Counting the cost of diabetic hospital admissions from a multi-ethnic population in Trinidad

Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections

Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.

A review on diabetic foot challenges in Guyanese perspective

BACKGROUND

Diabetes mellitus signifies a major public health threat worldwide. Type 2 diabetes has been reported as the fourth leading cause of death and has affected 15.5% of the adult population in Guyana, South America. Diabetes has also led to major lower extremity amputation at the only referral public hospital in Guyana. Diabetic foot and related complications are known to be multifactorial.

CONCLUSION

In this review, we highlight the information on the diabetic foot and related complications with an emphasis on Guyanese background.

Adverse events in diabetic foot infections: a case control study comparing early versus delayed medical treatment after home remedies

Background

The aim of conventional medical therapy in diabetic foot infections is to control infection, thereby reducing amputation rates, infectious morbidity, and death. Any delay incurred during a trial of home remedies could allow an infection to progress unchecked, increasing the risk of these adverse outcomes. This study sought to determine the effects of delayed operative interventions and amputations in these patients.

Methods

A questionnaire study targeting all consecutive patients admitted with diabetic foot infection was carried out over 1 year. Two groups were defined, ie, a medical therapy group comprising patients who sought medical attention after detecting their infection and a home remedy group comprising those who voluntarily chose to delay medical therapy in favor of home remedies. The patients were followed throughout their hospital admissions. We recorded the duration of hospitalization and number of operative debridements and amputations performed.

Results

There were 695 patients with diabetic foot infections, comprising 382 in the medical therapy group and 313 in the home remedy group. Many were previously hospitalized for foot infections in the medical therapy (78%) and home remedy (74.8%) groups. The trial of home remedies lasted for a mean duration of 8.9 days. The home remedy group had a longer duration of hospitalization (16.3 versus 8.5 days; P<0.001), more operative debridements (99.7% versus 94.5%; P<0.001), and more debridements per patient (2.85 versus 2.45; P<0.001). Additionally, in the home remedy group, there was an estimated increase in expenditure of US $10,821.72 US per patient and a trend toward more major amputations (9.3% versus 5.2%; P=0.073).

Conclusion

There are negative outcomes when patients delay conventional medical therapy in favour of home remedies to treat diabetic foot infections. These treatments need not be mutually exclusive. We encourage persons with diabetes who wish to try home remedies to seek medical advice in addition as a part of holistic care.

Acanthosis nigricans in type 2 diabetes: prevalence, correlates and potential as a simple clinical screening tool - a cross-sectional study in the Caribbean

BACKGROUND

This study aimed to evaluate the role of acanthosis nigricans (AN) as a marker of Type 2 Diabetes Mellitus (T2DM) by studying its prevalence and relationship with age, ethnicity, anthropometry and other risk factors for T2DM in the Trinidadian population.

METHODS

311 successive adult patients with T2DM were recruited at diabetic clinics and inpatient wards across Trinidad. The presence, severity and texture of AN at the neck were assessed. Demographic, clinical and anthropometric characteristics were also measured, and logistic regression was used to model their relationship with presence of AN.

RESULTS

The mean (SD) age was 58.1 years (12.6). 55.6% were female. 61.1% were East Indian, 24.4% African and 14.5% mixed ethnicity. The mean (SD) BMI was 27.3 kg/m(2) (6.0) and the mean (SD) waist circumference was 96.7 cm (14.2). Prevalence of AN was 52.7% (95% CI 47.2, 58.3). THERE WAS A GREATER ODDS OF AN AMONG DIABETIC PATIENTS WHO WERE: younger (p < 0.001); female (OR 1.67; 95% CI 1.06, 2.62); or East Indian rather than African (0.45; 0.26, 0.77) or mixed (0.43; 0.22, 0.84) descendents. There was a greater age-, sex- and ethnicity-adjusted odds of AN among those: overweight (3.98; 2.10, 7.55) or obese (8.31; 3.84, 18.00) versus normal BMI; centrally obese (4.72; 2.65, 8.43); with history of hypertension (2.19; 1.27, 3.79) or history of hypercholesterolemia (1.72; 1.02, 2.90), but there was no evidence of this demographic-adjusted association (p > 0.4) between AN and history of previous MI or CVA, family history of T2DM, T2DM treatment regimen, duration of T2DM or random blood glucose. On further multivariable analysis, only age, sex, ethnicity, BMI and waist circumference were independently associated with AN (p < 0.05) and the effect of BMI varied with ethnicity.

CONCLUSIONS

There was a high prevalence of AN both overall and across age, sex and ethnic groups of diabetic patients. AN exhibited much potential as a valuable addition to T2DM risk assessment in the Trinidadian and similar settings.

Self-directed treatment for lower limb wounds in persons with diabetes: a short report

AIM

There has been little focus on self-directed treatment for lower limb wounds, although it a common practice among persons with diabetes across the Caribbean. We sought to document this practice in a Caribbean nation.

METHODS

We prospectively interviewed all consecutive patients with diabetes who were admitted with lower limb wounds at the San Fernando General Hospital in Trinidad and Tobago over a period of 18 months. A questionnaire was used to collect data on patient demographics, use of self-directed treatment, and details of these treatments.

RESULTS

Of 839 persons with diabetes who were admitted with infected lower limb wounds, 344 (41%) admitted to self-directed treatment before seeking medical attention. These patients were predominantly male (59.9%) at a mean age of 56.4±12.4 years. The practice was most common in persons of Afro-Caribbean descent (45.9%) and those with type 2 diabetes (93.9%). In this group, 255 (74.4%) patients were previously admitted to hospital for lower limb infections. And of those, 32 (12.6%) had a prior amputation and 108 (42.4%) had at least one operative debridement specifically for foot infections.

CONCLUSION

Caribbean cultural practices may be an important contributor to negative outcomes when treating lower limb wounds in persons with diabetes. Despite being acutely aware of the potentially devastating consequences of inadequate treatment, 41% of our patients with diabetes still opted to use self-directed treatment for lower limb wounds. This deserves further study in order to give a more tailored approach in care delivery.

Epidemiology of diabetic foot infections in an eastern Caribbean population: a prospective study

INTRODUCTION

This study evaluates the epidemiology of diabetic foot infections in an Eastern Caribbean nation in order to direct public health preventive measures.

METHODS

We prospectively identified all patients with diabetic foot infections who were admitted to tertiary care hospitals across Trinidad and Tobago from July 2011 to June 2012. A questionnaire was used to collect data on demographics, patient knowledge, avoidance of risk factors for chronic diseases (a proxy to unhealthy lifestyles), and glycosylated hemoglobin measurements on admission as an index of blood glucose control. The data were analyzed with statistical software.

RESULTS

There were 446 patients with diabetic foot infections (mean age = 56.9 years, standard deviation = 12.4 years). Most patients had Type 2 diabetes (93.3%) and were of Indo-Trinidadian (49.1%) or Afro-Trinidadian (41.7%) descent. There were preexisting complications of diabetes in 82.9% of patients with Type 2 diabetes: foot infections requiring hospitalization (70.2%), ischemic heart disease (32.5%), renal impairment (13.7%), and retinopathy (22.1%). Despite most patients claiming compliance with treatment, 75% had glycosylated hemoglobin levels above 7.1% at presentation, and 49.3% continued unhealthy lifestyles. Despite the high prevalence of diabetic complications at admission, and despite 70% having had previous hospitalization for treatment of foot infections, only 57.4% of patients reported ever being counseled or taught about foot care by medical personnel.

CONCLUSIONS

There is room for improvement in public health strategies to prevent diabetic foot complications in this setting. Such strategies should focus on patient education with emphasis on lifestyle modification and compliance with medical therapy.

Secondary prevention of diabetic foot infections in a Caribbean nation: a call for improved patient education

Most countries have instituted measures to limit the complications of diabetes. We evaluate secondary prevention strategies for diabetic foot infections in a Caribbean country. We performed a prospective questionnaire study evaluating all patients admitted to tertiary care hospitals across Trinidad and Tobago from July 2011 to June 2012. Primary study end points were the number of patient-detected injuries and the time interval between injury and presentation. Secondary end points included the practice of regular foot inspection (≥2 foot examinations per week) for early detection and the use of self-directed nonmedical therapies to treat foot infections. There were 446 patients admitted with diabetic foot infections at an average age of 56.9 ± 12.4 years. Three hundred and fifty-six (80%) were previously hospitalized with foot infections and 226 (51%) had already sustained end organ injury from diabetes. There were 163 (36.6%) patients walking barefoot at the time of injury and 189 (42.4%) had footwear-related injuries. In 257 (57.6%) cases, patients identified their foot injury shortly after the event. Despite early detection, they presented to hospital after a mean interval of 6.2 ± 5.03 days, with 78 (30.4%) having tried some form of home therapy first. Overall, 190 (42.6%) patients did not practice regular foot examinations. There is room for improvement in secondary preventative measures for diabetic foot infections in this setting. Educational campaigns may be beneficial to educate diabetics on the dangers of walking barefoot, the importance of appropriate footwear, regular foot inspection, and the importance of seeking immediate medical attention instead of experimenting with home remedies.

Health-related quality of life predicts hospital admission within 1 year in people with diabetes: a nationwide study from Taiwan

AIMS

To investigate whether health-related quality of life (HRQOL) predicts hospital admission in a nationally representative sample of adults with diabetes.

METHODS

We conducted a prospective study on persons aged > or = 18 years with self-reported physician-diagnosed diabetes (n = 797) who participated in the National Health Interview Survey in Taiwan, 2001. Of these potential participants, 674 provided consent for data linkage and were successfully linked to the National Health Insurance claims data. We analysed the associations between the Short Form 36 (SF-36) subscales and summaries and the occurrence of hospital admission for any cause during 2002.

RESULTS

Approximately 23% of participants with diabetes had at least one hospital admission during 2002. After adjusting for demographic characteristics, co-morbidities and diabetics-related attributes, those who had been admitted to hospital had significantly poorer mean scores on each of the physical dimensions, physical components summary (PCS) and social functioning domain of the SF-36 at baseline. In logistic regression models, poorer scores on the PCS [odds ratio (OR) = 1.80; 95% confidence interval (CI) = (1.14-2.86)], duration of diabetes > or = 10 years [OR = 2.10; 95% CI = (1.14-3.89)] and the presence of heart disease [OR = 1.63; 95% CI = (1.01-2.63)] were significantly associated with an increased risk of hospital admission.

CONCLUSION

In people with diabetes, poorer scores on the PCS of the SF-36 at baseline may provide additional information for assessment of hospital admission risk, independent of other measures of health outcomes.

Taking the next step in 2005, the year of the diabetic foot

OBJECTIVES

To determine the age-standardized rate of lower limb amputations among Type 2 diabetics admitted to the Port of Spain General Hospital (POSGH), San Fernando General Hospital (SFGH) and Sangre Grande County Hospital (SGCH) for the period 2000-2004. To determine in-hospital mortality following amputation, for the same period. To determine the risk factors that contributed to diabetic foot complications.

DESIGN AND METHODS

All patients who had a lower limb amputation at the three major public health institutions in Trinidad during the study period were enrolled. In addition patients attending the surgical out-patient clinic and currently admitted to the ward with a diabetic septic foot was selected for the administration of a questionnaire to determine the major contributing factors. Data on the type of amputation, age, sex, ethnicity, from which an age-standardized mortality rate, was determined for the age group 30-60.

RESULTS

Of 822 patient files examined, 515 (80%) of these major amputations were performed on Type 2 diabetics, of which 352 (68%) were AKA and 163 (32%) were BKA. The AKA:BKA ratio for the period 2000-2004 was 2.2:1. There was a significant difference between the mean ages at which females had a major amputation to males (p=0.001). The overall ratio of Africans to South East Asians was 1.5:1 amongst the Type 2 diabetic amputees. For major amputations the average length of stay was found to be 22.5 (0-192) days. The age-standardized rate for the age group 30-60 was 13.85 per 100,000 for 2004. Of 66 deaths, 31 (47%) were septicemia cases and 14 (21%) cardio-respiratory failure cases. Finally, of 97 persons interviewed, the major causative agent for diabetic foot complications and amputations was foot trauma (51%).

CONCLUSION

Type 2 diabetic amputation status of Trinidad would seem to have improved as shown by this study. However, steps must be taken to improve patient awareness about prevention and care of the diabetic foot. Doctors must also seek to increase their vigilance when screening diabetic patient in the primary care setting in order to prevent the late detection and treatment of the septic lower limb.

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.

Glycaemic index of selected staples commonly eaten in the Caribbean and the effects of boiling v. crushing

Integrating information about the glycaemic index (GI) of foods into the Caribbean diet is limited by the lack of data. Therefore, we determined the GI of eight staple foods eaten in the Caribbean and the effect on GI of crushing selected tubers. Groups of eight to ten healthy volunteers participated in three studies at two sites. GI was determined using a standard method with white bread and adjusted relative to glucose. The mean area under the glucose response curve elicited by white bread was similar for the different groups of subjects. In study 1, the GI of cassava (Manihot esculenta; 94 (SEM 11)) was significantly higher than those of breadfruit (Artocarpus altilis; 60 (SEM 9)), cooking ‘green’ banana (Musa spp.; 65 (SEM 11)) and sadha roti (65 (SEM 9)) (P=0·018). There was no significant difference in the GI of the foods in study 2: dasheen (Colocasia esculenta var. esculenta; 77 (SEM 10)), eddoes (Colocasia esculenta var. antiquorum; 61 (SEM 10)), Irish potato (Solanum tuberosum; 71 (SEM 8)), tannia (Xanthosoma sagittifolium; 60 (SEM 5)) and white yam (Dioscorea alata; 62 (SEM 6)), and, in study 3, crushing did not significantly affect the GI of dasheen, tannia or Irish potato. However, when the results from studies 2 and 3 were pooled, the GI of dasheen (76 (SEM 7)) was significantly greater than that of tannia (55 (SEM 5); P=0·015) with potato being intermediate (69 (SEM 6)). We conclude that dasheen and cassava are high-GI foods, whereas the other tubers studied and sadha roti are intermediate-GI foods. Given the regular usage of cassava and dasheen in Caribbean diets we speculate that these diets would tend to be high GI, although this could be reduced by foods such as sadha roti and white yam. The range of GI between the staples is sufficiently large that health benefits may be accrued by replacing high-GI staples with intermediate-GI staples in the Caribbean diet.

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

OBJECTIVES

To determine the proportion of diabetic patients that achieved glycemic control (HbA1c pound7.0%) and to explore some of the barriers to achieve this control.

DESIGN

Cross-sectional, observational study.

SETTING

Health centres in North and Central Trinidad.

PATIENTS

One hundred and thirty-two type 2 diabetics attending the health centres for more than 1 year.

MAIN OUTCOME MEASURES

HbA1c levels and the proportion of patients who achieve glycemic control, HbA1c pound7.0%.

RESULTS

The patients were categorized into two groups: well controlled, HbA1c Y7.0% and poorly controlled, HbA1c>7.0%. The majority of patients were poorly controlled (55.3%), duration of diabetes impacted negatively older patients and patients attending the clinics for longer periods were less likely to be well controlled. There was no correlation between pharmacological treatment, availability of individual counselling by a dietician or regular monitoring of blood glucose and glycemic control (p>0.05).

CONCLUSION

A 44.7% of patients with type 2 diabetes were found to be well controlled. Old age (51-70 years) and lengthy periods of attendance seem to be barriers to achieving glycemic control. This study highlights the fact that there is a need for re-evaluation of the diabetic program since despite changes in the primary care system over the past 5 years a large proportion of diabetics are still uncontrolled.

Ethnomedicines used in Trinidad and Tobago for urinary problems and diabetes mellitus

BACKGROUND

This paper is based on ethnobotanical interviews conducted from 1996-2000 in Trinidad and Tobago with thirty male and female respondents.

METHODS

A non-experimental validation was conducted on the plants used for urinary problems and diabetes mellitus: This is a preliminary step to establish that the plants used are safe or effective, to help direct clinical trials, and to inform Caribbean physicians of the plants' known properties to avoid counter-prescribing.

RESULTS

The following plants are used to treat diabetes: Antigonon leptopus, Bidens alba, Bidens pilosa, Bixa orellana, Bontia daphnoides, Carica papaya, Catharanthus roseus, Cocos nucifera, Gomphrena globosa, Laportea aestuans, Momordica charantia, Morus alba, Phyllanthus urinaria and Spiranthes acaulis. Apium graviolens is used as a heart tonic and for low blood pressure. Bixa orellana, Bontia daphnoides, Cuscuta americana and Gomphrena globosa are used for jaundice. The following plants are used for hypertension: Aloe vera, Annona muricata, Artocarpus altilis, Bixa orellana, Bidens alba, Bidens pilosa, Bonta daphnoides, Carica papaya, Cecropia peltata, Citrus paradisi, Cola nitida, Crescentia cujete, Gomphrena globosa, Hibiscus sabdariffa, Kalanchoe pinnata, Morus alba, Nopalea cochinellifera, Ocimum campechianum, Passiflora quadrangularis, Persea americana and Tamarindus indicus. The plants used for kidney problems are Theobroma cacao, Chamaesyce hirta, Flemingia strobilifera, Peperomia rotundifolia, Petiveria alliacea, Nopalea cochinellifera, Apium graveolens, Cynodon dactylon, Eleusine indica, Gomphrena globosa, Pityrogramma calomelanos and Vetiveria zizanioides. Plants are also used for gall stones and for cooling.

CONCLUSION

Chamaesyce hirta, Cissus verticillata, Kalanchoe pinnata, Peperomia spp., Portulaca oleraceae, Scoparia dulcis, and Zea mays have sufficient evidence to support their traditional use for urinary problems, "cooling" and high cholesterol. Eggplant extract as a hypocholesterolemic agent has some support but needs more study. The plants used for hypertension, jaundice and diabetes that may be safe and justify more formal evaluation are Annona squamosa, Aloe vera, Apium graveolens, Bidens alba, Carica papaya, Catharanthus roseus, Cecropia peltata, Citrus paradisi, Hibsicus sabdariffa, Momordica charantia, Morus alba, Persea americana, Phyllanthus urinaria, Tamarindus indicus and Tournefortia hirsutissima. Several of the plants are used for more than one condition and further trials should take this into account.

Explanations for the high risk of diabetes-related amputation in a Caribbean population of black african descent and potential for prevention

OBJECTIVE

Diabetes-related lower-extremity amputation (LEA) rates are elevated in blacks compared with whites in the U.S., but are lower in African Caribbeans in the U.K., whereas anecdotal reports suggest high rates in the Caribbean. We aimed to establish the incidence and risk factors for diabetes-related LEA in a Caribbean population.

RESEARCH DESIGN AND METHODS

We conducted an incident and prospective case-control study of case patients (individuals with diabetes having a LEA) and community-based control subjects (individuals with diabetes without a LEA) in Barbados, West Indies. Participants completed an interview and examination of risk factors for amputation, including footwear use.

RESULTS

The overall 1-year incidence of LEA (n = 223) was 173 per 10(5) population and 936 per 10(5) population with diabetes (557 per 10(5) for minor amputation and 379 per 10(5) for major amputation). Women had higher amputation rates than those reported in the Global Lower Extremity Amputation Study, apart from the U.S. Navajo population. Independent risk factors for all diabetes-related LEAs were poor footwear (odds ratio [OR] 2.71 [95% CI 1.23-5.97]), elevated GHb (1.40 per percent increase [1.26-1.57]), peripheral neuropathy (1.05 per volt increase [1.03-1.08]), and peripheral vascular disease.

CONCLUSIONS

Diabetes LEA rates in Barbados are among the highest in the world. Inadequate footwear independently tripled amputation risk. Education of professionals and patients, particularly about footwear and foot care, coupled with improved diabetes clinical care, is key to reducing amputation risk in this population.

Glycaemic responses after ingestion of 3 local carbohydrate-based foods in West Indian patients with type-2 diabetes mellitus

BACKGROUND & AIM

Previous studies suggest that inadequate glycaemic control in diabetic patients might be related to the type of carbohydrates the patients consume regularly. Thus, we aimed to assess glucose and insulin responses after diabetic and non-diabetic subjects ingested 3 commonly consumed carbohydrate-based foods.

METHODS

Thirty-eight type-2 diabetic and 27 non-diabetic subjects were studied in 3 different occasions of 7 days apart. On each day of the study, anthropometric indices were measured and after collecting fasting blood samples, subjects randomly consumed bread, roti or rice within 10 min. Subsequently 7 ml of venous blood samples were collected at 60, 90, 120 and 150 min for determination of glucose and insulin responses.

RESULTS

Although the diabetic patients were older than the healthy subjects (P < 0.05), both subjects had similar weight, body mass index and waist and hip circumferences (P > 0.05). The mean fasting and post meal plasma glucose concentrations for the 3 test foods were higher in diabetic patients than the corresponding values for the healthy subjects (all; P < 0.001). Generally, roti elicited the highest total incremental glucose responses in the diabetic patients irrespective of ethnic group (P < 0.05).

CONCLUSION

There were variations in glucose and insulin responses to the 3 test foods. However, roti elicited the highest postprandial hyperglycaemia and should therefore be discouraged in regular dietary plan of diabetic patients.

Diabetes-related inequalities in health status and financial barriers to health care access in a population-based study

AIMS

We evaluated the relationship between diabetes, health status, household income and expenditure on health care in the general population in Trinidad.

METHODS

Multistage sampling of 300 households was used to select a sample of 548 adults aged > or = 25 years. There were 64 (12%) who reported a diagnosis of diabetes. Comparison was made with 128 non-diabetic controls who were frequency matched for age and sex.

RESULTS

Subjects with diabetes had lower income levels than non-diabetic controls [income < or = US dollars 533 per month for 66% diabetes cases and 48% controls, test for trend P = 0.007]. Compared with controls, subjects with diabetes were less likely to have good or very good self-rated health (diabetes 32%, controls 67%; P < 0.001), and more frequently reported long-standing illness, limitation of activities, visual impairment, or self-reported history of high blood pressure, angina or heart attack. Subjects with diabetes (11%) were less likely than controls (30%) to have private health insurance (P = 0.005). Diabetic subjects (35%) were more likely than controls (16%) to have incurred expenditure on doctors' services in the last 4 weeks (P = 0.021).

CONCLUSIONS

Diabetes is associated with worse health status and more frequent expenditure on medical services but greater financial barriers to access in terms of low income and lack of health insurance. Policies for diabetes should specifically address the problem of income-related variations in risk of diabetes, health care needs and barriers to uptake of preventive and treatment services, otherwise inequalities in health from this condition may increase.

Diabetic foot disease and foot care in a Caribbean community

We estimated the prevalence of foot symptoms and disease and evaluated foot care practices in a primary care based sample including 2106 people with diabetes in Trinidad. Symptoms of neuropathy were reported by 1030 (49%), previous foot ulceration by 257 (12%), and amputation by 92 (4%). Previous foot ulceration was associated with longer duration of diabetes (odds ratio 1.05, (95% CI 1.04-1.06) per year) and greater severity of neuropathy symptoms (1.17 (1.10-1.24) per unit increase in score). A history of foot ulceration gave relative odds of amputation of 16.3 (8.1-32.9). In those with previous foot ulceration, 120 (47%) went barefoot in the home, and 44 (17%) went barefoot outside the house. Overall, 1491 (71%) subjects reported they cut their toenails themselves, help was provided by a friend or relative to 584 (28%) and by a nurse or chiropodist to 13 ( < 1%). Most patients (1320, 63%) reported that they would treat a cut or blister on the foot themselves, while only 650 (31%) would attend for health care. Diabetic foot disease is common but care practices predispose to foot injury. Implementation of a strategy to improve care of the feet is needed.

Cardiovascular risk in obese and nonobese patients with type 2 diabetes in the West Indies

OBJECTIVE

To evaluate the impact of obesity on glycemic control and the risk of progressing to cardiovascular disease (CVD) in obese and nonobese type 2 diabetic patients in primary care settings.

METHODS

One hundred and ninety patients (64 men, 126 women) with type 2 diabetes (mean duration 9.2 years) were studied after an overnight fast. Weight, height, waist and hip circumferences and blood pressure were measured and blood samples were taken for glucose, glycated hemoglobin (HbA(1c)), total cholesterol, triglyceride, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol and creatinine determinations.

RESULTS

About 85% of the patients had HbA(1c) levels > 7.0%, and 48% had a diastolic blood pressure (BP) >83 mm Hg, while 40% had a total cholesterol/HDL-cholesterol ratio greater than 6. The prevalence rates of hypercholesterolemia, hypertriglyceridemia, high BP and ratios of total cholesterol to HDL-cholesterol between the obese and nonobese patients were similar irrespective of sex (p > 0.05). Multiple linear regression analysis confirmed that ethnicity, sex, age and duration of diabetes had significant impact on the cardiovascular risk in this population.

CONCLUSION

Both obese and nonobese diabetic patients had poor glycemic control and their risk of CVD was not independent of age, sex, ethnicity and duration of diabetes. We suggest strict metabolic control and improved diabetes health education at the primary care level.

A five-year evaluation of intervention in diabetes care in Trinidad and Tobago

AIMS

To evaluate an intervention to improve diabetes care in government-run heath centres in Trinidad and Tobago over 5 years.

METHODS

A cross-sectional survey of 690 subjects with clinical diabetes attending nine health centres was carried out in 1993. The intervention was: reports to the Ministry of Health, dissemination of management guidelines and annual training workshops for healthcare staff. Re-evaluation was through a survey of 1579 subjects with diabetes, attending 23 health centres in 1998.

RESULTS

Comparing 1993 with 1998, foot examinations in the previous year increased from 38 (6%) to 346 (22%) and fundoscopy from 6 (1%) to 139 (9%). For subjects attending for 1 year or less, 34/96 (35%) had dietary advice recorded in 1993 compared with 77/143 (54%) in 1998. Exercise advice was recorded for 3/96 (3%) in 1993 and 48/143 (34%) in 1998. In 1993, 329 (48%) were taking chlorpropamide but this fell to 57 (4%) in 1998. Glibenclamide use increased from 214 (31%) to 856 (54%) and gliclazide from four (1%) to 205 (13%). In 1993, 198/338 (56%) of hypertensive subjects were taking Brinerdin, this fell to 56/829 (7%) in 1998 while use of thiazide diuretics, methyldopa and angiotensin-converting enzyme (ACE) inhibitors increased. There were no changes in indicators of metabolic control, blood pressure control or body weight.

CONCLUSIONS

Use of audit data to inform health policy and practice, linked with educational interventions, may modify patterns of care in government-run primary care health centres in a middle-income country with a high prevalence of diabetes.

Relationship of health-related quality of life to symptom severity in diabetes mellitus: a study in Trinidad and Tobago

Our objective was to estimate the effect of greater symptom severity in diabetes mellitus on measures of health-related quality of life in a cross-sectional design in 35 government primary care health centres in Trinidad. Data were gathered on 2,117 subjects with clinical diabetes and analysed for 1,880 (89%). For each scale of the short form 36 (SF-36) questionnaire (a generic measure of health-related quality of life), scores were presented by quartile of symptom severity, measured using the Diabetes Symptom Checklist. Mean (SD) SF-36 scores were 44 (10) for the physical component score (PCS) and 45 (12) for the mental component score (MCS). Greater severity of diabetic symptoms was associated with lower scores on each of the subscales of the SF-36. Comparing lowest and highest quartiles of DSC score, the adjusted difference in PCS was -11 (95% confidence interval -12 to -9) and for MCS -16 (-18 to -14). Our results provide standardised data for health related quality of life in relation to severity of illness from diabetes, these might be used to aid the evaluation of relevant interventions.

Social inequalities in morbidity from diabetes mellitus in public primary care clinics in Trinidad and Tobago

Associations between socio-economic status and non-communicable diseases in middle income countries have received little study. We conducted an interview survey to evaluate the associations of morbidity with social conditions among people attending government primary care health centres with diabetes mellitus in Trinidad. Data collected included morbidity from hyperglycaemia, foot problems, visual problems and cardiovascular disease, as well as social and demographic variables. Of 622 subjects, 35% were aged > or = 65 years, 54% were Indo-Trinidadian, 13% had no schooling, only 11% were in full-time employment, and 33% had no piped drinking water supply in the home. Prevalent symptoms included itching, reported by 215 (35%), nocturia in 315 (51%), burning or numbness in the feet in 350 (56%), and difficulty with eyesight in 363 (58%). A morbidity summary score was used as dependent variable in regression analyses. Comparing those with no schooling with those with secondary education, the mean difference in morbidity score was 1.77 (95% CI 1.15-2.39), attenuated to 0.71 (0.06-1.37) after adjusting for age, gender, ethnic group and diabetes duration. The equivalent differences for those with no piped water supply in the house, compared with those with, were 0.53 (0.17-0.88) and 0.57 (0.24-0.89). For the unemployed, compared with those in full-time jobs, at ages 15-59 years the differences were 0.85 (0.14-1.56) and 0.58 (-0.11-1.27). We conclude that morbidity in persons with diabetes is associated with indicators of lower socio-economic status and that this association is partly explained by confounding with older age, female gender, longer duration of diabetes and Indo-Trinidadian ethnic group. A negative association between socio-economic status and morbidity from diabetes contributes to a justification for investment of public health resources in the control of diabetes and other non-communicable diseases.

Design of cost-effective packages of care for non-insulin-dependent diabetes mellitus. Defining the information needs

This review concludes that: a) the global burden of disease from non-insulin-dependent diabetes mellitus (NIDDM) cannot be completely estimated at present; b) evidence for the efficacy of key elements of a package of care is still needed; c) generalizing the results of evaluations of costs or effectiveness across different populations is not straightforward; and d) for this complex intervention, the costs and effectiveness of intervention may be highly dependent on methods of organizing care. Addressing this information deficit represents an important task for researchers and health decision makers.