That Health Rules

My article on Diabetes Care in the Philippines is now published in the Annals of Global Health Volume 81, issue 6 November-December 2015. This is a thorough review of the kind of Diabetes Care the Philippines available to our countrymen.

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Diabetes Care in the Philippines

Gerry H. Tan, MD

Abstract
Background

Diabetes is increasing at an alarming rate in Asian countries including the Philippines. Both the prevalence and incidence of type 2 diabetes (T2D) continue to increase with a commensurate upward trend in the prevalence of prediabetes.

Objectives

The aim of this study was to review the prevalence of diabetes in the Philippines and to describe extensively the characteristics of diabetes care in the Philippines from availability of diagnostics tests to the procurement of medications.

Methods

A literature search was performed using the search words diabetes care and Philippines. Articles that were retrieved were reviewed for relevance and then synthesized to highlight key features.

Findings

The prevalence of diabetes in the Philippines is increasing. Rapid urbanization with increasing dependence on electronic gadgets and sedentary lifestyle contribute significantly to this epidemic. Diabetes care in the Philippines is disadvantaged and challenged with respect to resources, government support, and economics. The national insurance system does not cover comprehensive diabetes care in a preventive model and private insurance companies only offer limited diabetes coverage. Thus, most patients rely on “out-of-pocket” expenses, namely, laboratory procedures and daily medications. Consequently, poor pharmacotherapy adherence impairs prevention of complications. Moreover, behavioral modifications are difficult due to cultural preferences for a traditional diet of refined sugar, including white rice and bread.

Conclusions

Translating clinical data into practice in the Philippines will require fundamental and transformative changes that increase diabetes awareness, emphasize lifestyle change while respecting cultural preferences, and promote public policy especially regarding the health insurance system to improve overall diabetes care and outcomes.

Key Words
diabetes; diabetes care; Philippines; Southeast Asia; type 2 diabetes

I was just scanning through some articles and this interesting review on MODY caught my attention because definitely some of our patients that are labelled Type 2 as insulin resistant diabetes may actually have MODY where the tissues are actually insulin sensitive.  As a result the way we treat these patients will actually change. 

Below is a summary of the salient features of MODY from Janet Ruhl published in Diabetes In Control online website:

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1. People with MODY are extremely sensitive to insulin.  A dose of as little as two units may have a strong effect on their blood sugar.

2. People with MODY, no matter how high their blood sugars might be after meals, may have near normal fasting C-peptide levels. This is because the defects characteristic of MODY does not affect basal insulin secretion but only the ability to secrete insulin as blood sugars rise after eating.

3. People with MODY do not have GAD or islet antibodies. Though people with severe expressions of MODY genes may be misdiagnosed in their teens with Type 1 diabetes, they can be distinguished from true Type 1s by the very low doses of insulin they need and the lack of the autoimmune antibodies.

4. People with MODY may respond extremely strongly to sulfonylurea drugs. These drugs are often prescribed as the appropriate treatment for MODY. However, these drugs  are most effective for people whose severe expression of these genes causes blood sugars high enough to be mistaken for Type 1 diabetes. For those whose MODY is milder, even 1/4 of a 1 mg tablet of Amaryl ( Glimipride) may cause a dramatic hypo. For these people the use of very small doses of insulin–no more than 2 to 4 units per meal–is more effective and more easily tailored to varying food intake.

5. MODY should always be suspected in a woman of normal weight who develops gestational diabetes early in a pregnancy and who tests negative for autoimmune antibodies. This is often how MODY first reveals itself.

6. The different forms of genetic diabetes that are lumped together under the heading of MODY have different complication profiles. The two most common forms are MODY-3 caused by a defect in HNF1-a and MODY-2 caused by a defect in the glucokinase gene GCK.

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The point of this post is for us doctors to be aware that this form of diabetes exists and that the way these patients respond to our medications differ from the typical insulin resistant Type 2 Diabetic.

Likewise patients should be aware that this kind of Diabetes exist and may need to inform their doctors if the features of the above fit their kind of diabetes.

I see a lot of diabetic patients and the need to be informed and updated all the time regarding new research on the pathophysiology, diagnosis and treatment of this epidemic is the main reason why I continue to study and learn in whatever mode or material either through books, journals, websites or conventions. 

I guess the same is true to everyone everyday…

We Should Never Stop LEARNING!

I have to write about this new guideline in interpreting A1c for my Diabetic Patients who have been loyal followers of this website.  Or to those who are not used to doing home glucose monitoring and rely solely on A1c results in their blood test to check if their control is good or not.  Although I am not advocating to do away with monitoring…in fact I strongly advise all diabetics to do so!

Recently a new calculation was made to correlate A1c to average blood glucose levels.  Now there is a computation one can do and based on data from continuous home glucose monitoring, the correlation is now better than what it used to be.

This is a new information I gathered from the American Association of Diabetes Glucose Control Trials from the ADA News as reported in Diabetes in Control:

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Prior to this new information, the A1c was tied to the results of the DCCT, where a 6% was equal to 135mg/dL.  This came about when they checked the A1c and then looked at a couple of thousand finger sticks and averaged them out.  Now with the use of hundreds of thousands of readings, not just with the finger sticks but also with the use of continuous blood glucose monitors, we have more accurate results.  The equation yields a linear correlation over a wide range of A1c. This means that a 6% is no longer an average of 135mg/dL:  The new numbers:

o 6% = 126 mg/dl
o 7% = 155 mg/dl
o 8% = 182 mg/dl
o 9% = 211 mg/dl
o 10% = 239 mg/dl

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So for all patients who wonder what this A1c means…now this new information will help you decide what to do to your lifestyle especially if you go beyond the A1c of 6.5% that we recommend to help prevent the onset of complications. 

Remember a single blood sugar alone does not give you the whole picture…so if your physician keeps on checking just a Fasting blood sugar and tells you you’re doing fine…demand for an A1c level!

Just came back from a successful preceptorship at the UCSF- Stanford University- Whittier Institute for Diabetes in San Francisco and San Diego.  There were only 10 MDs from the Asia Pacific region being taught by more that 12 professors.  It’s actually more than a 1:1 learning from the 4th Best institution in Endocrinology from the survey in The US News and World Report 2007.

One very interesting topic we discussed was snoring and the risk of developing diabetes.  Needless to say…snroing can be very common and yet often negelcted symptom.  We alwaus associatet snoring as… the person is either being too tried from work or just in a deep good night sleep.  But now studies have shown that snoring is indeed an unhealthy sign of future disease risk.

In a study published in the Journal of Epidimeology… it was noted that snoring actually increases a persons risk to develop Diabetes….

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Purpose: To examine the association between snoring and risk of developing type II diabetes mellitus, the authors analyzed data from the Nurses’ Health Study cohort.

Methods: This analysis included 69,852 US female nurses aged 40–65 years without diagnosed diabetes, cardiovascular disease, or cancer at baseline in 1986. Snoring patterns were ascertained by questionnaire.

Results: During 10 years of follow-up, 1,957 women were diagnosed with type II diabetes. In analyses adjusted for age and body mass index, snoring was associated with risk of diabetes

1. for occasional snoring vs. nonsnoring, relative risk (RR) = 1.48 (95% confidence interval (CI): 1.29, 1.70);
2. for regular snoring vs. nonsnoring, RR = 2.25 (95% CI: 1.91, 2.66); p for trend < 0.0001).
3. Analyses stratified by body mass index, smoking history, or parental history of diabetes showed a consistent association between snoring and diabetes within the categories of these variables.

Conclusion: These results suggest that snoring is independently associated with elevated risk of type II diabetes.

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Snoring can be benign but can also be due to a more difficult disease called Obstructive Sleep Apnea where patients intermittently stop breathing with episodes of snoring suggesting obstruction.  Inability to breath causes them to cough and then resume sleeping.  Unfortunately these patients dont get into deep sleep and therefore feels tired when they wake up and tend to sleep or nap while awake in the chair or anywhere they feel sleepy.

We now know lack of sleep can be a stress factor that can contribute to increasing ones risk to develop diabetes.  It is therefore not surprising that snoring as a sign of sleep apnea is one way of being sleep debt!

Treating sleep apnea therefore in a person who is diabetic or at risk to develop diabetes can definitely have an impact on ones health…by improving his risk profile and improving blood sugar control.

My recommendation therefore for all  my diabetics who snore is to get a sleep study.  The sleep lab can determine what kind of sleep disorder one has and then implement measures to help one sleep including the administration of a CPAP machine.

Ask your partner if you snore… discuss it with your specialist and demand for a sleep study.  Treating sleep apnea can have a tremendous impact in controlling your blood sugar including ones risk to be overweight!  Plus.. you feel better when you wake up and a better sense of well being.

Snoring Can Be Bad For Your Health!