Diabetes Management in Primary Care in Tanzania

Diabetes Management: Primary Care Doctor Role In Tanzania

Introduction

I once attended a 19-year-old patient who had type 1 diabetes, he came to the hospital with a heart rate of 120 beats/min. He looked emaciated and tired. He was studying business in a college and had bright dreams of being a successful businessperson once done with studies. But here he was struggling to catch his breath and having sky-rocketing HbA1c and his random blood glucose was over the roof.

His urine had 3+ ketones and 3+ glucose. His ECG revealed sinus tachycardia. His body revealed hyperpigmentation lichenified skin on his forearms, deltoids and thighs due to wrong techniques of insulin injection he had been practicing for so long since his diabetes diagnosis 5 years ago. We admitted him due to diabetic ketoacidosis following other numerous admissions in the past for the same reason.

This is one story of a diabetic patient, but for sure every patient has their unique stories. Some are extreme and some are not. But all are stories of suffering and struggle to survive that we as primary care doctors can help to change them to stories of hope, productive life and a healthy society.

1 in 10 people in Tanzania has diabetes, this makes it the first country among top 5 countries with high prevalence (12.3%) of diabetes in the age group 20-79 years as of 2021 a rise from 2.8% in 10 years. This same age group amount to 2.9 million people with diabetes living in Tanzania. Addition of other age groups not included will rise the number even more. It is also estimated that 44.4% of patients with diabetes are undiagnosed in Tanzania. The costs of managing diabetes per person per month in Tanzania is about 149.8 USD which equates to 349,483 Tsh, an amount most Tanzanian’s cannot afford (IDF, 2021). This age group is the work-force of the country and if such trend continues then the dream of developing our country will be jeopardized.

The 2021 International Diabetes Foundation report shows that globally diabetes is one of the fastest growing global health emergencies of the 21st century. In Africa the situation is also worse (IDF, 2021). This calls for cooperative efforts to halt the trend.

These statistics reveals that diabetes is a huge burden in our country. We all know the devastating effects diabetes has on almost every system and organ in a human body. Diabetes is associated with mental disorders, visual defects, oral diseases, digestive conditions, sexual dysfunction, heart and kidney disease, sensory diseases and amputations. Some or all of these complications (and more that aren’t mentioned) could exist in a single patient if glucose levels aren’t controlled. This drastically impair the life of the patient and those of people surrounding him/her.

Primary care providers are the gate way for diabetic patients contact with healthcare. Primary care doctors are the one who get to know at first hand the patient’s personal complaints, their challenges to adhere to medications and lifestyle interventions. It is at the office of the primary care doctor that signs of complications of diabetes will be detected and addressed. But this won’t happen if doctors will not embrace this opportunity and use it effectively to provide the much-needed expert care to the diabetic patient.

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Issues in Diabetes Management

1.?????Education

Many diabetic patients do not know about their disease. They don’t know about how to change their diets. For the most part they have heard a lot of conflicting messages such as ‘don’t eat carbohydrates’ ‘don’t eat fats’ ‘use honey as substitute for sugar’ etc. They have also tried alternative medications hailed to completely treat diabetes for good. But of course, most wouldn’t tell you this unless they have trust and you probe for this information! Most experience complications such as reduced vision and heartburn with constipation but doesn’t know its diabetes that causes these. Few patients have been to the ophthalmologist for fundoscopy since their diabetes diagnosis. Fewer more have had their feet assessed to rule out sensation dysfunction.

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For patients on insulin, most don’t know how to inject insulin properly. Some don’t know the signs of hypoglycemia when using insulin or what to do when they get hypoglycemic. Most are injecting on thighs fearing the prospect of stomach injection which is a more effective sight for injection. Most also don’t know how to self-regulate their insulin dosage depending on their glucose levels.

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Educating patients on self-care helps to improve glucose control by reducing 1% of HbA1C. This is a huge step in managing diabetes as it shortens the period of prolonged hyperglycemia with its associated damaging effects leading to complications (Malathy R et al, 2011).

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An encounter with a diabetic patient is the perfect time to see if they are really educated about their disease. To be confident on these issues we as practitioners have to be updated and knowledgeable, this can be achieved by regular studying and learning.

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2.?????Adherence

Taking medications every day can be a real burden especially when you have to take them for the rest of your life! Most people who have been found to have diabetes find it a daunting task to now being obliged into taking daily medicines. Other patients experience side effects and from time to time stop taking their medications.

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To others is about the cost of drugs or other tools for managing diabetes. Most insurers provide limited amount of glucose strips which for a diabetic patient needs regular monitoring. This makes patients sometimes to skip taking drugs because they can’t measure their random blood glucose. For those without insurance the costs become unbearable.

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Other patients stop taking their medications because they have taken alternative medications and hope that diabetes will go away. All these makes the patient to have poor adherence.

Few patients do adhere to lifestyle modification therapy such as diet and physical activity. Why?

Because most patients simply don’t know how to do it! They have been just told ‘take less carbohydrates and do exercise most of the days’ They don’t know how much carbohydrates is fine and how much is too much. They can not do exercise because they have painful knees and doesn’t know its impact on their health anyway. These reasons and more are the reasons they have poor adherence to their management plan.

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As primary care doctors we can help patients by listening to their perspective on medication and then tailor therapy to each individual according to their ability in terms of education, financial and social support around them. This is what is called as person-centered care which allows health practitioner to provide a holistic care to a patient. Personalized care has four principles which needs to be upheld:

????????????????????????????????i.???????????Affording people dignity, compassion and respect.

??????????????????????????????ii.???????????Offering coordinated care, support or treatment.

????????????????????????????iii.???????????Offering personalised care, support or treatment.

????????????????????????????iv.???????????Supporting people to recognise and develop their own strengths and abilities to enable them to live an independent and fulfilling life.

When we practice a person-centered care we will achieve far more positive results with regard to adherence to medications especially for chronic diseases such as diabetes.

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3.?????Glucose Control

Prolonged hyperglycemia results into more complications. Many patients with diabetes doesn’t have controlled glucose levels. For most patients it’s a roller coaster ride of high and low glucose levels over the entire period of disease.

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This stems from lack of self-care education on diabetes, lack of medication and glucose monitoring devices due to poor adherence or high cost compared to the patient financial status.

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As primary care doctors we can also address this issue by communicating the impact of prolonged hyperglycemia to patients, how to use their medication, how to eat a balanced diet and help them with low cost but effective medications and regular follow up on them to see how they are doing, encouraging and giving guidance along the way.

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4.?????Complications

Diabetes affects many organs and systems in the human body. This is a fact patients should know very early in their management of diabetes. Patients should understand the importance of doing a fundoscopy once a year, get their lipid levels, urine and renal function tests investigated once a year and their HbA1c levels determined and monitored. Their feet should be checked in every encounter for any changes hinting on foot complications. Patients should know how to take care of their feet and be able to identify the signs of loss of sensations and risks for developing a diabetic foot.

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5.?????Inertia for therapy intensification

For those patients with uncontrolled glucose levels we as practitioner we are sometimes reluctant on changing their dosage or regimen. Most type 2 diabetic will in the future needs to be shifted to insulin therapy if the oral antidiabetic doesn’t work anymore. For those on oral drugs they may need to be kept on the highest effective dose before changing to insulin. Most of the times this change is delayed while the patient continues to endure the deleterious effects of prolonged hyperglycemic status leading to more diabetic complications (Khunti and Miller-Jones, 2017).

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Its not only health care practitioners who are affected by clinical inertia, there are other patient-related and healthcare-related barriers. To be effective in addressing clinical inertia all three areas have to be intervened. One way to reduce clinical inertia is by employing the patient-centered perspective in medical practice (Jennifer et al, 2018).

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I remember participating in an online webinar in February this year, it was about management of diabetes. The presenter, a physician, talked about the dosage of metformin. 2g is the most effective highest dose of metformin for diabetic patients. In practice we see patient with less dosage and having uncontrolled diabetes. After addressing other causes and increasing the dose to 2g dramatic changes occur and the diabetes which seemed invincible suddenly becomes easier to manage. That is the power of knowledge and benefit of continual learning and applying the lessons learned into real life. Nothing is more rewarding in managing diabetes when the patient at last has hope and a smile after their glucose becomes stable.

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6.?????Multidisciplinary approach

In the end primary doctors don’t work alone. There are other health care professionals which are as important as the doctors. We should empower each other with knowledge and passion in caring of diabetic patients. Nurses plays a major role in caring for patients. Nurses can educate patients on how to measure their glucose, how to store and inject insulin etc. Pharmacists also can use their vast knowledge on drugs to educate patients on what the drugs are all about and any side effects to be expected and what to do. Dieticians can teach patients on how to prepare delicious healthy foods and physiotherapists can guide patients on how to safely navigate the exercise world.

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When patients have complications, we have to immediately identify them and timely refer them to appropriate specialists. But in the end, they will return to primary care where this intricate and wonderful relationship will continue.

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A typical multidisciplinary diabetic team includes: pharmacist, social worker, physicians, behavioral health counselors, clinical care coordinator, and a nurse. Several studies have shown this approach results in statistically improved A1c values as well as improvement in health-related quality of life, patient self-care abilities, and patient knowledge of diabetes (Shay et al, 2021).

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In a nutshell is that we as health care professionals we need each other to help our patients. We should therefore be a team and work together in reducing the morbidity and mortality of diabetes.

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In concluding this article we have to remember the following roles of a primary care doctor found in the book Diabetes Management in Primary care by Jeff Unger:

Role of Primary Care Doctor

1.?????Identification and screening of high risk patients

Patients with high risk are:

·????????Family history of diabetes (first-degree relative)

·????????History of impaired glucose tolerance or impaired fasting glucose

·????????History of gestational diabetes or patients who have delivered a baby weighing >4kg

·????????Obesity (BMI, >25 kg/m2)

·????????History of hypertension (>140/90)

·????????History of low HDL-C, <35 mg/dL, and elevated triglycerides, >250 mg/dL

·????????Members of high-risk patient populations: Hispanic, Asian American, Pacific Islanders, African Americans, Native Americans

·????????History of polycystic ovary syndrome (PCOS)

·????????History of metabolic syndrome

·????????Inactive lifestyle

·????????History of major depressive disorder (MDD)

·????????History of vascular disease

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2.?????Counselling

We are the guardians of chronic ill and acute ill patients. We should be able to counsel patients regarding lifestyle intervention strategies that may reduce or delay their chance of diabetes developing: weight reduction, meal planning, and exercise. This need patience, honest and regular fails and successes but we shouldn’t be tired but be helpers and hold hands with patients to go together in their journey of living with diabetes.

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3.?????Providing equitable care

We have to ensure that systematic, structured, and standardized diabetes care is available for each patient.

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This also refers to the person-centered care. It is a relationship in which health care professionals and patients work together to understand what is important to the person, make decisions about their care and treatment, identify and achieve their goals. This is done to all patients regardless of their status and thus equitable care.

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4.?????Incorporating current evidence base care into practice

Learn, learn, learn. The depth of diabetes knowledge out there is huge and vast. As primary care doctors we have to learn a lot and update our knowledge every day. It gives you confidence and assurance that your practice is up-to-date and effective. It also makes managing diabetes which is demanding more feasible. Take online courses, listen to podcasts and watch webinars and educative videos on diabetes. It takes passion and commitment but it will be rewarded when we help patients live their life to the fullest with less suffering and achieve their dreams.

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5.?????Facilitate transfer of information

Managing diabetes is a team work and thus primary care doctor should make sure information is passed among all members of the diabetes team, including specialists, educators, dieticians, and other clinicians.

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6.?????Offering education about diabetes

This includes providing initial and ongoing education to enhance self-care practices and positive lifestyle interventions. Patients should know what their target glucose levels are and what to do to reach their targets.

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This can be done by practicing Diabetes self-management education and support (DSME/S). Diabetes self-management education (DSME) is the process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. Diabetes self-management support (DSMS) refers to the support that is required for implementing and sustaining coping skills and behaviors needed to self-manage on an ongoing basis. DSME/S improves hemoglobin A1c (HbA1c) by as much as 1% in people with type 2 diabetes, reduce costs, reduce hospitalizations and complications (Powers et al, 2015)

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7.?????Offer interventions.

These interventions include those to modify high-risk behaviors such as inactivity, smoking, alcohol and substance abuse, eating disorders, mental illness, obesity, and nonadherence to treatment regimens.

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CONCLUSION

This is an article to call of action and awareness on what is the role of a primary care doctor in Tanzania. If you have read until here, I applaud your commitment and kindly ask to carry on learning and applying knowledge to help diabetic patients whenever you meet them.

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Diabetes is a complex and onerous chronic disease which requires patients to make a multitude of daily self-management decisions and to perform complex care activities. We as primary health care we can assist, teach and guide patients to achieve targeted glucose levels.

The management may be burdensome but its worth every effort. Together we can.

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REFERENCE

Jennifer Okemah, John Peng, Manuel Quin?ones (2018).Addressing Clinical Inertia in Type 2 Diabetes Mellitus: A Review. Adv Ther;35:1735–1745. https://doi.org/10.1007/s12325-018-0819-5

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International Diabetes Foundation Atlas. 10th Edition. Pg 5, 74-75.

Khunti K and Millar-Jones D (2017). Clinical inertia to insulin initiation and intensification in the UK: a focused literature review. Prim Care Diabetes. 11(1):3–12.

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Malathy R, Narmadha MP, Ramesh S, Alvin Jose M, Dinesh Babu N (2011). Effect of a Diabetes Counseling Programme on Knowledge, Attitude and Practice among Diabetic Patients in Erode District of South India. Journal of Young Pharmacists Vol 3 / No 1. 65-72

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Shay Phillips, Jamayla Culpepper, Madelyn Welch, Katherine J. O’Hare, Willa Chen, Yhenneko Taylor, William Anderson and Hazel Tapp (2021). A Multidisciplinary Diabetes Clinic Improves Clinical and Behavioral Outcomes in a Primary Care Setting. https://jabfm.org/content/ 34/3/579.full. doi: 10.3122/jabfm.2021.03.200307

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Diabetes Management in the Primary Care Setting. Unger, Jeff. 1st Edition. 2007. Lippincott Williams & Wilkins. Pg 40-41.

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TAARIFA YA KUONGEZA KASI YA UTEKELEZAJI WA HATUA ZA KUJIKINGA NA

MAGONJWA MBALIMBALI NCHINI. WIZARA YA AFYA, MAENDELEO YA JAMII, JINSIA, WAZEE NA WATOTO. Dodoma, Alhamisi 29 Aprili, 2021. https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.tmda.go.tz/uploads/1620116483-Tamko%2520la%2520WAMJW%252029%2520aprili%25202021_afya_2.pdf&ved=2ahUKEwix69ynrY_5AhUD9IUKHQBXDh0QFnoECAkQAQ&usg=AOvVaw0qpveSUQpA7uhDLM7XTBUq