Type 2 Diabetes Mellitus (T2DM) is a chronic disease characterized by hyperglycemia brought about by defects in insulin secretion (beta cell dysfunction) and insulin action (insulin resistance). Diabetes is the leading cause of devastating complications such as cardiovascular events, strokes, end stage renal disease, blindness and lower extremity amputation.1 The global burden of diabetes with its accompanying risk factors and complications, is upon us.2 Asia is the focus of this burden, owing to huge population numbers and increasing prevalence rates.3 The Philippines is an archipelago consisting of 7,100 islands. As of 2015, the projected population is 102,965,300.4 The challenges presented to us relate with increased Westernization of diets and decrease in physical activity, leading to obesity. Lifestyles of majority of Filipinos revolve around food. Celebrations and gatherings put emphasis on a bountiful table of food. Physical activity generally consists mostly of house work for the women and a few meters of walk and work-related activities as form of usual exercise for working men and women. Sadly in the Philippines, while under-nutrition continues to be a major health problem, obesity is an emerging concern.5
Burden of Disease and Etiology
The latest Philippines' National Health and Nutrition Survey (NNHeS) 20136 as compared to 20087 has provided the health and disease score with identification of the major risk factors among adults >20 years of age, respectively: diabetes (5.4%, 6% using OGTT); hypertension (22.3%, 24.6%); dyslipidemia, low HDL (71.3%, 72%); obesity, BMI >25 kg/m2 (31.1%, WHR of 0.85 in females 65.6%); smoking (25.4%, 31%) and metabolic syndrome, IDF Harmonized Criteria, Alberti et al, 2009 (27% in 2008, unpublished data). The trends are steady for most except for smoking. This reduction in smoking habits may be attributed to the legislative measure, the Sin Tax bill, which has recently been passed.8
With regards to gestational diabetes (GDM), the reported prevalence of gestational diabetes was 14% among 1203 pregnant women using the AFES Study Group on Diabetes in Pregnancy (ASGODIP) criteria.9 Uniformly across various hospital and clinic settings, follow up after gestational diabetes for re-classification using OGTT post-partum is low. Limited data from a private university hospital among 124 women with previous GDM revealed that the prevalence of diabetes and pre-diabetes 6-12 weeks post-partum is 7.3% and 34.7%.10 Although there has been no study on the financial cost of the diagnosis of GDM to the Filipino family, this is probably significant given that gestational DM increases the risk of primary CS (OR=1.79, 95% CI: 1.02-3.16, p=0.041) and infant admission to the Neonatal ICU (OR=2.66, 95% CI: 1.3 -5.44), p=0.007). A trend for higher risk of LGA, pre-eclampsia, preterm delivery and congenital anomalies was observed in those with GDM, was also found but these did not reach statistical significance.11 The local guideline advocates routine screening of all pregnant women for GDM using 75-gm OGTT, as well as follow up after delivery to determine glycemic status.
What characterizes diabetes among Asians, among Filipinos
Data from our region shows emerging data describing an Asian phenotype, somewhat different from our Caucasian counterparts.12 Asian populations have differing demographic and socio-cultural characteristics in the setting of a genetic susceptibility impacting the development of diabetes. In Asia, India and China will account for the highest numbers (79.4 M and 42.3 M, respectively) by 2030, but South East Asia will have the highest rates worldwide. This increase will affect developing countries substantially as these countries including the Philippines, often have limited resources to cope with the disease. T2DM is seen to develop at a younger age, usually a decade earlier than Caucasians; young onset diabetes is increasing at alarming rates. As diabetes starts early in life, this brings with it an associated increase in morbidity and mortality and a lifetime risk of cardiovascular disease. This was clearly shown in the CANDI Manila study where newly diagnosed adult T2DM patients (mean age of 50 years) showed high prevalence of diabetic complications and cardiovascular risk factors, at the apparent onset of their DM diagnosis. Electrocardiographic findings demonstrating myocardial infarcts and ischemic changes were seen in 5% of study participants, 42% had proteinuria by urinalysis and 12% had retinopathy. Hypertension was present in 42% of individuals (mean BP of 144/88 mm Hg), and dyslipidemia was predominant (80% with LDL ≥100 mg/dL, with another 38% with elevated triglyceride ≥150 mg/dL).13
Characteristics are heterogeneous with high rates of clustering of cardiovascular risk factors. Indeed, metabolic syndrome is manifesting even at a young age. Young onset diabetes in children is common. Both thrifty genotype and phenotype may occur in Asian groups. Several distinctive features are apparent in the pathogenetic factors, ranging from epigenetics, such as maternal imprinting, genetic susceptibility markers to unhealthy lifestyle changes leading to high rates of obesity.14
What drives the continued increase in these major risk factors?
Diabetes among Filipinos is not exclusively mediated by obesity per se, as increased rates are seen in relatively lower BMI, as compared to Caucasians. Philippine data show that despite an obesity prevalence that is less than 10%, visceral adiposity as measured by waist-to-hip ratio is 65.6% in females.7Clearly, the risk is driven by visceral adiposity. Data from Araneta et al revealed excess visceral adipose tissue accumulation15 with low adiponectin levels among Filipino-Americans in San Diego, California, USA.16 The low adiponectin levels were likewise demonstrated among diabetics, as compared with non-diabetic controls from the population based study in the Philippines (NNHeS 2008).17 In the same survey, lipid profiles among Filipinos revealed a remarkably low HDL, comprising 70% of the population, a consistent finding from surveys as early as 1998.7
Despite early studies on genetics of T2DM and its complications18-20 among Filipinos, there is a need to more comprehensively elucidate this relationship. Relevant questions on distinctive lifestyles, food choices and other preferences have to be clearly understood to form the framework for prevention strategies. The geography of the country led to regions separated by bodies of water, and has created regional preferences and lifestyles. These refer to food preferences for choices that are abundant in the region, as well as activities that are part of the daily chores.
Goals of long-term care for diabetes, a chronic disease
The bottom line is improved survival rates and quality of life for all Filipino diabetics. Chronic care models from various developed countries21 have demonstrated benefits in reduction of outcomes through an organized system of care.
Prevention is the best investment, as it limits diabetes rates and complications that eventually take its toll on the financial status of families. Diabetic breadwinners have reduced work opportunities and earning capacities. Complicated diabetes is an expensive disease, worsened by lack of government funding support or subsidy for medications, hospitalization and other services. Concurrent coordinated efforts should be directed towards early detection through aggressive nationwide screening and diagnosis of diabetes, obesity and the components of the metabolic syndrome. To date, there is no national screening program for non-communicable disease (NCD) in the Philippines. Efforts by various groups include random screening activities conducted by several health facilities, employers, religious groups and medical organizations. Obesity prevention should begin with children, as these alarming increase in rates will translate to adult diabetes.
Comprehensive and optimal treatment requires strategies that will allow multi-factor risk control involving hyperglycemia, dyslipidemia, hypertension, weight and smoking cessation. After an initial control, sustainability is an essential goal, that is, to effectively maintain risk control, to reduce complications and outcomes and improve survival and quality of life of all affected individuals.
DiabCare Philippines 2008, a survey on glycemic control among diabetic patients seen by both general practitioners and diabetes specialists showed that less than 20% have good glycemic control (HbA1C of <7%) Mean duration of diabetes was 10 years with the age of onset of DM in the early 50's. Mean BMI was between 24.7- 25.7 kg/m2. About 10% had some form of nephropathy (6-7% with serum creatinine values greater than 2 mg/dL) and more than 40% of patients already had neuropathy.22 Future surveys with more strict selection to represent the national average should be conducted to chronicle and plan for the burden of diabetes and its complications on families, the healthcare system, and the economy.
The Infrastructure for Healthcare Delivery in the Philippines
The national healthcare system of the Philippines consists of a three-tiered system similar to other countries. Until 1991, all levels of healthcare delivery from primary to tertiary were under the direct control of the central government through the Department of Health (DOH). Following the implementation of the Local Government Code of 1992, the Philippine government devolved or delegated the management and delivery of health services from the national DOH to the local government units (LGU's). There are currently six "facility levels" managed by different political and administrative units that include: barangay health units (managed by barangay and municipal governments); rural health units (managed by municipal governments); city health offices (managed by city governments); municipal or "district" hospitals (managed by the provincial government); provincial hospitals (managed by the provincial government); and regional hospitals and medical center levels (managed by the DOH). Following the District Health System (DHS) model of the World Health Organization (WHO), facility levels 1-3 correspond to the primary level of care, facility 4 to the secondary level of care and facilities 5-6 to the tertiary level of care.23 In this decentralized set-up, the DOH serves as the governing agency, and both LGUs and the private sector provide services to communities and individuals. The DOH is mandated to provide national policy direction and develop national plans, technical standards and guidelines on health. The LGUs have autonomy and responsibility for their own health services, but are to receive guidance from the DOH through its regional centers for health and development (CHDs).
In the current system, provincial governments are primarily mandated to provide hospital care through provincial and district hospitals, and to coordinate health service delivery provided by cities and municipalities of the provinces. City and municipal governments are charged with providing primary care including maternal and child care, nutrition services and direct service functions through public health and primary healthcare centers called the city health offices or (municipal) rural health units (RHUs).24 These city and municipal health centers are linked to the smallest unit of the health delivery that are the peripheral barangay health centers or stations (BHS).
A major share of the national expenditures on health, approximately 60%, goes to a large private sector that also employs over 70% of all health professionals in the country. The private sector consists of for-profit and non-profit providers, which are largely market-oriented. Healthcare is paid through user or professional fees at the point of service, or subsidized by official aid agencies or philanthropy. This sector provides services to an estimated 30% of the population who can mostly afford to pay these fees out of pocket. Although the private health sector is regulated by the DOH and the national health insurance system called the Philippine Health Insurance Corporation, health information generated by private providers is generally absent in the information system of the DOH.24 Organizational structure and accountability in the Philippine healthcare system is shown in Figure 1.
Click here to download Figure 1Figure 1. Organizational structure and accountability in the Philippine healthcare system.24
Health Program for Diabetes in the Philippines
A National Diabetes Prevention and Control Plan has been drafted by the Philippine DOH since the late 1990's, in order to curb the mortality and morbidity from this chronic disease. The management of diabetes subsequently became part of the Integrated Community-Based Noncommunicable Disease (NCD) Prevention and Control Project which were rolled out in the various cities and municipalities of the Philippines. This included the "Healthy Lifestyle (HL)" campaign to increase awareness and consciousness regarding diet, exercise and healthy lifestyles such as smoking cessation.
Other aspects of the integrated NCD program were the development and conduct of training modules for healthcare workers. There is now systemic change through legislation which include the "Clean Air Act" which prohibits smoking in public buildings, or enclosed public spaces including public vehicles. The country has its own Food Pyramid Guide to curb overweight and obesity among Filipinos, and in 2014, the Food and Nutrition Institute also launched the "Pinggang Pinoy" or the Filipino Plate which is similar to the MyPlate concept of the US Department of Agriculture. It uses a locally adapted way to show Filipinos what a healthy balanced diet should look like, complimenting the food pyramid.
Other programs of the DOH include the provision of low cost medications (metformin and sulfonylureas) to the CHO's and RHU's for distribution to indigent diabetic individuals, together with statins and some anti-hypertensives. Access to insulin of indigent patients is also now being expanded through the Insulin (Medicine) Access Program which is active in select DOH-retained hospitals.
Comprehensive strategies to curb the epidemic of diabetes and obesity
The prescription for lifestyle modification is complex. "Reduce intake and increase physical activity" is easier said than done. Proper food choices is a daily challenge for the diabetic and the pre-diabetic, as fast food choices at cheaper prices abound. Fish, fruits and vegetables are not readily available and are often beyond the budgets of ordinary working individuals. Advertising has enticed many to prefer high fat delectable choices. Simple walking as exercise is not readily doable in a busy metropolis where sidewalks have been converted to vending stalls. Gyms and the like with structured exercise programs with equipments are costly and not within reach by many. Proposed strategies include use of designated walking and cycling only streets, walking paths (indoor track) in office buildings, malls; designated exercise rooms and half basketball court at office buildings for lunchtime and end of day exercise classes; keeping the stairways clean and well-lit and encourage exercise breaks. Government has to invest in efficient mass transit systems to reduce traffic and reduce commute (and sitting times) and provide incentives to workers/teams who reach exercise goals.
Education is key to success. As Elliott P. Joslin, an American pioneer on diabetes stated, "The diabetic who knows the most, lives the longest."25 Regardless of educational attainment, patients at risk for diabetes and the diabetics themselves require an adequate understanding of this condition, the chronicity of care and control and the discipline expected of them to maintain optimal control. Behavioral modification is essential; tailor-fit strategies have to be employed to direct the diabetic to improved lifestyles. For the Filipino, it is a "family affair." Food choices and activity schedules are led by family members; in this matriarchal society often determined by the mother.
Diabetes self-managed education (DSME) is a strategy that has been shown to reduce hyperglycemia and improve outcomes. A pilot study done in San Juan Batangas, an agricultural rural community south of Manila, utilized locally modified educational materials and tapped support from peers and barangay health workers (BHW) as health educators. This study has shown that health education delivered by peer diabetic educators is effective in achieving important health outcomes for diabetics in the rural setting. Diabetics in the DSME group consistently had better blood sugar control (improved HbA1C levels and greater proportion of diabetics achieving HbA1c ≤7.0%. compared to the standard care group for up to the 6th month). More diabetics now perform foot examination after they have been taught on its importance. There are no consistent significant differences in the other anthropometric, biochemical and other health behavior outcomes in the short-term.26-27
Country specific clinical practice guidelines incorporating cost-effective care, appropriate use of oral hypoglycemic agents, insulin and other medications for multiple risk factor control should be widely disseminated. There is a need for partnership with various governmental and non-governmental agencies under the leadership of the DOH to deliver best practices with best use of meager resources to cover a greater number of the diabetic population.28
Service for diabetics should also be integrated within in-hospital settings, as costly hospitalization is often not affordable to many. There has to be optimal in-hospital protocols for admitted patients, including insulin administration and patient education.29-30
Research is a tool that allows proper understanding of a condition for a specific population. For years, comprehensive epidemiological data in the Philippines was lacking. Practice guidelines and approaches are based on international, mostly American and European data. Our treatment options, drug doses and algorithms are derived from recommendations that are based on predominantly Caucasian populations; that differ greatly in genetic susceptibility, drug responses, as well as variable behaviors and preferences as it relate to nutritional and physical activity prescriptions. With successful collaboration of government with technical input from specialty organizations, there are now data from which Philippine health policy may be derived. The National Nutrition and Health Survey is one such effort that incorporated subspecialty expertise into the mandated Food and Nutrition Research Institute (FNRI) survey for nutritional parameters every 5 years. As a result, a variety of research outputs have been completed and some more awaiting publication. In addition, investigators in other countries studying Filipino populations contribute the needed information. There is also increased research interest from various academic institutions in the Philippines. Research funding for non-communicable diseases has become more readily available, mostly coming from the Philippine Council for Health Research and Development of the Department of Science and Technology (PCHRD) and the DOH with smaller amounts received from other funding agencies such as medical organizations, the Philippine Society of Endocrinology, Diabetes and Metabolism, the Philippine Lipid and Atherosclerosis Society and others. Interest for research is increasing as awareness is seen among medical students and other trainees, initially as course requirement and hopefully, as a career path for many.
Telemedicine can be effective, given the high use of cellphones within the population. Smartphone use is however not as widespread, as cost is limiting. Physicians can network through internet facilities to link with specialists who can provide input to patient care, particularly in underserved areas. Social media through Facebook, Twitter and other platforms may be organized to provide education and links to various resources for a huge number of diabetics especially in remote areas.
It is essential to train others, by increasing subspecialty programs to provide key opinion positions in various regions of the communities. In this way, genuine subspecialty reach to communities may be realized, by providing links with grass-roots practitioners. It is envisioned that these links will provide the needed subspecialty inputs to difficult individual cases, as well as the over-all guidance in achieving improved outcomes in the barrios through feasible well organized programs.
The epidemic is upon us. There is no room for complacency. National governmental health agencies should lead with contributions from subspecialist organizations to formulate comprehensive sustainable programs that will detect diabetes early, provide prevention programs, and assist every diabetic in maintaining health and quality of life. Truly we all have to put our our act together with the overall aim of reducing the burden of diabetes and other risk factors for every Filipino.
Acknowledgement
We thank Melissa Tandoc for the assistance in manuscript formatting.
1. Khardori R. Type 2 diabetes mellitus. Medscape. http://emedicine.medscape.com/article/117853 -overview. Accessed September 20, 2015.
2. Paz-Pacheco E. Facing up to the challenges of the diabetic epidemic. Acta Medica Philippina. July-December 2005;39(2):43-47. 3. International Diabetes Federation. IDF Diabetes Atlas, 6th ed. Brussels, Belgium: International Diabetes Federation, 2014. https://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf. Accessed September 21, 2015 4. Philippine Statistics Authority-National Statistical Coordination Board. Population projections. http://www.nscb.gov.ph/secstat/d_popnProj.asp. Accessed September 21, 2015. 5. Florentino RF. The double burden of malnutrition in Asia: A phenomenon not to be dismissed. J Asean Fed Endocr Soc. 2011;26(2):133-136. http://dx.doi.org/10.15605/jafes.026.02.09. 6. 2013 NNHeS. Presented by Dr. Mario Capanzana, Director, Food and Nutrition Research Institute (FNRI) at the National Occupational Safety and Health (NOSH) Congress, November 21, 2014. 7. NNHeS, Sy RG, Morales DD, Dans AL, Paz-Pacheco E, Punzalan FER, Abelardo NS and Duante CA. Prevalence of atherosclerosis-related risk factors and diseases in the Philippines. NNHeS 2008. Advance Publication by J Epidemiol. 2012. http://dx.doi.org/10.2188/jea.JE20110095. 8. Sin Tax. Official Gazette. http://www.gov.ph/sin-tax/. Accessed on September 21, 2015. 9. Litonjua AD, Waspadj S, Pheng CS, et al. AFES Study Group on Diabetes in Pregnancy: Preliminary data on prevalence. Philipp J of Intern Medicine. 1996;34:67-8. 10. Malong CL, Sia-Atanacio A, Andag-Silva A, Cunanan E. J ASEAN Fed Endocr Soc. 2013;28(1):56-63. http://dx.doi.org/10.15605/jafes.028.01.11. 11. Urbanozo H, Isip-Tan II. J of the ASEAN Fed of Endocr Soc. 2014;29(2):157-162. 12. Yeung RO, Zhang Y, Luk A, Yang W, Sobrepena L, Yoon KH, et al. Metabolic profiles and treatment gaps in young-onset type 2 diabetes in Asia (The JADE programme): A cross-sectional study of a prospective cohort. Lancet Diabetes Endocrinol. 2014;2(12):935-43. http://dx.doi.org/10.1016/S2213-8587(14)70137-8. 13. Fojas MC, Lantion-Ang FL, Jimeno CA, Santiago D, Arroyo M, Laurel A, Sy H, See J. Complications and cardiovascular risk factors among newly-diagnosed type 2 diabetics in Manila. Philipp J Intern Med. 2009;47(3):99-105. 14. Ramachandran A, Ma RCW, Snehalath C. Diabetes in Asia. The Lancet. 2009; 375(9712):408-41. http://dx.doi.org/10.1016/S0140-6736(09)60937-5. 15. Araneta MRG and Barrett-Connor E. Ethnic differences in visceral adipose tissue and type 2 diabetes: Filipino, African-American, and white women. Obesity Res. 2005;13(8):1458-1465. http://dx.doi.org/10.1038/oby.2005.176. 16. Araneta MRG, Barrett-Connor E. Adiponectin and ghrelin levels and body size in normoglycemic Filipino, African-American, and White Women. Obesity. 2007;15(10):2454-62. http://dx.doi.org/10.1038/oby.2007.291. 17. Paz-Pacheco E, Lim-Abrahan MA, Sy RAG, Jasul Jr. GV, Sison CMC, Laurel AF. Adiponectin levels and its association with hyperglycaemia in adult Filipino participants in the 2003-04 National Nutrition and Health Survey. Diabetes Vasc Dis Res. 2009; 6(4):231-37. http://dx.doi.org/10.1177/1479164109344933. 18. Bugawan TL, et al. Association and interaction of the IL4R, IL4, and IL13 loci with type 1 diabetes among Filipinos. Am J Hum Genet. 2003;72(6):1505-14. http://dx.doi.org/10.1086/375655. 19. Paz-Pacheco E, Cutiongco-dela Paz EM, Halili-Manabat C, Lim-Abrahan MA, Padilla C, Corvera KD, et al. Mitochondrial DNA (T/C) 16189 polymorphism, variants and heteroplasmy among Filipinos with type 2 diabetes mellitus. Acta Medica Philippina. 2008;42(1):17-21. 20. Paz-Pacheco E, Cutiongco-dela Paz EM, Jasul Jr. G, Aňonuevo-Cruz MC, Montemayor R. Angiotensin-I converting enzyme gene polymorphism and diabetic nephropathy in Filipino type 2 diabetes mellitus patients. J ASEAN Fed Endocr Soc. May 2012;27(1):87-90. http://dx.doi.org/10.15606/jafes.027.01.14. 21. Platt G, Orchard T, Emerson S, et al. Translating the chronic care model into the community. Diabetes Care. 2006;29:811-17. 22. Jimeno CA, Sobrepena LM, Mirasol RC. DiabCare 2008: Survey on glycaemic control and the status of diabetes care and complications among patients with type 2 diabetes mellitus in the Philippines. Philipp J Intern Med. 2012;50(1):15-22. 23. Grundy J, Healy V, Gorgolon L, Sandig E. Overview of devolution of health services in the Philippines. Rural Rem Health. 2003;3(2):220. 24. Romualdez Jr. AG, dela Rosa JFE, Flavier JDA, Quimbo SLA, Hartigan-Go KY, et al. The Philippines health system review. Health Systems in Transition. 2011;1(2):1-155. 25. Krall, Leo C. 2th edition, Philadelphia: Lea and Febiger, 1985. Joslin's Diabetes Mellitus, ch. 23, p. 465. 26. Ardeňa GJRA, Paz-Pacheco E, Jimeno CA, Lantion-Ang FL, Paterno E, Juban N. Knowledge, attitudes and practices of persons with type 2 diabetes in a rural community. Phase I of the community-based Diabetes Self-Management Education (DSME) program in San Juan, Batangas, Philippines. Diabetes Res Clin Pract. 2010;90(2):160-6. http://dx.doi.org/10.1016/j.diabres.2010.08.003. 27. Paz-Pacheco E, Ardeňa, G, Jimeno C, Lantion-Ang FL, Juban, N, Paterno E, Diabetes Study Group of UP-PGH Endocrinology Section. Effectiveness of a community-based Diabetes Self-Management Education (DSME) program: A pilot study in San Juan, Batangas, Philippines, phase 3. Funded by the International Diabetes Federation Bridges grant, the Philippine Diabetes Association and DOST, PCHRD. Manuscript submitted for publication. 28. Jimeno CA on behalf of the Technical Review Committee of the UNITE for DM Clinical Practice Guidelines on the diagnosis and management of diabetes. A summary of the Philippines UNITE for Diabetes Clinical Practice Guidelines for the diagnosis and management of diabetes (Part 1: Screening and diagnosis of DM). J ASEAN Fed Endocr Soc. 2011;26(1):26-30. http://dx.doi.org/10.15605/jafes.026.01.05. 29. Adorable-Wagan P, Paz-Pacheco E, Aligui G. Efficacy and safety of insulin protocol among medical and surgical patients admitted in the Medical City Hospital. J ASEAN Fed Endocr Soc. 2014;29(2): 179-186. http://dx.doi.org/10.15605/jafes.029.02.12. 30. Ngalob Q, Jimeno CA, Isip-Tan IT. Evaluation of effectiveness and safety of an ICU insulin infusion protocol. J ASEAN Fed Endocr Soc. 2014;29(1):33-9. http://dx.doi.org/10.15605/jafes.029.01.05.Authors are required to accomplish, sign and submit scanned copies of the JAFES Declaration that the article represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere.
Consent forms, as appropriate, have been secured for the publication of information about patients; otherwise, authors declared that all means have been exhausted for securing such consent.
The authors have signed disclosures that there are no financial or other relationships that might lead to a conflict of interest. All authors are required to submit Authorship Certifications that the manuscript has been read and approved by all authors, and that the requirements for authorship have been met by each author.