option. Neira of the World Health Organization, nomic and environmental. The prevention and John Tooke, Chairman of Bupa’s and treatment of diseases like diabetes Katie Dain and Lucy Hadley medical advisory panel. represent an opportunity to alleviate hu- Katie Dain is the Global Advocacy man suffering and social inequity, support Manager of IDF. We held this dialogue at WHA in order economic development and lessen the Lucy Hadley is a Junior Professional Officer in Policy and Advocacy at IDF. to engage the health policy-makers of environmental burden of health systems.
26 DiabetesVoice July 2012 • Volume 57 • Issue 2 health delivery Creating a network to tackle diabetes and NCDs in Latin America
Noël Barengo and Ruby Trejo
Diabetes has become a critical health issue Registered in Mar de Plata in Argentina, the Fundación in Latin America. From Mexico, in the north, para la Prevención y Control de las Enfermedades Crónicas no-trasmisibles en América Latina (FunPRECAL) operates to Argentina in the south, sweeping rural- in North, Central and South America. Founded in 2010, urban migration and the worldwide nutrition FunPRECAL’s mission is to contribute to the planning, im- transition to high-fat, low-nutrient processed plementation and evaluation of population-based initiatives foods – especially among poor people – are to prevent and control diabetes and non-communicable driving a potentially devastating explosion diseases (NCDs) in Latin America. in the numbers of people affected by non- The basic premise underpinning FunPRECAL is derived communicable disease (NCD). The diabetes from the experiences of the North Karelia Project in northern population, estimated at around 16 million Finland. That 1972 community-based intervention provided people, is set to double within a decade if convincing evidence that it is possible to improve lifestyle effective steps are not taken in protect at- habits and reduce risk factors for NCDs via the creation of a broad community network, the reorganization of the risk communities. The authors describe local community, and the implementation of educational the objectives, activities and achievements campaigns providing the tools needed to improve lifestyles. to date of a growing network throughout Latin America that aims to translate robust The FunPRECAL network In the short time since its inception, FunPRECAL has built a findings on chronic disease prevention into collaborative network of universities, health ministers and pri- real-world initiatives to reduce risk factors vate companies in order to facilitate health promotion and the for diabetes and NCDs in the community. implementation of initiatives to prevent and control diabetes, cardiovascular diseases. At the moment, FunPRECAL is part- nered with entities in 10 Latin American countries: Argentina, Brazil, Colombia, Cuba, Ecuador, Guatemala, Mexico, Paraguay, Peru and Uruguay. The aim of the Foundation is to bring together individuals and organizations in most of the
July 2012 • Volume 57 • Issue 2 DiabetesVoice 27 Health Delivery
Latin American countries, establishing by the end of 2012 a research, which is supported by an educational grant from strong network for the prevention and control of diabetes and Lilly Diabetes (see page 30 for more about BRIDGES) uses NCDs throughout the region. FINDRISC to identify people in the community who are at high risk for diabetes. Key figures in health promotion, such as Pekka Puska, Jaakko Tuomilehto, Ricardo Uauy and Michael Pratt have offered The key objective is weight control their support and collaboration to FunPRECAL’s activities. and the use of regular physical The Foundation was one of the NGOs invited to take part in activity to prevent diabetes. the CARMEN 2012 Forum in Brasilia, organized by the Pan- American Health Organization (PAHO), to discuss how to If someone scores higher than 13 points, he or she is referred implement the prevention and control of NCDs in the region. for an oral glucose tolerance test; people are found to have impaired glucose tolerance or impaired fasting glucose are FunPRECAL encourages healthcare provided with health education and the tools they need professionals who are engaged to switch to healthier eating and increase their physical in effective projects in their activity. The key objective is weight control and the use of regular physical activity to prevent diabetes. A similar country to share their findings. strategy is planned for implementation in 2012 in Mar de How we work Plata, Argentina. FunPRECAL applies a range of preventive strategies. Another project, ‘Peru Migrant’, is determining the prevalence
Sharing data and ideas of type 2 diabetes using fasting glucose and HbA1C testing. FunPRECAL encourages collaborating healthcare profession- This is very significant in the region as the impact of using
als who are engaged in effective projects in their country to HbA1C as a diagnostic criterion for diabetes in Latin America share their findings with the rest of the network – using the has not yet been studied. most popular channels of communication, such as Facebook and Twitter. The Foundation also promotes exchange stays be- Promoting community-based projects tween healthcare professionals working in different countries. In Mar de Plata, Argentina, 40 health workers were selected to receive training through a project called Guardacorazon – a Applying results to study the population prevention programme run by the Argentinean Programme FunPRECAL encourages the application in the region of to Prevent Atherosclerosis (see www.propia.org.ar for more findings from high-level scientific studies of the general information). The project, which was funded by PAHO, se- population outside Latin America. An example is the im- lected some 30 people from the community. They received plementation in Argentina, Colombia, Cuba and Paraguay training via a specially developed teaching manual covering of the Finnish Diabetes Prevention Study. To this end, the the most important issues around the prevention of NCDs. first step is to use the Finnish diabetes risk questionnaire, These include blood pressure, cholesterol, diabetes, healthy FINnish Diabetes Risk SCore or FINDRISC. This is currently nutrition, physical activity and mental health. Twenty health underway in Paraguay, Colombia, Cuba and Argentina. The workers completed the training and have been integrated into questionnaire involves eight questions about body weight, local health centres in order to provide community health family history of diabetes, physical activity and other risk education about diabetes and NCD prevention. Future plans factors for type 2 diabetes. include using the experience from Guardacorazon to replicate the approach in other parts of Latin America. The second step is to apply FINDRISC at the primary care level. An excellent example is the DEMOJUAN project, Developing national demonstration sites organized by the local FunPRECAL partner, the Health In Paraguay, FunPRECAL is collaborating with the University Research Centre (CIIS Ltd) in Barranquilla, Colombia. That of Oriente to create a demonstration site for diabetes and project, which receives the majority of its funding from cardiovascular disease prevention in the city of Minga Guazú. the International Diabetes Federation (IDF) via a grant The cross-sectional population study, DemoMinga, reached from BRIDGES – an IDF initiative to promote translational the local population through lifestyle questionnaires, which
28 DiabetesVoice July 2012 • Volume 57 • Issue 2 health delivery Photo: Tim Nolan Tim Photo:
Findrisc being applied in Barranquilla, Colombia
were completed in 2011, and included blood tests and labora- This year, FunPRECAL plans to stage courses in Paraguay, tory tests (lipids, fasting blood glucose). Argentina and Colombia.
Training for healthcare professionals Looking ahead One of FunPRECAL’s newest projects is Exercise is Medicine, So the wave of health protection and disease prevention that with the US American College of Sports Medicine, the swept through Finland nearly 40 years ago has finally reached Centers for Disease Control (USA) and University of the Latin America. Here, we are confident that if all parties Andes (Regional Coordination Centre, Bogotá, Colombia) engaged in the prevention of type 2 diabetes and NCDs col- as key partners. The project aims to train physicians in pre- laborate effectively, contributing knowledge and experience scribing physical activity, providing them with education on to the network, we will have a major impact in improving the scientific evidence about the benefits of physical activ- lifestyles, reducing risk factors for diabetes throughout the ity, and give advice to the public on engaging in physical population of the entire continent. ¡Viva América Latina! activity. This includes awareness of the benefits of physical activity, both in people at high risk of diabetes and those with established diabetes.
As general practitioners are often the first point of contact for Noël Barengo and Ruby Trejo people at high risk of diabetes, it is important that they are Noël Barengo is the President of FunPRECAL well trained in how to motivate such people to increase levels ([email protected]). of physical activity in order to reduce their risk of diabetes. Ruby Trejo, field epidemiology training programme, FunPRECAL. FunPRECAL’s Exercise is Medicine courses are organized in For more about FunPRECAL and their activities, visit www. collaboration with our partner institution in Argentina and funprecal.org or them Facebook (www.facebook.com/pages/ FunPRECAL/155116047880355) or Twitter (@FunPRECAL). Uruguay, the Physical Activity Network of Uruguay (RAFU).
July 2012 • Volume 57 • Issue 2 DiabetesVoice 29 Clinical care IDF breaking new ground – building BRIDGES around the world
Ronan L’Heveder
With its latest round of funding complete, the International Diabetes Federation’s translational research programme, BRIDGES, has raised its game again, receiving 57 appli- cations from 32 countries. This round of financial support ensured USD 65,000 per project and was dedicated to short-term projects lasting a maximum two years. Having undergone rigorous screening by recognized experts, nine of the projects were selected and will benefit from financial backing from IDF. Ronan L’Heveder describes the latest innovative projects to quality for BRIDGES funding.
30 DiabetesVoice July 2012 • VolumeVolume 57 • IIssuessue 2 clinical care
“The quality and geographical spread Pathway to Health – a lifestyle inter- of the applications received is un- vention to prevent diabetes in China precedented,” said Professor Linda Shanxi Evergreen Service, Uci District, Siminerio, Chair of the BRIDGES People’s Republic of China Executive Committee. “Through this In response to the recent surge in the fourth round, we will address the needs number of people in China with type 2 of communities in new countries such diabetes, this project proposes to test as Thailand, Fiji and the Netherlands. the feasibility of a nine-month lifestyle Now, more countries will be able to reap intervention, Pathway to Health (PATH), the benefits of translational research.” to reduce risks for diabetes in Chinese women. Based on the successful US These new BRIDGES projects, like those Diabetes Prevention Program, the China already underway, will test innovative Da Qing Diabetes Prevention Study and ideas for the prevention of type 2 diabe- the accumulative work of the research tes (primary prevention) and the chron- team, PATH is built on the infrastruc- ic, potentially disabling complications of ture of the recently restructured Chinese diabetes (secondary prevention). This healthcare system. It is hoped that this time around, these ideas include the project, if successful, will be replicated use of community theatre in diabetes and maintained throughout China. education in Fiji; a lifestyle intervention for overweight children in Tunisia; and Integrated care through a community the development of a peer leader system hospital model in Beijing in six countries in the Caribbean. Beijing Tongren Hospital, Beijing, People’s Republic of China Using community theatre to promote Diabetes has become a major public diabetes education and prevention health problem in China; chronic com- in Fiji plications are the major causes of dis- University of the South Pacific, Fiji abilities and death for people with the Previous investigations undertaken by condition. It is well known that good these researchers in the South Pacific control of blood glucose, blood pressure, has shown that people being treated for lipids and aspirin use reduce the risk diabetes pay little heed to brochures, of complications. This project, whose pamphlets, or posters most commonly methods are based on the previous used by Health Ministries to provide Beijing Community Diabetes Study, de- public health information. This project scribes a community hospital integrated proposes to transmit the message of management system for people with healthy lifestyles through community diabetes in Beijing, China, which aims theatre, using professional actors to to optimize control of blood glucose, dramatize some practical approaches to blood pressure and lipids. dealing with illness and the best meth- ods to prevent developing diabetes. The Bridging the knowledge gap in a rural acting professionals will audition lo- Pakistan cal community members to establish United Arab Emirates University, Gilgit a network of community theatre ‘cells’ Baltistan Province, Islamic Republic of in Fiji to ensure the sustainability of the Pakistan concept and its ability to address the The primary prevention of chronic dis- increasingly severe problem of diabetes eases such as diabetes, coronary heart in the South Pacific region. disease and stroke is a public health
July 2012 • VolumeVolume 57 • IssueIssue 2 DiabetesVoice 31 clinical care
priority throughout Pakistan. Non- drain on health resources is compounded a school-based intervention to man- communicable diseases in rural popula- by the high numbers of healthcare pro- age overweight and obesity among tions place a particu- school-age adoles- larly heavy burden There are 38 projects underway cents in the region on healthcare sys- of Sousse. This one- tem. This project in 35 countries thanks to IDF’s year behavioural will pull together the intervention will existing expertise of support through BRIDGES. include components team members with focusing on nutri- diverse backgrounds. Most of them al- fessionals, particularly nurses, migrating tion, physical activity and psychologi- ready have established networks that away from the region. So diabetes edu- cal issues. cross disciplinary boundaries. The ob- cation plays an integral role in diabetes jective is to assess the effectiveness of management – and a lack of education Smile Healthy with Your Diabetes – home-based lifestyle intervention on might contribute to poor management health coaching for people with dia- blood glucose and other cardiovascular and increased complications. This study betes in Denmark risk factors in adults aged between 18 aims to evaluate existing diabetes edu- University of Copenhagen, Denmark and 64 living in a rural area. cation curricula to determine whether In Denmark, diabetes type 2 and oral these are easily used by non-healthcare diseases constitute major public health A pioneering model to reduce cardio- professional educators in each of the par- concerns with an increasing burden vascular risk in the Netherlands ticipating Caribbean countries. among adults. Poor oral health contrib- The EMGO Institute for Health and Care utes negatively to blood glucose control; Research, Netherlands Community-based diabetes preven- and poor diabetes management nega- Medical and lifestyle interventions can tion in Thailand tively affects oral health. This project reduce diabetes complications. A key School of Nursing, Walailak University, aims to design and evaluate a new be- component for targeting these interven- Thailand havioural intervention based on oral- tions is to assess using prediction models This community-based project will test health coaching among adults. a person’s risk of developing a complica- a pre-designed knowledge management tion within a defined time period. But programme to prevent or delay of type Bringing research in diabetes to global current models are flawed, targeting the 2 diabetes in people at high risk. This environments wrong people for prevention of com- will be a sizeable project involving 32 BRIDGES (Bringing Research in plications and resulting in both under primary care units and 2,240 people at Diabetes to Global Environments and treatment and overtreatment. This pro- high risk of diabetes. The participants Systems) is an International Diabetes ject aims to develop an improved and will be assigned randomly either to the Federation programme, supported practically applicable prediction model intervention programme or in the usual by an educational grant from Lilly for cardiovascular complications in care group. Diabetes. There are 38 projects un- people with type 2 diabetes. Using this derway in 35 countries thanks to IDF’s model, it is hoped, treatment plans will Protecting children in Tunisia from support through BRIDGES. You can be improved, leading to a reduction in overweight and obesity find a description of each of them on complications and treatment costs. University Hospital Farhat Hached the BRIDGES website (www.idf.org/ Sousse, Tunisia BRIDGES/4th-round). Innovative diabetes education for The prevalence of diabetes is increas- adults with type 2 diabetes in the ing dramatically throughout Tunisia English-speaking Caribbean in association with obesity – a key risk Diabetes Association of Jamaica, factor for type 2 diabetes. Worryingly, Ronan L’Heveder Ronan L’Heveder is in overall Jamaica, Grenada, Antigua, Belize, St obesity among children constitutes a charge of BRIDGES. Lucia, Barbados major public health challenge in Tunisia Contact Ronan at [email protected] for more Diabetes is the third leading cause of and worldwide. This project proposes information on any aspect of BRIDGES. death in the Caribbean. The consequent the implementation and evaluation of
32 DiabetesVoice July 2012 • Volume 57 • Issue 2 Clinical CARE Exploring ethnicity in people with type 2 diabetes in Australia
Margaret McGill and Stephen Twigg
In 2011, the Royal Prince Alfred Hospital Diabetes The multicultural nature of the diabetes service at the Royal Centre in Sydney, Australia, joined the voluntary Prince Alfred Hospital Diabetes Centre in Sydney often comes as a surprise to many people. Our catchment population network of International Diabetes Federation comprises people of Anglo-Celtic, Mediterranean, European, (IDF) Centres of Education. There are currently Arabic, Chinese, Indian, South-East Asian, Aboriginal, and eight such centres providing excellent diabetes Torres Strait Islander origins. In fact, almost 60% of the people care and education services in Latin America, Asia we see are from a non-English-speaking background. This (including the Indian sub-continent and China), diversity brings its own complexities to diabetes manage- ment and education, and our staff need to be familiar with Europe and now Australia. Central to the aims of and sensitive to the many cultural differences among our the Centres of Education are efforts to increase diabetes population. regional capacity to respond to the diabetes epi- Many of our first-generation demic. Here, Margaret McGill and Stephen Twigg of migrants have not report from the Royal Prince Alfred on work received formal education to understand the nature and impact of demo- in their first language. graphics, specifically in terms of ethnicity, on blood glucose control, complications and diabetes Fortunately, the New South Wales Ministry of Health provides outcomes in general. The lessons learned in this interpreters who are fully trained in a multitude of languages and dialects. It is the policy of our Diabetes Centre that field in Sydney will be translated into effective all people who have difficulty speaking or understanding initiatives to improve equity in access to care and English must have an interpreter present at each consulta- education elsewhere in Australia and abroad. tion. Moreover, many of our first-generation of migrants have not received formal education in their first language, so in many cases providing written material as an adjunct to education is not useful.
July 2012 • Volume 57 • Issue 2 DiabetesVoice 33 Clinical CARE
In our experience, education is successful when it is pro- This melting pot of nationalities places us in a unique posi- vided through interactive ethnicity-specific groups. These tion to examine differences in blood glucose control and are conducted by our dietitian and nurses. As part of the complications across the various ethnic groups. In an audit education programme, each participant brings a traditional of our clinic population of 9822 people with type 2 diabetes, dish to be analyzed for carbohydrate, fat and protein content the most commonly seen ethnic group after Anglo-Celts and portion size, and – respecting these caveats, of course – (38% of the total) is from the Mediterranean region (23%) – enjoyed. The support the participants receive from each other reflecting post-World War II migration. In addition to, and is demonstrated in the difficulty we have in getting them all maybe because of, the challenges around self-management to leave when the group session has finished! education, there is a great diversity in terms of phenotype, surrogate markers of risk and complication status among the different ethnic groups. For example, in our audit, the Promoting excellence diagnosis of diabetes in all non-Caucasian groups occurs at a significantly younger age than in Caucasian groups. in education and care Moreover, these non caucasian groups, including Indigenous
An IDF Centre of Education is an institution selected to form Australians have comparatively poorer blood glucose con- part of an international voluntary network to initiate, facilitate, trol. This translates into higher rates of microvascular and conduct, coordinate and evaluate high-quality education for in some cases macrovascular complications, such as an health professionals in diabetes and other related chronic diseases. overall higher prevalence of retinopathy and ischaemic heart disease compared with the Anglo-Celtic population. The goals of the Centres of Education are to increase acces- What role is played by migration sibility to high quality interdisciplinary diabetes education in access to healthcare delivery? for health professionals; increase regional capacity to respond to the diabetes epidemic; and build a network that supports Why do these differences in outcomes occur? Is it due to centres to advance their education programming and influ- environmental or genetic factors or a mixture of both? And ence system change. what role is played by migration and culture in accessing healthcare delivery?
Eight institutions have been designated as International Diabetes Federation Centres of Education: The answers to such questions are likely to be complex. And Assoçiacão Protectora dos Diabéticos de Portugal, Lisbon, there is an additional question: should we have ethnicity-specific Portugal clinical targets? This issue is recognized for BMI amongst Asian 2 Dr Mohan’s Diabetes Specialties Centre and Madras Diabetes populations, where a reading of 23-25 kg/m puts an Asian Research Foundation, Chennai, India person in the overweight range, whereas a Caucasian with the Asociación Colombiana de Diabetes, Bogotá, Colombia same reading remains in the normal range. Vivir con Diabetes Education and Information Centre, Cochabamba, Bolivia Yet the major reversible risk factors for the micro- and mac- Associação Nacional de Assistência ao Diabético, Sao Paulo, rovascular complications of diabetes, as per IDF’s clinical care Brazil guidelines, have the same general targets across all ethnic groups. How, then, can we improve HbA , blood pressure and Baqai Institute of Diabetology and Endocrinology, Karachi, 1c Pakistan albuminuria in those people who have higher levels, such as Diabetes Centre of the Royal Prince Alfred Hospital and Australian Aboriginal and Torres Strait Islander populations, University of Sydney, Sydney, Australia despite receiving similar care to people of Anglo-Celtic origin, Chinese University of Hong Kong – the Prince of Wales based on the percentage of prescribed insulin and treatment Hospital Diabetes and Endocrine Centre, Hong Kong, People’s to regulate blood pressure? Republic of China. An initiative by the Australian Federal Government, ‘Closing
Visit www.idf.org/idf-centres-education for more about the the Gap’, aims to reduce the difference in health outcomes Centres of Education and how to apply to join the network. between indigenous and non-indigenous Australians by taking the following steps:
34 DiabetesVoice July 2012 • Volume 57 • Issue 2 Clinical CARE
Our immediate challenge is to achieve high-quality clinical outcomes in all people, irrespective of their ethnicity.
promoting and supporting good health initiatives through Our experiences providing diabetes care to such a variety of the involvement of local communities and delivering healthy ethnicities place us in a unique position to reach out to our lifestyle programmes regional and global partners. Our highly skilled multidisci- Non-Caucasians have poorer plinary team has developed an understanding of the cultural differences and sensitivities inherent in modern diabetes care. glycaemic control and higher rates Our immediate challenge is to achieve high-quality clinical of microvascular complications, outcomes in all people, irrespective of their ethnicity. such as retinopathy. supporting accredited Indigenous health services and gen- eral practices by providing new funding for the delivery of better healthcare for Indigenous Australians removing barriers in order to improve access to essen- tial follow-up services, such as allied health, specialist Margaret McGill and Stephen Twigg care and the medicines available via the pharmaceutical Margaret McGill AM is Adjunct Associate Professor in the Sydney Medical School, University of Sydney and Manager of benefits scheme the Royal Prince Alfred Diabetes Centre, Sydney Australia. building the capacity of the primary health care system Stephen Twigg is Professor in Medicine at the Sydney Medical School, to care for people by increasing the range and skills of the senior endocrinologist and Deputy Head, Department of Endocrinology at Royal Prince Alfred Hospital and the University of Sydney, Australia. Indigenous health workforce.
July 2012 • Volume 57 • Issue 2 DiabetesVoice 35 Haiti fights for a brighter future
Philippe Larco and Nancy Charles Larco The devastating earthquake that struck Haiti on 12 January 2010 killed over 200,000 people and left more than 1.5 million homeless. Two years later, more than half a million people still live in tents in relief camps and 50% of the rubble is yet to be removed. The earthquake exposed infrastructural weaknesses and institutional shortcomings. Haiti is struggling with reconstruction efforts that, according to the authors of this report, have been hampered by political paralysis and the lack of coordination in international aid. Yet from among the debris of Haiti’s decimated healthcare system is arising a renewed force capable of protecting the current and future health and wellbeing of people with diabetes. Diabetes in society
In the immediate aftermath of the 2010 of a national plan to combat diabetes istence of a huge need for training of earthquake, healthcare services quickly and cardiovascular disease. medical staff. In an attempt to meet this became saturated by the urgent needs need, FHADIMAC decided to develop of people rescued from the rubble with Without the intervention of a national protocol for the treatment multiple trauma. With this extraordi- FHADIMAC, diabetes surely would of diabetes and launched an extensive nary and overwhelming demand on have killed many of the people who training programme for health person- healthcare, medical attention was di- had survived the initial impact of the nel. This began in February 2011 with verted away from people with diabetes disaster. More than 1500 people af- sessions for doctors, nurses, pharma- and hypertension; their cases were not fected by chronic disease were seen in cists, laboratory technicians and social considered urgent. Drug supplies were the FHADIMAC facilities, and received workers, and has continued since with complicated due to the collapse of sev- free care – medical consultations, blood numerous seminars over the years. eral pharmacies in the affected areas. glucose monitoring, medication, educa- When returning to their respective In the days after the earthquake, the tional sessions – for the first six months institutions, these healthcare provid- Haitian Foundation for Diabetes and following the earthquake. Many of these ers reported feeling more comfortable Cardiovascular Diseases (FHADIMAC), people arrived with high blood glucose, with the assessment and management a private Haitian foundation, was the inappropriately treated and with a lack of people with diabetes. only organization to provide services to of any diabetes knowledge. people with diabetes and other chronic Without the intervention Many people were unable to attend diseases. FHADIMAC had been con- appointments due to difficulties mak- tacted by the Ministry of Public Health of FHADIMAC, diabetes ing the journey to their clinic. In re- and Population (MSPP), which made would have killed many sponse, and in addition to its daily the Foundation the reference centre for clinical premises in downtown Port- of the survivors. the management of people with diabe- au-Prince, FHADIMAC (with the help tes and hypertension. In April 2010, Improving care AmeriCares) opened four outreach the Ministry and FHADIMAC signed Seeing the poorly supported people clinics throughout the capital. After a Memorandum of Understanding for who had been transferred from other nine months, that essential work was the development and implementation health institutions confirmed the ex- taken up and extended through another project supported by AmeriCares and the World Diabetes Foundation, which established 12 healthcare centres in the west of the city – the area most affected by the earthquake. FHADIMAC operates outreach clinics in neighbourhoods throughout the capital, including those most affected by the earthquake. Screening and awareness FHADIMAC also conducted a screening campaign in relief camps, churches, workplaces, markets and at public events in order to identify people with diabetes and provide treatment as early as
38 DiabetesVoice July 2012 • Volume 57 • Issue 2 Diabetes in society
possible. Some 10,000 people underwent NGOs and health institutions screening in metropolitan Port-au-Prince and several other regions, including Cape regularly contact FHADIMAC Haitien, Les Cayes, Jacmel, Gonaives and Hinche. People identified with diabetes for training or for support to were referred to the closest health centre manage people with diabetes. with trained personnel.
The screening campaign was comple- FHADIMAC managed to organize its as the number of referrals increased mented by intensive diabetes aware- first camp for children and adolescents daily. NGOs and health institutions reg- ness campaigns. Videos, pamphlets and with diabetes (and some mothers). It ularly contact FHADIMAC for training posters about the symptoms of diabetes was an amazing experience for the 24 or for support to manage people with and hypertension have been released children who took part in this camp. diabetes. FHADIMAC now plans to ex- with the support of the International "These days at the camp were undoubt- pand its activities and develop several Diabetes Federation (IDF) and the edly the happiest days of my life," de- sections to take care of screening and French Society of Diabetes. clared one of the camp participants. treatment for diabetes complications.
Special support for young people In June 2010, FHADIMAC joined IDF’s The earthquake of January 2010 was FHADIMAC provided psychological sup- Life For A Child programme. Currently, an opportunity for FHADIMAC to port for young people with diabetes, who more than 50 children in Haiti are sup- intensify its struggle to defend the received special attention and participat- ported by this project and the aim is to rights of people with diabetes and de- ed in special sessions with psychologists. reach 150 per year. velop a comprehensive programme of In those sessions, children and parents diabetes awareness and support. The shared their experiences managing dia- Advocating policy change ongoing lack of human and financial betes in exceptional circumstances. For several years, FHADIMAC has been resources continues to limit the actions striving to push chronic non-commu- of FHADIMAC. However, thanks to the In February 2012, nicable diseases (NCDs) like diabetes dedicated approach of its employees and FHADIMAC organized its and hypertension up the agenda of the supporters, the Foundation is trying to first camp for children Ministry of Health of Haiti. After several carry out a range of activities to ensure a meetings with authorities, FHADIMAC better life for people affected by diabetes and adolescents was invited to form part of the gov- and cardiovascular diseases. with diabetes – and ernment delegation that attended the some parents. UN high-Level Meeting on NCDs in September 2011. For several years prior to the earth- quake, FHADIMAC had dreamed about After that historic UN summit, organizing a camp for children with dia- FHADIMAC continued its advocacy betes. These camps can provide young work and established with the Ministry of people with diabetes with an opportu- Health the National Committee Against nity to learn and share their knowledge NCDs. Other Haitian institutions work- and experiences with their peers. In ing in the field of NCDs, particularly Philippe Larco and February 2012, after several months cancer, are part of this committee. Nancy Charles Larco of preparation and with the support of Philippe Larco is the Vice-President of Francine Kaufman (Past President of Fighting adversity for a brighter future the Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC). the American Diabetes Association), To meet the needs of the community Nancy Charles Larco is internist and Neal Kaufman, Evelyne Fleury-Milfort and the demand for services in diabetes, diabetologist, is the Project Coordinator at (University of Southern California) and FHADIMAC has had to double its staff. the Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC). Merith Basey (from the NGO AYUDA), Our premises quickly became too small
July 2012 • Volume 57 • Issue 2 DiabetesVoice 39 Diabetes in society Civil society facing down the diabetes emergency in Mali
Stéphane Besançon and Sidibe Assa Traore
Santé Diabète emerged in response to a double emer- gency: the lack of access to care for people with diabetes in Africa and the lack of recognition on the part of the development actors that this is even a problem. Santé Diabète’s overarching objective is to improve the preven- tion and management of diabetes in Africa. Founded in 2001, it was the first international development-focused NGO to concentrate on the fight against diabetes.
40 DiabetesVoice July 2012 • VolumeVolume 57 • IIssuessue 2 Diabetes in society
Since its inception, Santé Diabète has Douentza; recently, only one private consistently taken on a holistic ap- pharmacy in Timbuktu had diabetes proach, covering all the bases required medications – although these were on to establish quality diabetes prevention sale at very high prices, keeping them and management. The approach was beyond the reach of many people. In developed in the field, in close collabo- Gao, Kidal and Douentza, where at ration with the Mali Ministry of Health, the time of writing no medicines at all the Department of Endocrinology- were available, people with diabetes Diabetology of the National Hospital continue to find themselves trapped and other institutional partners. This in a barren medical desert. The criti- positioning in technical assistance to cal circumstances that have arisen as a support the policies of national fight result pose a grave threat. For example, against diabetes has yielded very sig- two children with type 1 diabetes in nificant advances for many people with the region (one in Timbuktu and the diabetes in Mali. The decentralization other in Douentza were found recently of care has helped establish 22 diabetes to have run out of insulin entirely and clinics, supporting more than 10,000 risked imminent death if a supply was people with diabetes. All these centers not organized very quickly. have equipment for analysis and edu- Care needs have cational materials. Access to medica- tions has been greatly improved through skyrocketed as large extensive work with the Ministry of numbers of displaced Health. Insulin is available at the clin- people arrive daily ics at a 50% reduction (down from EUR with no resources 10 to EUR 5 per vial) on the previous price – and oral blood glucose-lowering whatsoever. medications with a discount 10%. Complications in the south – but care In regions where no continues In southern Mali, care has remained ac- drugs are available, cessible, despite strong concerns about people with diabetes large displaced populations and the in- remain trapped in creasing frequency of diabetes compli- cations. Diabetes consultations are still a medical desert. running in all state structures in the re- A major threat to diabetes care gion but resources are severely stretched. A crisis situation was provoked in Mali in March 2012 after on a military coup At Mopti regional hospital and the in the capital, Bamako, and an attack Hospital of Mali in Bamako, care needs of the Tuareg rebels in the north of the have skyrocketed with the daily arrival country. This has been very dangerous of large numbers of displaced people for the hundreds of thousands people coming from the north with no re- with diabetes and the more than 100 sources whatsoever. With the physical children registered with type 1 diabetes. and social hardships of being displaced and the tremendous stress provoked An increasingly critical situation in the by the crisis, there has been a marked north increase in the frequency of diabetes- Most physicians have left the northern related coma and diabetic foot prob- region of Timbuktu, Kidal, Gao and lems. The period of economic embargo
July 2012 • VolumeVolume 57 • IssueIssue 2 DiabetesVoice 41 Diabetes in society
has also profoundly affected the capacity of state structures, hospitals and central pharmacies to source monitoring equip- ment and drugs.
A quick response to address the hu- manitarian emergency Santé Diabète, in close partnership with the Ministry of Health, the Department of Endocrinology-Diabetology, the Hospital of Mali and the National Federation of Malian People Diabetes (FENADIM), has launched an emer- gency response on two levels. Diabète Santé has partnered with
NGOs like Médecins Santé Diabète provides support in difficult conditions. Sans Frontières and Médecins du Monde to improve Structural intervention in the south to offer support to hundreds of people and expand care. Donations have helped secure domestic with diabetes who had lost all access to supply of insulin at the central phar- healthcare. The intervention has saved Humanitarian intervention in the north macy of Mali. In parallel, kits for the countless lives. It would not have been Emergency donations of insulin, sy- management of emergencies, including possible without financial support or ringes and oral blood glucose-lowering coma and foot complications, have been donations from private individual do- medications have been transported in distributed in the national and regional nors, the Sanofi Foundation, Insulin Zum the regions of Kidal, Timbuktu, Gao and hospitals closest to the refugee camps Leben, Novo Nordisk and Sanofi Aventis. Douentza in order to cover the needs of and displaced populations. hundreds of people with type 2 diabetes. Specific supplies also have been sent to Humanitarian corridors of hope the two children mentioned above liv- As soon as humanitarian corridors ing in Timbuktu and Douentza. These through the devastated regions are open donations will allow all those people and secure, doctors from Santé Diabète, with diabetes to maintain a reserve for in collaboration with the Endocrinology several months of treatment. and Diabetology service of the Hospital of Mali, will hold weeks of free consulta- Meanwhile, emergency kits have been tions in Douentza, Timbuktu and Gao. prepared for the management of peo- These missions will be complemented ple in coma. Collaborations have arisen by training sessions for onsite doctors with the Médecins Sans Frontières team in working with emergency NGOs on Timbuktu, who took care of two people monitoring people with diabetes. Stéphane Besançon and Sidibe Assa Traore who were in a critical condition. Other Stéphane Besançon is the CEO of the NGO partnerships have been forged with Donate and protect Santé Diabète (www.santediabete.org). Médecins du Monde and other NGOs to In this major humanitarian crisis, the Sidibe Assa Traore is the head of service provide further coma and foot kits on a emergency response coordinated by of endocrinology and diabetology of the Mali Hospital, Bamako, Mali. larger scale to other northern regions. Santé Diabète and its partners continues
42 DiabetesVoice July 2012 • Volume 57 • Issue 2 The right education f o r a l
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