Diabetes Care in the Philippines
Diabetes is increasing at an alarming rate in Asian countries including the Philippines. Both the prevalence and incidence of type 2 diabetes (T2D) continue to increase with a commensurate upward trend in the prevalence of prediabetes.
The prevalence of diabetes in the Philippines is increasing. Rapid urbanization with increasing dependence on electronic gadgets and sedentary lifestyle contribute significantly to this epidemic. Diabetes care in the Philippines is disadvantaged and challenged with respect to resources, government support, and economics. The national insurance system does not cover comprehensive diabetes care in a preventive model and private insurance companies only offer limited diabetes coverage. Thus, most patients rely on "out-of-pocket" expenses, namely, laboratory procedures and daily medications. Consequently, poor pharmacotherapy adherence impairs prevention of complications. Moreover, behavioral modifications are difficult due to cultural preferences for a traditional diet of refined sugar, including white rice and bread.
Translating clinical data into practice in the Philippines will require fundamental and transformative changes that increase diabetes awareness, emphasize lifestyle change while respecting cultural preferences, and promote public policy especially regarding the health insurance system to improve overall diabetes care and outcomes.
Introduction
Diabetes is a chronic disease and is increasing in both prevalence and incidence worldwide. Diabetes exerts a major impact in third-world countries, particularly in the Philippines. It is said that Asia will see the greatest increase in the number of people with diabetes by 2025.1 This increase in the burden of chronic diseases in Asia will significantly affect nations' respective health care systems, both acutely and chronically.
The Philippines is unique in that Filipinos in different regions of the country speak different dialects but all Filipinos can speak one national language called Tagalog. The Philippines has an estimated population of approximately 101 million as of 2015 and is categorized by the World Bank as a lower- to middle-income country and by the United Nations as a country with a developing economy.
The gross domestic product of the Philippines real growth rate averaged 7.3% in a report in 2007, the highest in 31 years.5 In 2014, the economy of the Philippines grew from 6.1% in 2014 to 6.5 % in 2015 fueled by sustained increases in private consumption, higher fixed investment, and recovery in exports.4 The challenge for the government is how to make these economic gains felt among the poorer sectors of society. The recent 2014 poverty incidence stands around 25.8%.4 This latest figure is lower than the 2006 recorded official poverty statistic of 26.9%.5 Thus, with economic growth and decreasing poverty, the Philippine government is realigning the national budget to improve social services. More specifically, this will allow an effective population management program focusing on education and health care.
Noncommunicable diseases (NCD; noninfectious or nontransmissible diseases)—including diabetes—in the Philippines account for 6 of the top 10 causes of mortality and are considered a major public health concern. Diseases of the heart and vascular system continue to be the leading causes of death, comprising 31% of all deaths. Other NCDs include malignant neoplasms, chronic obstructive pulmonary disease, and chronic kidney disease. What is alarming is that as deaths due to preventable diseases have been on a decline, lifestyle-related diseases due to “Westernization” of the culture have begun to dominate as the leading causes of death, particularly due to cardiovascular diseases, malignant neoplasms, diabetes, and chronic lower respiratory diseases.
At present, there are no published nationwide prevalence or incidence studies on type 1 diabetes (T1D). However, one survey was done in a municipality of Bulacan in Central Luzon Region that showed a very low prevalence of T1D with only 7 cases diagnosed among children aged 0 to 14 years during a 10-year period from 1989 to 1998.6 A recent survey on pediatric type 2 diabetes (T2D) in the Philippines also found a low prevalence at 0.91%. As a result of the low prevalence of T1D, continuous glucose monitoring (CGM) devices and continuous subcutaneous insulin infusion (insulin pumps) are not widely used. Standard home glucose monitoring devices are readily available and affordable as well as various insulin preparations that are generic and biosimilar via subcutaneous injections. There is little research on stem cell therapy or islet cell transplantation for T1D in the Philippines.
Gestational diabetes (GDM) is prevalent in the Philippines. Published data from the Asian Federation of Endocrine Societies Study Group on Diabetes in Pregnancy (ASGODIP) showed that the Philippines has a GDM prevalence of 14% in 1203 pregnancies surveyed. Because of this high prevalence rate, the Unite for Diabetes Clinical Practice Guideline (CPG) recommends universal GDM screening for the Filipino population. The ASGODIP data found that about 40.4% of high-risk women were positive for GDM when screening was performed beyond the 26th week of pregnancy. In a cohort of Filipino women with GDM delivering babies with macrosomia in the Cardinal Santos Medical Center, >75% were diagnosed between gestational weeks 26 and 38.10 In another cohort population from the Veterans Memorial Medical Center, 50% of GDM cases were diagnosed between gestational weeks 31 and 40. The Filipino CPG recommends adopting the criteria by the International Association of Diabetes & Pregnancy Study Groups for interpretation of the 75-g oral glucose tolerance test as GDM screening.
T2D is the most common type of diabetes in the Philippines. In 2009, a cohort study derived from the a larger population-based investigation in 1998 was revisited and demonstrated a 9-year incidence rate of T2D in the Philippines to be around 16.3%. In the latest survey published by the Food and Nutrition Research Institute in the Philippines (the Eighth National Nutrition Survey of 2013), the prevalence of high fasting blood glucose based on the World Health Organization criteria of >125 mg/dL for individuals >20 years old was 5.4%, an increase of 0.6%, compared with the same study in 2008.13 The highest prevalence rate was found among the richest in the wealth index, those living in urban areas, and those in the 60- to 69-year age group in both sexes. These studies show an alarming growth rate of T2D in the Philippines commensurate with an upward trend in worldwide prevalence. In the 2014 prevalence estimates published by the International Diabetes Federation, it is estimated that there are 3.2 million cases of T2D in the Philippines with a 5.9% prevalence rate in adults between the ages of 20 and 79 years. Around 1.7 million people with T2D remain undiagnosed. The estimated cost per person with T2D in 2013 in the Philippines is $205, which is comparable with neighboring countries such as Thailand ($285) and Indonesia ($174.7).
DOH LEADS WORLD DIABETES OBSERVANCE IN THE PHILIPPINES
The Department of Health (DOH) together with partners from non-government organizations and the private sector urged the Filipino public to mount early preventive action against diabetes during the observance of World Diabetes Day (WDD) held last Thursday, November 23, with the theme, “Prevent Diabetes! Know Your Risk.”
The celebration of WDD was held at the Quezon Memorial Circle with an estimated 1000 participants from the government, nongovernment, and private sectors. Activities included a parade/walk around the circle, Zumba exercise, free screening for participants to know their risk of diabetes and the formation of a human blue circle which is the global symbol of diabetes awareness. A lay forum was also conducted to provide important information and educate participants on diabetes and its risk factors.
Diabetes is the 6th leading cause of death among Filipinos based on the data from the 2013 Philippine Health Statistics, and over 6 million Filipinos are diagnosed to have diabetes, as declared by the Philippine Center for Diabetes Education Foundation in 2016.
It is a chronic disease characterized by high levels of sugar in the blood (hyperglycemia) because of inadequate production and/or action of insulin, the hormone that regulates blood sugar levels. Uncontrolled diabetes leads to serious complications such as stroke, heart attack, end-stage kidney disease and diabetic retinopathy among others. Diabetic retinopathy accounted for about 5% of world blindness in 2002.
Screening for diabetes and educating the people on its signs, symptoms, ways to prevent and avoid complications play a great role in addressing this debilitating disease.
The DOH, as the country’s leading public health government agency, spearheads nationwide efforts in the prevention and control of diabetes and its complications. The DOH provides free diabetes risk screening at the barangay health stations, rural health units/health centers, public hospitals, and other government health facilities.
DOH also provides free medicines such as oral anti-diabetes medicines and insulin to Filipino patients diagnosed with diabetes. In its commitment to enhance health service delivery, DOH has also created a partnership with the Philippine Society of Endocrinology, Diabetes and Metabolism (PSEDM) to empower and build capacity among our primary healthcare workers in managing diabetes. An estimate of more than 1,700 health care providers accross the country were already trained.
DOH, and its key partners from different sectors are committed to change the landscape of diabetes in the Philippines and ensure better quality of life for all Filipinos.
Philippine Society of Endocrinology Diabetes and Metabolism (PSEDM) president Dr. Pete Dela Peña, an endocrinologist, confirms the importance of preventing diabetes and its complications. ”Diabetes ia a familial as well as a lifestyle disease. By exercising, eating healthy, and avoiding sugary drinks, we can prevent diabetes. For the 4 million Filipinos who are already affected by diabetes, it is important not just to do this but also to see their doctor regularly and ensure that they stay on medications to avoid complications such as kidney failure or diabetic foot.”
World Diabetes Day (WDD) is an annual global event for driving awareness on diabetes and its risk factors. This is officially observed in the Philippines through Proclamation No. 1942, s. 2009 declaring November 14 as World Diabetes Day Celebration.
”Diabetes keeps on increasing in prevalence, but we shouldn’t give up the fight against the disease. It may be chronic and incurable, but diabetes can be managed. We need to strengthen multi-stakeholder collaboration in increasing awareness of this disease and for people to follow a healthy lifestyle,” Health Secretary Francisco Duque III emphasized.
