How well controlled are our type 2 diabetic patients in 2002? An observational study in North and Central Trinidad

Physician related barriers towards insulin therapy at primary care centres in Trinidad: a cross-sectional study

BACKGROUND

Physician related factors with respect to insulin therapy can contribute to diabetes mellitus (DM) mismanagement. Patient related factors have been previously explored in a Trinidad survey. The main objective of this study was to explore primary care physicians' (PCPs) related barriers towards insulin therapy.

METHODS

A cross-sectional study on a convenience sample of PCPs in the public primary care system was done using an online survey.

RESULTS

Of the 170 PCPs contacted, 75 (44%) responded. There were 47 females (62.7%) and 28 males (37.3%) with a mean age of 35.9 yrs. Nearly 40% of physicians admitted that the education given to patients was inadequate to allow initiation of insulin therapy. Half the respondents admitted to insufficient consultation times and inadequate appointment frequency to allow for intensification of insulin therapy. Forty percent of PCPs admitted that HbA1c results were unavailable to guide their management decisions. Only 6.7% of physicians said they had access to rapid acting insulin, while 5.3% said they had access to insulin pens.

CONCLUSION

PCPs in Trinidad treating diabetes at the public primary care clinics face several barriers in administering proper insulin therapy. Addressing these factors can improve glycemic control in this population.

A Protocol for the Study of Polymorphisms and Response to Metformin in Patients with Type 2 Diabetes in Trinidad

Background

Metformin is the drug of first choice in people newly diagnosed with type 2 diabetes. Most patients respond to metformin monotherapy, but many others remain uncontrolled even at maximal doses. Although non-adherence is a major contributor to non-response, genetic polymorphisms of organic cation transporters play an important role in clinical response. We hypothesize that genetic variants are partly responsible for non-response.

Objective

This study aims to determine the allele and genotype frequencies of three single nucleotide polymorphisms (SNPs; ATM rs11212617, SLC22A1 rs594709 and SLC47A1 rs2289669) most commonly associated with failure to respond to metformin.

Setting

Ten primary health care facilities in the North Central Regional Health Authority region of Trinidad.

Patients

The study population will include 216 patients with diabetes adherent to metformin monotherapy for at least three months.

Methods

Following a 12-hour overnight fast, blood samples will be taken to measure fasting insulin and HbA1c. DNA would be isolated and PCR will be used to determine the allele and genotype frequencies of these three SNPs in adherent diabetic patients. DNA samples will be stored for future sequencing of these three genes to determine whether other, possibly novel, mutations are associated with poor metformin response in Trinidad.

Clinical Significance

This study will highlight the prevalence of these polymorphisms in our population. Should an association be found between the polymorphisms tested and glycemic control in adherent patients on metformin monotherapy, this will have implications for further research on medication initiation in newly diagnosed patients with diabetes in Trinidad.

An updated systematic review and meta-analysis on the social determinants of diabetes and related risk factors in the Caribbean

OBJECTIVES

To conduct an analysis of the most recent data on diabetes and its risk factors by gender and other social determinants of health to understand why its prevalence is higher among women than men in the Caribbean; to inform policy agenda-setting for diabetes prevention and control in the Caribbean; and to identify gaps in the evidence that require further research.

METHODS

A previous systematic review of the literature describing studies conducted in the Caribbean that presented the distribution of diabetes, its outcomes, and risk factors, by one or more social determinants, was updated to include sources from 1 January 2007 - 31 December 2016. Surveys by the World Health Organization (WHO) were also included. Where data were sufficient, meta-analyses were undertaken.

RESULTS

A total of 8 326 manuscripts were identified. Of those, 282 were selected for full text review, and 114, for abstraction. In all, 36 papers, including WHO-related surveys, had sufficient information for meta-analysis. More women compared to men were obese (OR: 2.1; 95%CI = 1.65 - 2.69), physically inactive (OR: 2.18; 95%CI = 1.75 - 2.72), and had diabetes (OR: 1.48; 95%CI = 1.25 - 1.76). More men smoked (OR: 4.27; 95%CI = 3.18 - 5.74) and had inadequate fruit and vegetable intake (OR: 1.37; 95%CI = 1.21 - 1.57).

CONCLUSION

Thirty-six papers were added to the previously conducted systematic review; of those, 13 were added to the meta-analysis. Diabetes and its risk factors (primarily obesity and physical inactivity) continue to disproportionately affect women in the Caribbean. Smoking interventions should be targeted at men in this geographic area.

Health system dynamics analysis of eyecare services in Trinidad and Tobago and progress towards Vision 2020 Goals

Avoidable blindness is an important global public health concern. This study aimed to assess Trinidad and Tobago's progress towards achieving the Pan American Health Organization, 'Strategic Framework for Vision 2020: The Right to Sight-Caribbean Region,' indicators through comprehensive review of the eyecare system, in order to facilitate health system priority setting. We administered structured surveys to six stakeholder groups, including eyecare providers, patients and older adult participants in the National Eye Survey of Trinidad and Tobago. We reviewed reports, registers and policy documents, and used a health system dynamics framework to synthesize data. In 2014, the population of 1.3 million were served by a pluralistic eyecare system, which had achieved 14 out of 27 Strategic Framework indicators. The Government provided free primary, secondary and emergency eyecare services, through 108 health centres and 5 hospitals (0.26 ophthalmologists and 1.32 ophthalmologists-in-training per 50 000 population). Private sector optometrists (4.37 per 50 000 population), and ophthalmologists (0.93 per 50 000 population) provided 80% of all eyecare. Only 19.3% of the adult population had private health insurance, revealing significant out-of-pocket expenditure. We identified potential weaknesses in the eyecare system where investment might reduce avoidable blindness. These included a need for more ophthalmic equipment and maintenance in the public sector, national screening programmes for diabetic retinopathy, retinopathy of prematurity and neonatal eye defects, and pathways to ensure timely and equitable access to subspecialized surgery. Eyecare for older adults was responsible for an estimated 9.5% (US$22.6 million) of annual health expenditure. This study used the health system dynamics framework and new data to identify priorities for eyecare system strengthening. We recommend this approach for exploring potential health system barriers to addressing avoidable blindness, and other important public health problems.

Barriers to optimal diabetes care in Trinidad and Tobago: a health care Professionals' perspective

BACKGROUND

The republic of Trinidad and Tobago (T&T) is a middle income country with a comparatively high prevalence of diabetes mellitus (DM) compared to others in the Caribbean. To date, there have been no studies on health care professionals' (HCP) perspectives regarding the barriers to achieving optimal care of patients with DM in this country and few previous studies in the Caribbean, yet such perspectives are imperative to develop strategies that reduce the global burden of this disease.

METHODS

An electronic invitation was sent to prospective HCP in T&T inviting them to attend a symposium on DM and cardiovascular disease. A total of 198 HCP participants attended of whom approximately 100 participants completed an Audience Response Survey at the completion of the conference. The Audience Response Survey included questions regarding access to resources, need for prevention and education, and coordination of care for to diabetes care in T&T. Responses were analyzed in aggregate.

RESULTS

The 198 HCP participants attending the symposium included mostly nurses (40 %) and physicians (43 %). The most common specialty indicated by the 198 HCP participants was Internal and Family Medicine (28 %), followed by Anesthesiology (7 %), Emergency Medicine (6 %), Endocrinology and Diabetes (5 %) and Cardiology (3 %). Among the ~100 HCP who completed the Audience Response Survey, multiple barriers to achieving optimal care of patients with diabetes were reported such as: limited access to blood testing (75 %), ophthalmological evaluations (96 %), ECGs (69 %), and cardiac stress tests (92 %); inadequate time to screen and evaluate DM complications (95 %); poor access to consultants for referral of difficult cases (77 %); and lack of provider education regarding cardiovascular complications of DM (57 %). HCP agreed that nurses could potentially be considered to have a more active role in the care and prevention of cardiovascular disease and diabetes through leading patient education efforts (98 %), screening patients for complications (91 %), coordinating care efforts (99 %) and educating family members (98 %).

CONCLUSIONS

The HCP in our study reported significant barriers to achieving optimal diabetes care in T&T. In the future, such barriers to care will need to be addressed in order to respond to the projected growth of diabetes in developing countries both within the Caribbean and globally.

Female gender is a social determinant of diabetes in the Caribbean: a systematic review and meta-analysis

Background

Diabetes (DM) is estimated to affect 10–15% of the adult population in the Caribbean. Preventive efforts require population wide measures to address its social determinants. We undertook a systematic review to determine current knowledge about the social distribution of diabetes, its risk factors and major complications in the Caribbean. This paper describes our findings on the distribution by gender.

Methods

We searched Medline, Embase and five databases through the Virtual Health Library, for Caribbean studies published between 2007 and 2013 that described the distribution by gender for: known risk factors for Type 2 DM, prevalence of DM, and DM control or complications. PRISMA guidance on reporting systematic reviews on health equity was followed. Only quantitative studies (n>50) were included; each was assessed for risk of bias. Meta-analyses were performed, where appropriate, on studies with a low or medium risk of bias, using random effects models.

Results

We found 50 articles from 27 studies, yielding 118 relationships between gender and the outcomes. Women were more likely to have DM, obesity, be less physically active but less likely to smoke. In meta-analyses of good quality population-based studies odds ratios for women vs. men for DM, obesity and smoking were: 1.65 (95% CI 1.43, 1.91), 3.10 (2.43, 3.94), and 0.24 (0.17, 0.34). Three studies found men more likely to have better glycaemic control but only one achieved statistical significance.

Conclusion and Implications

Female gender is a determinant of DM prevalence in the Caribbean. In the vast majority of world regions women are at a similar or lower risk of type 2 diabetes than men, even when obesity is higher in women. Caribbean female excess of diabetes may be due to a much greater excess of risk factors in women, especially obesity. These findings have major implications for preventive policies and research.

Frequency of fat mass and obesity-associated gene rs9939609 and peroxisome proliferator-activated receptor gamma 2 gene rs1801282 polymorphisms among Trinidadian neonates of different ethnicities and their relationship to anthropometry at birth

BACKGROUND

The fat mass and obesity-associated gene (FTO) rs9939609 and peroxisome proliferator-activated receptor gamma 2 gene (PPARG2) rs1801282 polymorphisms are type 2 diabetes mellitus susceptibility gene variants associated with obesity. This study examined whether these variants are associated with anthropometry at birth among a representative multi-ethnic sample of Trinidadian neonates.

METHODS

Cord blood was obtained from consecutive term live births and DNA was genotyped for FTO and PPARG2 variants using polymerase chain reaction. Associations between neonate anthropometry at birth and genotype frequency were assessed using the χ(2) test and linear regression.

RESULTS

Significant associations were observed between neonate ethnicity and PPARG2 (p = 0.005) and FTO (p = 0.017) variants: high-risk alleles were more prevalent among African than South Asian neonates for both variants. The allelic and genotypic frequencies for mixed neonates were between those for the African and those for the South Asian neonates. No significant relationship was observed between rs9939609 and rs1801282 and anthropometric measures. For both variants, the allelic and genotypic frequencies among the African and South Asian neonates mirrored those found elsewhere for similar ethnic groups.

CONCLUSIONS

Neonates of African ethnicity possess the highest frequency of rs9939609 and rs1801282 alleles and genotypes; this may be associated with ethnic differences in the risk of lifestyle diseases.

Diabetes in North America and the Caribbean: an update

The North America and Caribbean (NAC) Region faces a high burden of diabetes. In 2013, the number of children (aged 0-14 years) with type 1 diabetes was 108,600, with 16.7 new cases diagnosed per 100,000 children. Furthermore, there were 36,755,500 individuals with diabetes (mostly type 2 diabetes) in adults (20-79 years), and an additional 44,277,700 individuals had impaired glucose tolerance. The age-adjusted prevalence of diabetes in adults was 9.6%; the second highest among the seven Regions of the International Diabetes Federation. This estimate is expected to grow to 9.9% by 2035. There was some heterogeneity in the estimates within the Region with the age-adjusted prevalence for the USA estimated at 9.2%, 7.9% for Canada, 12.6% for Mexico, and 9.6% for the Caribbean islands. Mortality due to diabetes in the NAC Region is not limited to older age groups, with 37.6% of deaths occurring in people under the age of 60. The economic impact was also enormous, with healthcare expenditure due to diabetes estimated at 263.2 billion USD for 2013 - the highest of all IDF Regions. Diabetes threatens the public health and economies of countries in the NAC Region, and efforts in prevention and management must be intensified in order to surmount this growing problem.

Do current standards of primary care of diabetes meet with guideline recommendations in Trinidad, West Indies?

AIMS

Primary care management of diabetes was examined using the Caribbean Health Research Council (CHRC) guidelines.

METHODS

We retrospectively examined a cross-section of 646 type 2 people with diabetics over 12 months with 1st visit between 1997 and 2005.

RESULTS

There were more women (65.8%) than men (34.2%) with age range between 29 and 89 years. Blood pressure and weight were evaluated in >95% of patients at each centre. Waist circumference and BMI were not measured at any time and HbA(1)c was infrequently measured (1.6-7%) over the 12 months. Information on family history (87.5%), smoking and alcohol (78.1%), exercise (21.4%), socioeconomic status (19.4%) and education (0.3%), and fasting blood sugar (97.2%), lipid profile (51.8%) and serum creatinine (37.9%) were assessed at the 1st visit. At follow-up patients were advised on treatment compliance (47.2%), diet (34.2%), exercise (18.5%) and rarely on home monitoring of blood glucose (0.3%). Peripheral sensations, pedal pulses (6%), visual acuity (3.3%), fundoscopy (12.1%) and ECG (3.9%) were scarcely examined at the annual visit.

CONCLUSIONS

Current management of diabetes in primary care in Trinidad falls short of Caribbean guideline recommendations. The CHRC and Ministry of Health should jointly educate caregivers of diabetes to implement the guidelines, with annual audits to identify shortfalls in management.

The impact of the chronic disease assistance plan (CDAP) on the control of type 2 diabetes in Trinidad

OBJECTIVES

(1) To measure the proportion of participants who used hypoglycaemic agents provided by CDAP only, for at least 6 months, and attained an HbA1c of <or=7% (a measure of glycaemic control) and (2) to determine the attitudes and practices of patients and pharmacist in this new programme.

DESIGN AND METHODS

The attainment of a glycosylated haemoglobin (HbA1c) concentration of <or=7% in patients with type 2 diabetes mellitus was used as a measure of good glycaemic control. Consequently we measured the HbA1c in 208 subjects who satisfied the entry criteria. Two questionnaires were designed, pre-tested and administered to both patients and pharmacist in the programme to determine their attitudes and practices.

RESULTS

Of the 208 eligible participants, 128 (61.5%) were well controlled, 94% of all participants were satisfied with CDAP and only 23.3% of participants experienced one or more minor side effect with the drugs used from CDAP. There were no significant differences between patients who were well controlled and poorly controlled with respect to gender, physical activity and diet.

CONCLUSION

The study demonstrated that CDAP has impacted favorably on the control of type 2 diabetes mellitus in Trinidad, most participants were satisfied with the programme and there were no major adverse effects from the drugs used.