THE world is your oyster; but don’t be one. For one, humans are far from being mollusks; for another, being sedentary doesn’t help, especially during lockdowns.
Being sedentary is doubly hard, and risky, for nearly four million Filipinos (3,993,300, according to the International Diabetes Foundation) with diabetes.
According to Makati Medical Center Endocrinology Section Chief and physician Jimmy B. Aragon, there is data that the prevalence of pediatric Type 2 diabetes mellitus is higher now compared to 10 years ago.
“This is largely due to a more sedentary lifestyle,” Aragon told the BusinessMirror. “Children are glued to computer screens and television [sets] and, with the online school happening because of the pandemic, this will potentially increase prevalence of obesity and diabetes.”
Aragon, the past president of the Philippine Chapter of the American Association of Clinical Endocrinologists (Aace), replied to the BusinessMirror’s inquiry on the prevalence of diabetes among children.
“Children who are unable to play outside tend to just play with video games or watch online shows,” he said. “Without exercise, sedentary lifestyle will prevail.”
DIABETES has been the leading cause of morbidity in the Philippines; the 6th in 2017 according to the Department of Health (DOH).
It [diabetes] “is a matter of concern for many Filipinos,” Abbott Laboratories Inc. (Philippines) General Manager Robert Wagner told the BusinessMirror.
Wagner cited a recent report by the Philippine Heart Association Inc., which stated that over four million Filipinos with diabetes are at a significant risk of developing cardiovascular complications.
Diabetes is also a major cause of mortality in the Philippines, he added.
Wagner said that countries in Southeast Asia, including the Philippines, have witnessed the highest rate of diabetes globally.
“What’s particularly worrying is the earlier onset of Type-2 diabetes, which brings with it increased risk of co-morbidities over the life-time of a young individual.”
He noted that Philippine data show that visceral adiposity the fat enclosed by the body cavity containing the viscera i.e., the thorax, abdomen and pelvis is an important risk factor for diabetes. Wagner also pointed to previous studies that also underline low levels of HDL (high-density lipoprotein or good cholesterol) among Filipinos.
“In recent months, Covid-19 has made a difficult condition complicated to manage [as] enhanced quarantines have limited movement, and those with diabetes are finding it difficult to remain active or visit their doctor regularly for regular consultations,” Wagner said. “Cooped up at home, away from friends and social interactions [have been] emotionally tough [for people].
Exposed to Covid
SANS the lockdown, the coronavirus disease 2019 is unforgiving to diabetics, according to Dr. Rima Tan, vice president of the Institute for Studies on Diabetes Foundation.
“At this time, we already know that when Covid-19 affects a person with diabetes, the symptoms are more severe and the mortality rate is higher than in those without diabetes,” Tan told the BusinessMirror. “Filipinos are resilient, resourceful and, especially for those that have the means, most have actually adjusted well to life in quarantine.”
She said that the “challenges at the start were availability or access to their maintenance medications and to their health care providers.”
“Regular follow-ups were delayed and even for those who had symptoms or signs of other medical conditions, consultations and, hence, therapy was delayed because of fear of exposure to Covid-19, when going to the hospitals,” Tan said.
Aragon agrees, saying that the correlation of Covid infection and diabetes is established in medical literature.
“This information has spilled to the general public, most of my patients know this and they have taken measures to avoid being exposed to the virus,” he said. “However, life in lockdown has its consequences: patients feel anxious and sometimes terrified.”
ACCORDING to Philippine Society of Diabetologists Inc. Vice President Dr. Richard Elwyn, “diabetes and Covid-19 is a ‘viral romance.’”
“Surveys, observations [and] scientific journal articles all attest that diabetes is a comorbidity that worsens Covid-19 outcomes,” Fernando told the BusinessMirror. “Let us leave these bad outcomes to the intensivists [critical-care physicians] and see the ‘viral romance’ outside the hospitals and intensive care units.”
He explained that the general community quarantine and lockdown forced all to stay home and a significant few were stranded away from home.
Fernando echoed Tan’s observations that “many who have diabetes had problems procuring their medical supplies, food and other needs; many stopped or modified their medications.”
“Dialysis patients were doubly challenged; doctor follow-up, check-up and laboratory exams all had to be postponed. Those in isolation may experience anxiety and depression,” he said.
Indeed, Aragon said that those who have no strong family support are at risk to be in depression. He cited as an example people living alone because of isolation.
“When there is no one to do the market runs, they order from fast-food restaurants and it can ruin their sugar and blood pressure control.”
“There were changes in diet and exercise,” Fernando reiterated. “A lot discovered the convenience of ordering food online and having [these] instantly delivered to doorsteps; and they gained weight and poor control.”
A costly treatment
THE downward spiral into a sedentary lifestyle may be good for oysters and those selling these as a luxury dish; it’s costly for those with diabetes.
And the cost of treating diabetes is costlier than treating Covid-19 patients, according to Health Undersecretary Maria Rosario S. Vergeire.
“Treating Covid-19 is less expensive compared to treatment of diabetes,” Vergeire told the BusinessMirror.
According to her, diabetes “requires long-term care including daily intake of maintenance medicines and, if with complications, will result in more financial difficulties.”
DOH data reveals that the highest first case rate for diabetes mellitus with coma or ketosis the state when a body gets fuel from ketones or the byproduct of fat is at P15,800 with healthcare institution fee at P11,060.
The lowest first case rate for the same group is at P12,600 with healthcare institution fee at P8,820.
The professional fee ranges from P3,780 to P4,740 per case, the DOH data revealed.
According to Vergeire, the DOH has not “costed” yet the impact of diabetes with Covid-19.
“Our case rates remain up to this moment,” she told the BusinessMirror. “This applies for Covid-19, diabetes and all others.”
Aragon told the BusinessMirror he’s unaware of local data for cost of diabetes treatment.
He noted, however, that in the US, this can reach hundreds of billions of dollars.
“This is because the complications of diabetes range from the minor wound infection to heart attacks and stroke, which can be devastating and can affect lifelong quality of life,” Aragon said. “So the key is prevention before the complications set in and education for patients and their families.”
ACCORDING to Wagner, the biggest hurdle in managing diabetes effectively is self-awareness of one’s condition.
He noted that Filipinos in urban areas who responded to a survey by Abbott Laboratories claimed that they manage diabetes well.
“In reality, their post-meal glucose levels and HbA1c levels told a different story,” Wagner said. “This needs to get better.”
The Global Diabetes Community website said the term HbA1c refers to glycated haemoglobin.
“It develops when haemoglobin, a protein within red blood cells that carries oxygen throughout your body, joins with glucose in the blood, becoming ‘glycated’.”
According to Wagner, another barrier in managing diabetes is the technology for monitoring glucose levels of people living with diabetes.
The technology hardly evolved for thirty-odd years and the only feasible option for a quick result was the finger-sticking method, Wagner said. He noted that the survey by his company “also highlights this, with surveyed doctors stating that finger-sticking during blood glucose monitoring is generally rated as a hindrance for effective diabetes management.”
“Glucose-monitoring technology has been a massive enabler for people living with diabetes, globally,” Wagner said pointing to the company’s technology as used by over 2 million people with diabetes, across 46 countries.
“The digital nature of this technology today enables real-world insights that make diabetes management more effective,” he said.
Nonetheless, Wagner admits that awareness is still key to diabetes management.
“While technology has been an enabler, it is the doctors, nurses and healthcare professionals, clinical bodies and patient associations and governments across the world that have recognized the need to drive awareness about diabetes and continue to make life better for the more than 460 million people living with this condition.”
Not managed well
A RECENT consumer survey commissioned by Abbott Laboratories among 200 urban area-based Filipinos with diabetes, their caregivers and doctors shows that 8 out of 10 people with diabetes surveyed believe that they manage diabetes ‘well’, Wagner said.
However, he said that 9 out of 10 respondents have high post-meal glucose, or sugar, levels greater than 140 milligrams per deciLiter (mg/dL).
Wagner said that the American Diabetes Association advises a normal fasting glucose level less than 100 mg/dL and a post-meal level less than 140 mg/dL. The survey also highlights that 62 percent of the survey’s respondents have HbA1C of 7 or more, indicating that diabetes is not being managed well over the longer term, he added.
Since 2011, the HbA1c has been endorsed by the WHO for the screening, diagnosis and monitoring of diabetes mellitus, which refers to a group of diseases that affect how the body uses blood sugar (glucose).
To track their glucose levels, most Filipinos would have to endure multiple, painful finger pricks each day to ensure they are in a normal glucose range, Wagner said.
“The hassles involved with this traditional technology were a significant barrier to knowing one’s glucose levels and consequently, being able to manage it effectively,” he explained.
Thankfully, technology has evolved.
OVER the past five years, new-age glucose technologies have transformed how people are living with monitor glucose levels without the hassles of routine finger-sticking, according to Wagner.
For instance, clinical trials and real-world data show that users of the Abbott’s technology have improved glucose control, decreased time in hyperglycemia and hypoglycemia as well as reduced hospitalizations, HbA1C levels and improved quality of life, he said.
Wagner also pointed to recent findings from a study in France that showed use of his firm’s technology it calls “continuous glucose monitoring” dramatically decreases diabetic ketoacidosis-related hospitalizations in people living with Type 1 and Type 2 diabetes. The study, according to him, was the first largest retrospective analysis of its kind of nearly 75,000 people living with diabetes.
Real-world data recently presented at the ADA’s 80th Scientific Sessions suggest people with Type 2 diabetes using Abbott’s CGM technology can achieve similar outcomes to adding insulin therapy, for both long-acting insulin users and non-insulin users, Wagner said.
The results demonstrated overall lower HbA1c levels associated with the use of our technology, he said. Wagner said there was a 0.8-percent drop after six months (from 8.5 percent to 7.7 percent) and 0.6-percent drop after one year of using Abbott’s system (from 8.5 percent to 7.9 percent).
He noted these are clinically significant reductions of average glucose levels over time toward the ADA’s recommended A1c goal of 7 percent for adults with diabetes.
“These results are similar to outcomes typically seen when adding insulin therapy to treatment regimens, indicating people may be able to manage their glucose levels with CGM technology instead of adding insulin,” Wagner said.
TECHNOLOGY is also in the mind of Tan.
“I think one best practice that has been identified or pushed forward is the use of telemedicine,” she told the BusinessMirror. “We now know that for some medical conditions, like diabetes, virtual consultations will work and we were forced to adapt quickly.”
According to the physician, virtual consultations “answered a need [that] was seen in the early days of the quarantine.”
“And moving forward, I believe this practice of telemedicine is here to stay.”
Tan added that “coupled with remote monitoring technologies such as Abbott’s flash glucose monitoring and other CGMs, telemedicine is now a powerful tool to overcome distances imposed by the pandemic.”
TAN personally thinks that the government is not doing much in the battle against diabetes, especially with the current Covid-19 pandemic.
“Today, prevention of diabetes is more important, than therapy,” she told the BusinessMirror. “Although some medications for diabetes have been made available for free by DOH, the promotion of healthy lifestyle and prevention of chronic non-communicable diseases (like diabetes) should be a priority. Setting the right priorities will be very helpful.”
According to Vergeire, provision of free maintenance medicines like Metformin, Gliclazide and insulin vials through city health offices and/or rural health units nationwide is also in place.
“Currently, diabetes services are continuously being given especially in primary care facilities since it is considered as an essential health service,” she said.
Still, Vergeire admits “government support can still be markedly improved.”
“At the moment, we need to strengthen the centralized registry of diabetes and its complications and more importantly, we need a nationwide campaign for diabetes prevention through healthy lifestyle,” she added.
The DOH expects the number of cases of diabetes in the Philippines to triple to 12 million in 20 years or by 2040.
Opportunity for unity
TAN noted that inequity differentiates the public and private responses to diabetes as a major health concern.
“The main issues are access to all kinds of resources: laboratory exams, educational and clinic and/or hospital facilities, medications, diabetes-trained health care providers, etc.,” she told the BusinessMirror.
Tan said the Institute for Studies on Diabetes Foundation has been working on the awareness and education side “so that we can help the public sector somehow adjust to their needs and, despite the limited resources, still improve care for persons with diabetes in their centers.”
“To have an integrated approach, the government should lead and all private diabetes-concerned organizations in the Philippines should come together, work hand-in-hand in this fight against diabetes.”
He also noted the opportunity for a unified approach.
“Both the public and the private sectors want the best for patients with diabetes; both work together for patient education and screening,” Fernando said. He said that the differences “may be obvious in choices for intervention.”
FERNANDO explained that government physicians treat the poorest and the most financially-challenged portion of the population.
“To be able to treat more, they have generic diabetes tablets and human insulin vials that are cheaper but also efficacious and safe,” he said. Fernando pointed out that almost all of the newer agents, tablets and injections are available “but at a cost.”
“Fortunately, guidelines in the management of diabetes from reputable international diabetes organizations, which we generally follow, also consider this real issue,” he said. “Diabetes organizations may have different programs and activities but all are focused on the patients and how their lives can be improved.”
According to the physician, urban institutions that treat patients with diabetes mostly have access to specialized referrals.”
“As this remains to be a challenge in rural areas, it is an opportunity to bring technology accessible to patients in these far areas,” Fernando said.
He noted, however, that there is a government integrated plan or approach for the prevention and control of non-communicable diseases by the DOH and involves many medical specialties and sub-specialties.
THE bigger challenge is still in the basic practice of people with or without diabetes, Fernando said.
And according to Aragon, to meet these challenges, “the best practices, though hackneyed, are still social distancing and wearing masks.”
Fernando agrees: “The proper wearing of face masks cannot be overemphasized.”
“You can still see people wear masks below the nose or under the chin [and] not all have accepted the fact that transmission can occur through the eyes so they need to have their eyes shielded in areas of high risk.”
He added that “sanitizing hands before touching the face must be a habit and physical distancing needs to be realized and practiced at all times.”
But people with diabetes seem to be more careful and compliant with health protocols, Fernando said.
The physician emphasized that every Filipino should adhere to these measures as “nobody can be definite if the country has reached the height of the epidemic or how much longer it will last.”
Nonetheless, Fernando said physicians and health workers in the private and public sectors “will continue to respond to this challenge with determination.”