health & science
Diabetes: New Zealand’s greatest epidemic
A crisis summit has called for an overhaul of how diabetes is managed after 25 years of South Auckland data shows there’s been no improvement
When Professor David Simmons started working in Middlemore in 1989, he saw an epidemic unfolding.
“People were walking in with end stage renal failure and undiagnosed diabetes. I thought this is incredible. How is this happening?”
It was clear to the diabetes expert something was amiss in either people seeing a GP, getting a diagnosis, or in the management of the condition.
Uncontrolled diabetes can lead to heart disease, kidney failure, strokes and blindness.
Gangrene, which requires amputations is another common issue. With a touch of dark humour, staff in the field sometimes joke a good day is one when there are more legs in the ward than patients.
Simmons decided to look into what was going on before people got to the point of turning up at hospital. The Diabetes Care Support Service was set up to audit diabetes primary care.
The aim was to understand why people were showing up to hospital with serious conditions, how many the hospital could expect to walk through their doors in the future, as well as intervene where possible to reduce complications.
Originally from the from the UK, Simmons had experience in the different rates of diabetes between ethnic groups, so auditing tracked ethnicity.
Twenty-five years of data later, Simmons said it’s time for someone to bite the bullet and provide some funding to reduce the future cost of hospital care, and to save lives.
Recognising the epidemic early has done nothing to reduce it, in fact numbers have increased. Around a quarter of New Zealand’s dialysis patients reside in South Auckland, and the need is beginning to outstrip capacity.
To understand the scale of the problem Simmons suggests looking around a room full of colleagues.
“One in three of them will develop diabetes.”
Spending hours at a time tethered to mechanical kidneys was probably not the bionic future most dreamed of when they were young.
Blood sugar out of control
Simmons presented preliminary results from the 25 years of audits to a full house at the South Auckland Diabetes Summit this week.
Event organiser Diabetes Foundation Aotearoa chair Dr John Baker said he had hoped there had been improvement during the audit period.
“Things haven’t really got any better, both in terms of management and inequality, the dire outcomes for Māori and Pacific patients. It was quite shocking.”
When compared to the general population death rates for Māori with diabetes are four times higher, for Pacific people three times higher and for European people twice as high.
It wasn’t all bad news. Simmons' presentation did show some positive aspects.
People are getting to the doctors regularly, and monitoring, while not perfect, is largely being done well. Blood pressure levels are being kept under control.
Where it falls apart is glucose control – making sure the blood sugar levels are kept within a normal range. The data shows this is not being managed well by Māori and Pacific patients, for either type of diabetes.
According to audit data, insulin therapy is being prescribed to patients to help control glucose at the same rate for all ethnicities.
“So, there was equality of therapy, but when you think about Māori and Pacific people having the worst glucose control, that’s not right,” said Simmons.
Another factor plays a part in mortality rates.
“Those of Māori and Pacific Island descent are leaking protein before they even have diabetes. They start off closer in that journey to end stage renal disease.
“With a worse start, so to speak - with reasons we don’t understand - plus the poor glucose control, it’s not surprising they’re accelerating toward end stage renal failure pretty quickly.”
He said in Auckland there are around 6000 Pacific Islanders and 2500 Māori with poorly controlled diabetes at present.
There’s also the issue of not having the best tools.
It’s something that astounds Simmons. Two new drugs are not available in New Zealand.
“These are available in all of the other OECD countries and these are the only drugs that have been shown, besides metformin, to reduce weight, improve your glucose substantially and reduce mortality.”
Lifestyle change takes a village
For type two diabetes lifestyle change makes a difference. Breaking decades old habits doesn’t come easy said Simmons.
“Your GP tells you what to do and you do it? Nah.”
One approach Simmons said had been successful was a peer-led approach where health coaches were embedded into primary care teams. These coaches, especially if they are people patients can relate to, have had good success working with patients alongside clinicians.
Simmons believes investment in peer-support programmes would reduce costly hospitalisations within one to two years.
“It's going to cost up front, but downstream we will have a healthier population and we'll be saving money at the same time.”
In his mind diabetes is the biggest threat facing New Zealand. Twenty-five years of data has shown what's being done is not enough and not working.
“This is bigger than the black death. This is bigger than the pneumonias and the flu that hit the world. This is the biggest epidemic that there is, and someone has to bite the bullet and say, we've got to fund this up front.”