Diabetes Voice - Digital Edition July 2015

Diabetes VoiceONLINE

GLOBAL PERSPECTIVES ON DIABETES July 2015

IN THIS ISSUE:Diabetic foot disease: when the alarm to action is missing

WDC15: Public health and epidemiology streamDiabetes camps: having fun in a safe and educational environment

Diabetes Voice Online - July 2015

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30 November – 4 December

International Diabetes Federation

Promoting diabetes care, prevention and a cure worldwide

Editor-in-Chief: Rhys WilliamsEditor: Elizabeth SnoufferEditorial Coordinator: Lorenzo PiemonteAdvisory Group: Pablo Aschner (Colombia); Ruth Colagiuri (Australia); Maha Taysir Barakat (United Arab Emirates), Viswanathan Mohan (India); João Valente Nabais (Portugal); Kaushik Ramaiya (Tanzania); Carolyn Robertson (USA)

All correspondence should be addressed to:

International Diabetes Federation Chaussée de La Hulpe 166, 1170 Brussels, Belgium Tel: +32-2-538 55 11 | Fax: +32-2-538 51 [email protected]

Diabetes Voice is available online at www.diabetesvoice.org

© International Diabetes Federation, 2015 - All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permission of the International Diabetes Federation (IDF). Requests to reproduce or translate IDF publications should be addressed to [email protected].

The information in this document is for information purposes only. IDF makes no representation or warrantires about the accuracy and reliability of any content in the document. 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 with your use of this document. Through this document, you may link to third-party websites, which are not under IDF’s control. The inclusion of such links does not imply a recommendation or 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.

Cover photo: © michaeljung, istockphoto.com

Diabetes views 3

News in brief 4

World Diabetes Congress 2015: Public health & epidemiology stream 9Edward J. Boyko

Having fun in a safe and educational environment 11Angie Middelhurst

Diabetic foot disease: when the alarm to action is missing 13Kristien Van Acker, Nalini Campillo


Pretty much on a daily basis, we’re bombarded by media announcements of research findings and scientific “breakthroughs” telling us what to do and what not to do; what to eat and what not to eat; what pills to take and what not to take; what might or might not be causing important medical conditions and so on and so on. Some of these reports could be wrong because they’re based on bad science. Some may be misleading because, even though they’re based on good science, they’re just chance findings. Occasionally they may be true and need to be taken seriously. What are we to make of all this media hype? How are we to judge what’s important and what’s not important? Indeed, what’s true and what’s false?

A recent example that’s come to our attention is the revelation that type 2 diabetes might be caused by skin infection with Staphylococcus aureus bacteria. This is featured in an article on Yahoo News entitled “Diabetes may be caused by bugs on your skin”. Interesting? Is this news to be taken seriously? A clue that we might need to approach this report rather sceptically is the fact that the work was carried out in, er, rabbits. Yes, Staph infection may cause type 2 diabetes in bunnies (or it may not) but, even if it does, does this matter to us? The best answer to that question at the moment must be: who knows? Let’s watch this space.

Some 50 years ago a set of criteria – known as the “Bradford Hill criteria” or simply “Hill’s criteria” – were put forward as a means to help us make sense of these emerging research findings - a way of guiding us through the minefield of deciding what’s important and what’s not in terms of our health. It’s a checklist consisting of, in most versions, 9 criteria. It’s not infallible: all the boxes need not be checked before we should act and, sometimes, all may be checked

and we’re still caught out. Nevertheless, it’s a useful filter through which to pass a body of emerging evidence to see how closely it comes to providing an answer to an important question.

Probably the two most important criteria in this checklist are consistency and biological plausibility. Consistency is easy to understand. We really shouldn’t take anything too seriously if it’s based on just one report or just a few. However, if a number of different groups of researchers, preferably using slightly different approaches or methods, find much the same thing then we may be on to something. Biological plausibility is slightly more difficult to judge. The implication of this criterion is not that we must understand exactly how any proposed cause achieves its effect – we didn’t really understand how smoking caused lung cancer until several decades after this effect was first put forward. No, rather that there is at least some theoretical basis for the connection between the possible cause and the effect such as the proposed deleterious or beneficial effect of a dietary component on health, for example. The checklist’s originator Sir Austin Bradford Hill (I had the privilege once of hearing him speak about his criteria) would have been pleased, I’m sure, if he’d been able to persuade us to make more use of them than we have.

Looking at the original research report on which the Staph media release was based, it is possible to argue some vestige of biological plausibility through the phenomenon of inflammation. The inflammatory response of the human body has consistently been proposed as part of the mechanics of type 2 diabetes and part of the way in which the condition produces its effects. However, the way in which these laboratory animals were challenged in this way was artificial

The diabetes media hype: what’s true, and what’s false?

DIABETES VIEWS

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– totally different from what would have been encountered in the real bunny-world out there. The effect the researchers found needs to be replicated by others before we’ll believe it and there’s the inevitable problem of deciding whether, if this applies to rabbits, does it also apply to humans? And then, of course, if it does, is it really an important contributor to the development of type 2 diabetes?

No one will find it surprising that the image chosen to illustrate the web announcement is of a lissom, scantily-clad brunette – chosen, no doubt, to capture the attention of at least half of the adult population. It may also be no surprise that the piece concludes by drawing our attention to the proposal that foods suggested in the author’s book “Zero Belly Diet” (which may be purchased, of course, online) may protect you from these “invaders” - or the Staphylococci.

In writing this I am, of course, not denying the interest and the possible importance of this or indeed any well-conducted research. Important, real advances have been made as a result of what might seem, at the time, to be rather abstruse research findings. Rather, I’m highlighting that when the

need to grab the public’s attention about new research that could, just plausibly, be important, is linked to commercial interests then we need to be on guard and cautious before we’re taken in. And that there’s a tried and tested framework to help us make sense of this welter of information, if we just take our time.

Rhys Williams is Emeritus Professor of Clinical Epidemiology at Swansea University, UK and Editor-in-Chief of Diabetes Voice.

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NEWS IN BRIEF

IDF launches WDD 2015 campaign, and introduces framework for action on sugarThe International Diabetes Federation (IDF) made sure diabetes was high on the agenda at the 68th World Health Assembly held on May 19 in Geneva by launching the World Diabetes Day (WDD) 2015 campaign and introducing IDF’s Framework for action on sugar.

Announcements for each were released at IDF’s WHA side event “Nourishing development: halting the diabetes epidemic through healthy eating,” co-hosted by Petra Wilson, IDF CEO and Michael Hirst, IDF President, with expert panellists from the World Health Organization. The event focused on healthy eating as a key factor in the fight against diabetes and a cornerstone of health and sustainable development.

Campaign materials for WDD will be released through to December 2015 making the event a year-long campaign, reflecting the 24/7 realities of life with a chronic condition. Two new WDD visuals have been released and

will be followed by the WDD Guidebook, containing key messages and ways to get involved in the campaign.

The Framework is IDF’s official response to the increase in global sugar consumption, increasing rates of obesity and the rising tide of diabetes, anticipated to affect 592 million people by 2035, a 53% increase on existing cases.

The Framework calls on national governments to implement policies to reduce sugar consumption advocating specific measures to increase access to healthy alternatives such as fresh fruit and vegetables and clean drinking water, in order to help prevent new cases of type 2 diabetes. IDF estimates that up to 70% of type 2 diabetes cases could be prevented through lifestyle interventions.

Find out more at www.worlddiabetesday.org.


IDF calls on G7 leaders to take action on diabetes In early June, IDF initiated a call to action campaign challenging G7 leaders to develop and implement cost-effective policy options to improve health outcomes of people with diabetes and prevent the onset of new type 2 diabetes cases. The effort ran over the course of the two-day G7 Summit held in Schloss Elmau, Krün, Bavaria, Germany, June 7–8, 2015. The 41st G7 Summit focused on the global economy as well as on key issues regarding foreign, security and development policy.

IDF directed the call to action to all prime ministers, ministers of finance and ministers of health of the G7 nations. In several cases, national parliamentarians belonging to IDF’s Parliamentarians for Diabetes Global Network personally

delivered messages to G7 attendees.

“For too long, national governments have sat back as diabetes, a largely preventable condition, has become the 8th leading cause of death in the world. We need to be serious

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Impact of sedentary lifestyle on risk of diabetes In a study published in June, scientists found that every hour overweight adults spent watching television increased their risk of diabetes by 3.4 percent. The study, The impact of lifestyle intervention on sedentary time in individuals at high risk of diabetes, published in Diabetolgia examined whether the Diabetes Prevention Program (DPP) lifestyle intervention not only increased physical activity levels but also reduced time spent being sedentary. In the DPP, the lifestyle intervention was effective at reducing sedentary time and as a result scientists concluded that individuals with lower levels of sedentary time had a lower risk of developing diabetes. Future lifestyle intervention programmes should emphasise reducing television watching and other sedentary

behaviours in addition to increasing physical activity.

For more information: http://www.ncbi.nlm.nih.gov/pubmed/25851102

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Hispanics 50% more likely to die from diabetes The United States Centers for Disease Control and Prevention (CDC) reported that Hispanics are about 50% more likely to die from diabetes or liver disease than whites.

Heart disease and cancer in Hispanics are the two leading causes of death, accounting for about 2 of 5 deaths, which is about the same for whites. Hispanics have lower deaths than whites from most of the 10 leading causes of death with three exceptions—more deaths from diabetes and chronic liver disease, and similar numbers of deaths from kidney

diseases. Health risks also vary by Hispanic subgroup—for example, 66% more Puerto Ricans smoke than Mexicans. Hispanics in the US are almost 3 times as likely to be unin-sured as whites. Hispanics in the US are on average nearly 15 years younger than whites, so steps Hispanics take now to prevent disease can go a long way.

For more information: http://www.cdc.gov/vitalsigns/

hispanic-health/index.html

in tackling this disease and its complications, with immediate investment in prevention and public health programmes, which would yield immediate and long-term rewards.” declared the Rt. Hon Keith Vaz MP, Member of Parliament for Leicester East (United Kingdom).

Learn more about the campaign and download the letters at www.idf.org/action-on-diabetes.

“New way to eat” for current generation of Chinese children“A New Way to Eat,” an initiative launched by a non-profit organisation is teaching Chinese kids to eat in a way that is good for them and good for the planet, through China’s first food-education programme built to integrate nutrition and

sustainability.

China has no formal food-education programme, although it accounts for 1/5 of the world’s population and one-third of

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Children’s perspectives on living with type 1 diabetes

A group of diabetes researchers from three universities in the US, gave 40 adolescents disposable cameras and asked them to take pictures about what diabetes means to them. They discovered key differences in adolescents of different genders and socioeconomic classes that could shape patient care and diabetes education, especially for boys and less-affluent young people.

The findings, published in Diabetes Spectrum in May(Using photography as a method to explore adolescent

challenges and resilience in type 1 diabetes), may also help parents and families understand what their children are going through as they learn to live with diabetes. In fact, the research team is currently performing a similar study with parents of children who have type 1 diabetes to gain insights into the differences between parental and child perspectives on the disease. The project, which began in 2011 and concluded this year, included adolescents ages 12 to 19 from throughout Florida, USA.

all people living with diabetes. Chinese kids are in crisis due to changing diets – fresh cooked meals to processed convenience foods loaded with sugar and salt. In one generation, the percentage of Chinese children who are overweight has skyrocketed from 5% to 20%.

The “A New Way to Eat” programme has three components: (1) A new “Food Hero Eating Framework” designed for kids, (2) innovative play-based primary-school curriculum across multiple subjects, and (3) healthy, tasty and affordable school-lunch recipes. The curriculum teaches kids to enjoy real food and be smarter food consumers. The full set of

activities is still being developed and field-tested, but the pilot has rapidly expanded with the help of channel partners.

UN sustainable development goals discriminatory?

One of the main health targets proposed by the UN Sustainable Development Goals is to reduce premature mortality from non-communicable diseases such as cancer, stroke and dementia by a third. The goals for 2016-2030 define “premature” mortality as deaths occurring among people aged 69 years old or younger. According to Professor Peter Lloyd-Sherlock, professor of social policy and international development at University of East Anglia, and colleagues this is blatant “ageism”.

The UN’s proposed Sustainable Development Goals target sends an unambiguous statement to UN member states that health provision for younger groups must be prioritized at

the expense of people aged 70 or more, according to the international group of signatories of the letter published in The Lancet, 30 May 2015.

For more information:http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61016-9/abstract


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FDA approves mid-stage trial of vaccine to reverse type 1 diabetesThe FDA (US) has approved a mid-stage trial to test an almost century-old vaccine for preventing tuberculosis. The vaccine, called bacillus Calmette-Guerin (BCG), will be tested in 150 adults with advanced cases of type 1 diabetes.

The approval was announced Sunday at the 75th Scientific Sessions of the American Diabetes Association by Dr. Denise Faustman, director of the Massachusetts General Hospital Immunobiology Laboratory in Boston and principal investigator of the study.

In a small preliminary trial, Faustman’s team found that two BCG injections given four weeks apart temporarily eliminated diabetes-causing T cells. Patients also showed evidence of small, temporary return of insulin secretion. Dr. Faustman and her colleagues are now enrolling patients aged 18 to 60 in a larger five-year trial. Participants will have low but detectable levels of insulin secretion from the pancreas. They’ll receive two injections, four weeks apart, of either

BCG or placebo, and then annual injections for the next four years.

The BCG vaccine was first used in humans in 1921 as a vaccine against tuberculosis. More recently, its most common use in the US has been in the treatment of bladder cancer.

For more information:http://www.faustmanlab.org/docs/clinicalt/BCG%20TRIALS%20FACT%20SHEET.pdf

The continuing global epidemic of diabetes exacts huge costs both in terms of human suffering and economics, and the importance of understanding the origins of the epidemic and the development of methods to abate it has never been higher. The Public Health and Epidemiology Stream at the World Diabetes Congress Vancouver 2015 will cover a broad range of topics of high relevance to the understanding of the causes of the global diabetes epidemic and potential means to stall or reverse its progression. In addition, a major focus of this stream will be to consider the risks of diabetes complications, both traditional and newly emerging, and the prediction and prevention of these adverse outcomes.

Several symposia will provide general updates on the worldwide progress of the diabetes epidemic but also focus on particular sub-groups and regions. One symposium topic will specifically focus on the impact of diabetes on women in developing countries, while another will cover the subject of diabetes in youth. Also, international trends in diabetes complications will be described and discussed, as well as the appropriateness of diabetes guidelines for testing and treatment in all countries. A symposium will feature the latest version of the International Diabetes Federation Diabetes Atlas where updates and developments in the global diabetes epidemic will be presented.

Paths to prevention of diabetes will be presented from several perspectives. Given that nutrition has been implicated as a culprit in the diabetes epidemic, a symposium will present and discuss the public health approaches that several countries have taken to effect healthier eating. Debates will address the effectiveness of diabetes screening and the

community-wide approach to preventive interventions. Also, the role of the built environment and the means to transform it to promote health will be presented.

New developments in technology and connectivity have spread around the globe and have the potential to assist in efforts to control the diabetes epidemic. Open forums will take place at the World Diabetes Congress on the role of social media, the Internet, and mobile technologies in promoting diabetes epidemiology and prevention research. “Big Data” is a term increasingly used to describe the accumulation of data from electronic health records, database linkages, national health care systems, and health insurance plans. A symposium will help to provide a better understanding of the nature of big data and its role in understanding the epidemiology of diabetes and potentially providing means to lessen its impact.

Symposia and lectures will take place on new and emerging aspects of diabetes etiology and complications. Advances in medical research provide new opportunities to identify risk

Public health and epidemiology stream

Edward J. Boyko

WORLD DIABETES CONGRESS VANCOUVER 2015

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factors for both types 1 and 2 diabetes. These include the study of epigenetics, the microbiome, microRNAs, and also the potential for probiotics in diabetes prevention. A primer will be presented on new methods such as Mendelian Randomization to better identify potential causal factors for the development of diabetes. Evidence continues to accumulate on oral complications associated with diabetes, and these will be discussed as well as treatments and associations with other metabolic disorders.

Several current controversies will be discussed in symposia and debated. The role of sugar consumption in chronic diseases will be one such topic, and the obesity paradox another. Also, the latest findings of ACCORDION (the ACCORD Trial Follow-Up Study) will be presented in a special symposium.

Last, but certainly not least, the second ever IDF Public Health and Epidemiology Award Lecture will be presented by Edward Gregg of the Centers for Disease Control and Prevention, United States.

We look forward to your participation in the exciting Public Health and Epidemiology programme at the World Diabetes Congress Vancouver 2015.

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About the Author

Edward J. Boyko is Professor of Medicine and Adjunct Professor of

Epidemiology at the University of Washington and Staff Physician at

VA Puget Sound Health Care System in Seattle, Washington, USA.

He is also the Stream Lead: Public Health and Epidemiology for the

World Diabetes Congress Vancouver 2015.

Having fun in a safe and educational environment

Angie Middelhurst

Worldwide, thousands of children living with type 1 diabetes participate in residential and day camps giving them the opportunity to fulfill a recreational, educational, and social need. Camp provides a safe and productive framework to manage diabetes in a fun and active environment. Successful diabetes camps are built upon solid diabetes education and management, qualified medical staff and purposeful camp activities. A camp experience can give a young person the opportunity to meet others like them and help them feel less isolated and more confident about their condition while learning how to manage type 1 diabetes in a very active yet supportive environment.

Although diabetes camps exist in abundance across North America and some countries in Europe, they are less common in other parts of the world, especially in low and middle-income countries. Angie Middlehurst, Education Manager for IDF’s Life for a Child Programme discusses the basic diabetes camp requirements and advantages for diabetes health and shares her two most recent visits to camps in Fiji and Jamaica.

Basics for diabetes camps worldwide

As diabetes camps become more popular, it is clear that every environment is different and funding for resources may be greater in one part of the world versus another. Howev-er, all diabetes camps must address the minimum stand-ards of health, diabetes education, and safety. There should be plenty of fun, but it must also be well organised. Every camp should have a licensed health professional (Registered Nurse or Doctor) knowledgeable in type 1 diabetes, who can help develop and monitor procedures, supervise others and

administer care to participants during the programme.

One of the greatest advantages for children and young people can be the effect on HbA1c results. Campers are often able to test blood glucose levels more frequently than at home as test strips may be more available. In this regard, blood glucose levels may improve with closer supervision of testing and insulin adjustment. Improvement in Hba1c may be seen with longer camp duration, but less so over weekend camps.

Fiji

Fiji is an island country made up of 332 islands in the South Pacific Ocean 1,300 miles northeast of New Zealand with a population close to one million inhabitants. Over the course of one weekend, the diabetes camp is conducted by health professionals from three main hospitals at a facility about an hour’s drive from Lautoka, the second largest city in Fiji. Children living further afield - from outlying islands - fly and then travel by bus to reach the camp. Funding for the camp is sought and sourced from local businesses. The theme for the Fiji camp was “Healthy Me: I ROCK!”

Around 15 children and teenagers ranging in age from 6 to 18 years attend with a relative who may be a sibling, parent, aunt, uncle, grandparent or a neighbour. The individual

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“All diabetes camps must address the minimum

standards of health, diabetes education and safety”

accompanying the camper is not necessarily educated in diabetes management but will gain a great deal of skill at camp in order to help. They also learn how to assist in everyday diabetes tasks such as the importance of remembering to check blood glucose levels or administer insulin.

Activities are rotated from diabetes education (injection technique, coping with diabetes) to painting and games. Children and accompanying adults are included and everyone learns and plays together, often making friends for life. Adults are asked to help with preparing and cooking meals, and a dietician teaches about the importance of carbohydrates and portion sizes pertaining to local food choices.

The last night of camp, all the campers, relatives, accompanying adults and camp staff participate in a talent show. This is a celebratory way to end the camp experience often reflecting growth and improved self-confidence. All the children with type 1 diabetes depart the next day expressing their desire to return to diabetes camp the following year. Nothing offers more proof on how much the children value diabetes camp then their excitement to return!

Jamaica

Jamaica is one of the slowest developing countries in the world, with 19.9% of the population living in poverty. It is another island country situated in the Caribbean with nearly one million people living in the capital city of Kingston.

A local clinical psychologist, in conjunction with Diabetes Association of Jamaica (DAJ) invited disadvantaged children from Kingston to attend this camp over two weeks of the school holidays. Children were scheduled to attend for six hours (9am to 3pm) Monday to Friday. Only ten of the children who participated out of the total number had type 1 diabetes. This is a very different model from the traditional diabetes camp that most of us are used to and we wondered whether it would work. We were pleasantly surprised.

Funding for the camp was supplied by the government and local businesses. Each child with diabetes was funded by DAJ for their transport to and from camp.

The children living with type 1 diabetes and those who did not have type 1 diabetes were a very good combination. Those

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Group of teenagers in Fiji, all living with type 1 diabetes, wait for the bus to take them back home after their diabetes camp experience.

without diabetes were fascinated with the tasks those with diabetes had to cope with day after day. Both groups learned a great deal, and it was touching to see the love and care they showed each other. Activities were age appropriate, divided between boisterous games, drawing, examining feelings and behaviour and diabetes education, where everyone, living with diabetes or not, joined in with gusto. A diabetes nurse from DAJ and myself attended the camp every day to check blood glucose levels, treat hypoglycaemic episodes , carry out valuable opportunistic education and generally interact with the children.

On one occasion, a boy had a severe hypo. Unfortunately, we did not have glucagon available so we treated him very cautiously but successfully with juice and biscuits, a vital part of the supplies needed at camp for this very reason.

Most of the ten children with diabetes attended each day and thoroughly enjoyed themselves. They made friends who they can now keep in touch with at clinic and the next camp!

The Fiji and Jamaica camps are great illustrations of different models that can be called ‘diabetes camp’. Neither of them are necessarily typical of camps conducted in developed and developing countries, however both are successful and the organisers are to be congratulated.

Funding

Cost for a child to attend camp varies depending on the country and the funding available. In Australia the cost per child would average AU$275, (approximately US$209).

Angie Middelhurst stands with children and teens with type 1 diabetes at the camp in Kingston, Jamaica.

Health professionals generally volunteer their time to attend camp. Their accommodation is included in the overall funding or they self-fund.

The Life for a Child (LFAC) Programme funds LFAC-supported countries with a donation to assist in starting a camp.

Camps are conducted in various LFAC-supported countries including Azerbaijan, Bolivia, Ecuador, Ghana Haiti, Kenya, Maldives, Nepal, Rwanda, Sri Lanka and Tajikistan. Most of the remaining LFAC-supported countries hold activity days or similar.

There are several ways to donate to Life for a Child. Visit www.lifeforachild.org/donate for more information.

“On one occasion, a boy had a severe hypo. Unfortunately, we did not have glucagon available

so we treated him very cautiously but successfully with juice and

biscuits”

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About the Author

Angie Middlehurst is a certified diabetes educator and the Education Manager for the IDF Life for a Child Programme.


Diabetic foot disease: when the alarm to action is missing

Kristien Van Acker

Did you know that every 20 seconds an amputation caused by diabetes occurs somewhere in the world? Paradoxically 85 percent of all amputations caused by diabetes are preventable. If amputation is almost always preventable then this is good news for people at greatest risk for diabetic foot disease. Sadly, amputations are still occurring at too great a rate in high, low- and middle-income countries.

Problems related to the feet are among the most serious and most feared complications of diabetes. It is well known that diabetic foot disease is a source of major suffering and financial burden for patients. People with diabetic foot ulceration and amputation are observed to be suffering from reduced quality of life (QoL) in terms of pain, time lost from work and reduced socialisation leading to isolation and despair.

The start of the diabetic foot disease process is the loss of protective sensation, meaning that a person is already suffering from relatively severe neuropathy. When blood glucose and blood pressure are excessively and consistently high, diabetes provokes damage to nerves throughout the body and this is called neuropathy. The most commonly affected areas are the extremities, particularly feet. Damage in the feet is called peripheral neuropathy, which may lead to pain and tingling but, more commonly, to loss of feeling. Even if an injury develops, the individual with peripheral neuropathy will not feel the pain associated at the site of the lesion. In other words, the alarm to action is missing. The development of lesions with no appropriate and immediate action leads to infection and further destruction of deep tissues. When impaired peripheral circulation is present the situation can escalate further and very quickly to minor or major amputation.

Worldwide, the number of ulcers and amputations are very high and diabetic foot ulceration precedes 85 percent of diabetes-related amputations. The yearly incidence is around 2%-4% in developed countries and at least 4%-8% in developing countries. This translates to approximately 1.1 million amputations in Africa (estimated to rise to 9.9 million in 2030) and 1.25 million in South and Central America (estimated to rise to 2.5 million by 2030). The statistics represent millions of personal tragedies but also the huge financial burden of diabetic foot disease and amputation on families. In low-income countries the cost of treating a complex diabetic foot ulcer can be equivalent to 5.7 years of annual income, potentially resulting in financial ruin for patients and their families.

Since 2006, the International Working Group on the Diabetic Foot (IWGDF) and the International Diabetes Federation (IDF) have collaborated to provide diabetic foot programmes worldwide. The strategic objective is to decrease the risk of diabetic foot disease to patients, and raise awareness with healthcare providers and governing bodies, too. There are three levels of intervention required to meet the specific targets.

Level 1:Programmes called “Train the Foot Trainer” (TtFT) implement

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“85% of amputations related to diabetes are preventable.”

the Step by Step Foot projects which are focused on the following processes: Investment in national structures with secondary and reference centres of interdisciplinary diabetic foot services. Many disciplines work together for early treatment of simple and more complicated ulcers. It is proven in the literature that this approach reduces amputation in developing and developed countries alike. Centres are responsible for setting up referral and contra-referral strategies, where the delay to referral will be set as low as possible. The trainees, national key-opinion-leaders, also give training to healthcare providers in their regions for prevention. As all of these interventions concern national healthcare, political involvement is a must. Before trainees can come to a four-day course they need a letter of collaboration from their national patient organisation and an approval of contact from their ministry of health.

Level 2: Members of the working group believe that success depends upon healthcare providers who can be considered “gatekeepers,” as they are able to determine the group of patients at the highest risk for developing foot-ulcers.

Patients at high risk are the following:

• Designated by an orange light: peripheral neuropathy and peripheral arterial disease and/or with foot deformities;

• Designated by a red light: peripheral neuropathy and a history of foot ulcer or any level of lower-extremity amputation.

Currently, only 20 countries have healthcare providers trained in specialist foot care, also known as podiatrists or podiatry care. Podiatrists are very good gatekeepers. To make up for the lack of podiatry care, the Diabetic Foot Care Assistant programme (DFC Ass) has been developed to fill the gap, particularly in developing countries. In the last phase of this programme the working group will help set up podiatry care on a mid-to long-term basis in those countries

Level 3: Preventive care must be encouraged and directed to the

patient with empowerment strategies. This intervention can be carried out with every national diabetes patient organisation. National associations can encourage the necessary skills and education for people with diabetes. We consider it a patient right to know their individual personal risk-category for developing a diabetic foot ulcer. From the moment red or orange has been designated, specific education on foot self-care is necessary. The patient will be asked to look daily at his or her feet and this sometimes requires the help of a family member. Good foot hygiene and nail care is a must, as is the protection of the feet with appropiate footwear. As the last condition is not always present in developing countries, patient organisations need to accept the idea that special shoes given to people at risk of diabetic foot disease is as important as ensuring that insulin or oral medications are available.

In 2012, a TtFT course for the IDF South and Central America (SACA) region included 58 delegates from 14 countries. In 2014, the two and a half year implementation phase of this great effort was complete. In a two year period, more than 3,000 healthcare providers (doctors and nurses) were trained in the countries of Latin America. Additionally, more then 150 new diabetic foot clinics were established. We hope that national patient organisations will help this advancement and empower people with diabetes to care for their feet.

What will it take to achieve success today and tomorrow? Trained healthcare providers who work together to improve diabetic foot care and informed patients who perform their

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daily foot-care regimen and recognise when an ulcer or infection is present and, without any delay, get immediate help.

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About the AuthorKristien Van Acker is a diabetologist, currently working in Chimay, Belgium. She is Chair of the International Working Group on the Diabetic Foot (www.iwgdf.org) and IDF Consultative Section on the Diabetic Foot.

FOR JEFFREY, DIABETES EDUCATION HAS MADE ALL THE DIFFERENCE Nalini Campillo

It was 32ºC in the Capital city of Santo Domingo in the Dominican Republic on the day I met Jeffrey, who at 28 had lived with diabetes for 14 years. It was so hot at the Plaza de la Salud General Hospital that volunteers were giving bottles of water to visitors at the front entrance. Jeffrey and I had never met when he appeared in my office and I did not know why he had come for a consultation. He was wet with sweat from the heat outside and I noticed he was not wearing shoes.

Jeffrey confessed he had no money to pay for his visit as we began to discuss his type 1 diabetes. When I asked him about insulin and how much he was taking everyday, he admitted that he could not always afford insulin because he had to buy food for himself, his mother and his two younger sisters. Instead, Jeffrey like so many poor people in my country turned to something called “insulin tea.” Insulin tea is made of various herbs that are believed to provide relief for diabetes, but of course, the tea has no effect.

It became apparent as I watched Jeffrey rub his feet that he was in pain. He had gotten a lift from a friend on a motorcycle and then walked a fair distance from a poor neighborhood in Santo Domingo called Katanga, about four kilometres from the hospital. He told me could not find his shoes.

Unfortunately for people like Jeffrey living with diabetes, they have not been educated about diabetes or diabetes self-management. Jeffrey had already lived with his disease for 14 years, and yet he did not know that insulin tea would not help reduce the glucose in his blood. He also wasn’t aware that high blood glucose leads to terrible complications such as the loss of sensation in his toes and feet, making shoes indispensable. Unfortunately, general illiteracy in the Dominican Republic population for people 15 years and over was estimated to be 9.9% in 2011.

General illiteracy, which leads to poor health literacy, is a barrier to diabetes self-management education. New initiatives must be explored to teach people like Jeffrey the importance of caring for diabetes, both type 1 and type 2.

When I had convinced Jeffrey to show me the bottom of his foot, I saw that an ulcer had formed below the 5th metatarsal bone. Jeffrey was admitted to the hospital that day to amputate his fifth toe. Fortunately, within two months, Jeffrey’s recovery was successful and he was motivated to care for his diabetes. Our volunteers gave him the opportunity to go to a local centre for adult education for reading and writing, and he accepted assistance for buying insulin and visiting the hospital for his appointments.

Today, Jeffrey is one of our “teachers” or “ulcerated patients” who talk about their experiences to the “non-ulcerated” patients waiting for their diabetes appointments with the doctor. It’s very evident he enjoys his mentoring role. One day I asked Jeffrey why he always prefers to come on Tuesdays and not any other day. “Because,” he explained, “I remember it was a Tuesday the first time that I realised I did not have any shoes on my feet and because Tuesday was the first time I met you, doctor. After that, my life changed.”

Nalini Campillo is a diabetologist and nutritionist coordinator at the Diabetic Foot Clínic at the Plaza de la Salud General Hospital in the Dominican Republic.

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Diabetes Voice - Digital Edition July 2015