Diabetes Clinical Practice Guidelines (CPGs) for the ASEAN region: Country Initiatives for Collectively Enhanced Diabetes Care in the Region

Elizabeth Paz-Pacheco

The prevalence of diabetes in the region is clearly increasing, and so is the burden of this chronic disease and its complications. The Philippines reports a true prevalence of about 7.2% among adults aged 20 years and older in 20081;  in the 2010 International Diabetes Federation Diabetes Atlas, Indonesia, Malaysia and Singapore report 4.6%, 10.9% and 12.7% prevalence rates, respectively.2 These rates are consistent with global estimates, and considering the increasing populations in these countries, the absolute numbers are certainly staggering.

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Diabetes Clinical Practice Guidelines (CPGs) for the ASEAN region: Country Initiatives for Collectively Enhanced Diabetes Care in the Region
Elizabeth Paz-Pacheco

The prevalence of diabetes in the region is clearly increasing, and so is the burden of this chronic disease and its complications. The Philippines reports a true prevalence of about 7.2% among adults aged 20 years and older in 2008;1 in the 2010 International Diabetes Federation Diabetes Atlas, Indonesia, Malaysia and Singapore report 4.6%, 10.9% and 12.7% prevalence rates, respectively.2These rates are consistent with global estimates, and considering the increasing populations in these countries, the absolute numbers are certainly staggering.

Through improvement in diabetes care, diabetes complications can be prevented or delayed. Various strategies at early screening, diagnosis, and appropriate interventions have demonstrated improved outcomes in several populations.

However, the practice of diabetes care is far from uniform and optimal in most of the developing countries in the ASEAN region. Specialized care is mostly confined to city centers, with minimal reach to financially challenged underserved communities. Efforts to enhance and increase access to quality care are therefore imperative. Such efforts include the development and deployment of Clinical Practice Guidelines (or CPGs).

CPGs provide recommendations to define standards of care. When properly developed and deployed, CPGs are expected to provide the best possible care to the greater majority of the population.

This issue features CPGs for diabetes of the AFES countries, with reports from Indonesia, Malaysia, Philippines, and Singapore. These four DM CPGs vary in their scope. The Indonesian and Philippine CPGs focus on classification, screening, and diagnosis, while the Malaysian and Singaporean CPGs provide further recommendations to include management of diabetes and its complications.

The CPG for Indonesia was based on an expert consensus; with several revisions, the current report was completed in 2010. It represents a simplified set of guidelines for screening and diagnosis of prediabetes and diabetes, derived from guidelines set by US diabetes organizations. Mass screening is not recommended; screening is directed to high-risk patient groups.

The CPG for the Philippines is a summary of the output of the multi-organization umbrella Philippine UNITE for DM, in response to the call of the International Diabetes Federation (IDF), focusing on outpatient care for adult Type 2 DM. It has utilized a well-developed guideline adaptation system, supplemented by de novo development for aspects where there were no guidelines. It reflects current evidence, mostly derived from Northern American data. It intends to provide physicians with a guide and does not mean to replace individual clinical judgment.

The CPG for Singapore is a comprehensive report involving various aspects of diabetes care including management of diabetes, its complications and associated metabolic disorders. With the tremendous amount of new data, a need for updating is recognized and a new working committee is being set up to update the current CPG, with possible re-publication in 2012. The use of HbA1c for the diagnosis of diabetes, as recommended by the American Diabetes Association, is carefully being considered. Relevant statements on therapeutic options are discussed, including the use of thiazolidinediones and insulin glargine. The Singapore CPG also provides an insight into the use of the newer agents such as DPP IV inhibitors and GLP-1 analogs.

The CPG for Malaysia is likewise recently updated (2009) to accommodate new evidences. This set of guidelines covers many aspects of the diagnosis and treatment of diabetes. In addition, it describes country specific information, such as carbohydrate content of common Malaysian foods. Application of local results particularly from their Malaysian National Health and Morbidity Survey provided inputs on the decision for diabetes screening cut-offs. This set of guidelines was printed and distributed through the Ministry of Health with downloadable PowerPoint slides for the training modules. Evaluation programs have been instituted to provide an audit mechanism for the use of the CPG.


What is the value of these CPGs for the region?

Delineation of CPGs is the first step in determining a set of guidelines for diabetes care that is specific and applicable to each country. Presently, data resource is generally derived from international guidelines, as these are generally well-established and evidence-based. International guidelines frequently become the main source of evidence, due to the paucity of national, or regional, studies.

To realize its goals, every CPG needs to be properly deployed to all end-users and its utility for improving diabetes care needs to be properly confirmed. In addition, it is critical to find a balance between what may be deemed to be minimum recommendation and what the department of health and its regulating agencies may impose to elevate the level of care. Challenges to the success of CPGs include the monitoring of appropriate use in all concerned populations. As a further step, research needs to be advanced to determine whether national guidelines derived from international guidelines prove to be adequate. There is a critical need to validate their correct application to developing countries. As diabetes is a heterogeneous disease, there is a need for better understanding of the etiopathogenesis of diabetes in various ethnic populations, with their respective dietary and lifestyle patterns.

The challenge to AFES is to stimulate discussion on these critical issues with parallel efforts and collective contributions from experts in the region. Particular issues such as country specific diets, popular physical activity practices, and the role of popular use of herbal supplements and alternative treatments have to be addressed. More public health strategies from both government and non-governmental organizations need to be pursued.

Discussion among AFES colleagues shall help advance the status of diabetes care not only individually among the member countries but collectively in the region. All this while, individual country-specific challenges and difficulties need to be identified as these will present as barriers to the true success of national CPGs. Coordination of country initiatives is the key to CPGs for a collectively enhanced diabetes care in the region.

References

1. Sy RG, Morales DM, Dans AL, et al. National Nutrition and Health Survey II: Prevalence of atherosclerosis-related risk factors and diseases among adult subjects in the Philippines. 2011, Manuscript in preparation.

2. IDF Diabetes Atlas. http://www.diabetesatlas.org/content/prevalence-estimates-diabetes-mellitus-dm-2010 . Accessed April 2, 2011.

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