Pacific approach to deal with the dual burden of TB-diabetes

Tue, 2015-09-08 By Shobha Shukla, Citizen News Service - CNS

Many of the 22 countries that comprise the Pacific Islands region have very high rates of type-2 diabetes (up to 37% prevalence in adults) and high rates of TB as well (up to 343 cases per 100000). In fact 7 of the world’s top 10 countries with the highest prevalence of diabetes are in the Pacific Islands region: Tokelau, Marshall Islands, Vanuatu, Cook Island, Nauru, Micronesia and Kiribati. Similarly, some countries also have very high TB rates. It is no wonder then that the problem of TB-diabetes co-morbidity afflicts this region as well.

During the ongoing 5th Asia Pacific Region Conference on Lung Health of the International Union Against Tuberculosis and Lung Disease (The Union) in Sydney, Dr Richard Brostrom, State TB Branch Chief and Pacific Regional Medical Officer, Centers for Disease Control and Prevention (CDC), spoke to CNS about his team’s innovative and integrated approach to deal with this dual burden.
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Dr Richard Brostrom

One Patient With Two Diseases!

According to Brostrom, "TB-diabetes co-morbidity is a global problem, but we in the Pacific region, see it as a local problem and approach it from the patient’s perspective - it is about one patient with two diseases. Rather than divide the care, we try to integrate the care for each patient. Once we started doing a blood glucose test for every adult TB patient the number of TB patients with diabetes became very high. It is known now that 60% of the adult Pacific islanders with TB also have diabetes. And many of them are unaware of their diabetes status when they first come to a TB clinic."

So this is a unique region where a majority of patients with active TB also have diabetes.

"This does not give us the luxury of building a special programme to deal with this problem but instead integrate TB and diabetes care. We not only check for diabetes in all our TB patients but also try to check for TB in diabetes clinics. This serves two purposes - find TB cases that are in a diabetes clinic and get an opportunity for prevention of TB. People with diabetes are a high-risk group for TB and so it makes sense to test them for latent TB infection and then give them preventive medicine so that they do not reach active TB stage. There is a list of special interventions for our clinicians to remind them that people with diabetes may have special needs - medication doses might have to be adjusted for those TB-diabetes patients who have kidney problem; we also have to look for drug resistance, as more and more drug resistance is associated with diabetes patients. Then again, we know that in people with diabetes, TB relapse rates are 3-4 times higher than in TB patients without diabetes. So in the Pacific, we very often treat TB patients with diabetes for 9 months, instead of the normal 6 months, to prevent relapse," said Dr Brostrom.

Dr Brostrom and his team have trained their TB clinic staff to manage diabetes, in order to maximize quality of care and improve TB treatment outcomes. The DOTS providers, community workers and nurses have been given basic diabetes education. With help from Australian Respiratory Council a flipchart of diabetes education has been developed to go along with TB education. A TB healthcare provider makes 100 home visits of a TB patient during his/her TB treatment period. It is during these regular face-to-face interactions that the patients are told on how to manage their diabetes, along with ensuring that they are swallowing their TB drugs.

"This has really helped in reducing the patients' glucose levels. As long as they are under TB treatment, we provide them with long lasting information for keeping their diabetes under control. This repeated teaching is done not only of the patients, but also of their family members. Messages are simple and repeated. Our TB nurses do not talk about diabetes medication, but they are competent to advice about the benefits of optimum food portion sizes, substituting carbohydrates with vegetables, and exercising. A typical TB patient with diabetes has very little understanding about diabetes and its risk factors. So this education really helps. When the patients get a chance to sit down with a nurse in their living room or kitchen, who not only gives them their TB medicine but talks about their diabetes too, it makes the whole issue more humane," feels Dr Brostrom.

It is perhaps because of this reason that, unlike the bigger countries, in the Pacific region, often the problem of adherence is less acute. Also as the population is small - most islands have 30,000-40,000 inhabitants - it becomes difficult for TB patients to escape the DOTS providers who do a good job of follow up. No wonder treatment success rates are as high as 90%-95% in some places, as shared by Dr Brostrom.

"We do not aim to change the diabetes incidence through a TB programme. But we do want to address how diabetes affects TB patients in not only the Pacific but also in other parts of the world," he said.

Is TB-Stigma A Barrier For TB Testing In Diabetic Clinics?

Ms Kerri Viney, Research Fellow at Australian National University and a TB Consultant shared similar thoughts with Citizen News Service (CNS): "Diabetes has been slowly increasing in this region, as across the world, to the point that it has become a major health problem. We have been talking about the TB-diabetes co-morbidity problem close to about 10 years, but it was only in 2008-2009 that we realized its seriousness. Bidirectional screening is part of the collaborative framework for TB-diabetes care and many countries like Fiji, Kiribati, Marshall Islands, and Micronesia are screening TB patients for diabetes. But the harder part is getting diabetes patients screened for TB. This could partly be due to the stigma attached with TB and also because screening for diabetes can be done easily in a TB clinic, but to test for TB is more complex”.

Common Risk Factors: Obesity And Tobacco!

According to Dr Brostrom obesity and tobacco are common risk factors for TB and diabetes. Other risk factors would include an unhealthy diet. "This is sort of a suicidal risk factor at this point of time with food insecurity, poverty, poor food choices that are available. It is expensive to eat well and diabetes has now become a disease of the poor because of food insecurity," he said.

Dr Brostrom strongly feels that having successfully integrated TB-diabetes care and control, the next step forward would be to integrate tobacco control with the DOTS programme. But this would not be easy. He cautions that it would be a much tougher job to get someone quit smoking or change his or her dietary habits as compared to completing TB treatment. Yet, it is high time that tobacco control becomes an important component of the collaborative efforts to tackle TB and diabetes.


Comments

  • Greetings my friend FM, just out of curiosity...

    Could the high rate of Diabetes in Micronesia also be attributed to the chemical toxins from the 67 US nuclear bombings/ testings that may have found their way into our food chain?

    Could it be also attributed to the Spamization(American or Western diet high in sugar, bad cholesterol, fats, etc...) of Micronesia?

    It is very interesting that all the top countries with highest prevalence or rate of diabetes are either affiliated with a Western country or US.

    ***************************************************
    An article on Diabetes states the following:

    Causes of Diabetes:

    There is no one common diabetes cause

    Diabetes causes vary depending on your genetic makeup, family history, ethnicity, health and environmental factors.

    There is no common diabetes cause that fits every type of diabetes.

    The reason there is no defined diabetes cause is because the causes of diabetes vary depending on the individual and the type.

    For instance; the causes of type 1 diabetes vary considerably from the causes of gestational diabetes. Similarly, the causes of type 2 diabetes are distinct from the causes of type 1 diabetes.

    Type 1 diabetes causes:

    Type 1 diabetes is caused by the immune system destroying the cells in the pancreas that make insulin. This causes diabetes by leaving the body without enough insulin to function normally.

    This is called an autoimmune reaction, or autoimmune cause, because the body is attacking itself.

    There is no specific diabetes causes, but the following triggers may be involved:

    1) Viral or bacterial infection
    2) Chemical toxins within food
    3) Unidentified component causing autoimmune reaction

    Underlying genetic disposition may also be a type 1 diabetes cause.

    ******Note: For Diabetes 1,Two key triggers are 1) Chemical Toxins within our food. 2) Unidentified component causing autoimmune reaction.

    A recent September 2015 sampling/testing report on Radiation In The Ocean revealed that prior to the Fukushima nuclear disaster, cesium-137 & other radioactive elements have been detected in the Pacific Ocean because of the US & French nuclear testings in the 50's & 60's.

    http://m.huffpost.com/us/entry/8072914

    ****************************************************

    Type 2 diabetes causes:

    Type 2 diabetes causes are usually multifactorial - more than one diabetes cause is involved. Often, the most overwhelming factor is a family history of type 2 diabetes.

    There are a variety of risk factors for type 2 diabetes, any or all of which increase the chances of developing the condition.

    These include:

    1)Obesity
    2)Living a sedentary lifestyle
    3)Increasing age
    4)Bad diet

    Other type 2 diabetes causes such as pregnancy or illness can be type 2 diabetes risk factors.

    Detailed causes of diabetes are still not so well understood, however, a number of factors have been identified as increasing the chances of developing different types of diabetes.

    Saturated and trans fats, processed foods and excessive carbohydrate having all been mooted as possible causal factors.

    ********* For Diabetes 2, Two key factors are 1) Bad diet. 2) Obesity



  • This is a result of uncontrollable desire for someone else's junk, junk food that is.

    Eat your own healthy food which are grown on your islands. It is a shame because some of those in the government public health systems are themselves obese and overweight or malnourished, yet they preach good healthy eating and habits.

    No wonder they general populace find it difficult to slow their medicine. 
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