Diabetes a $1 billion timebomb

By REBECCA WALSH and KATHERINE HOBY

When Eva Siono lived in Niue, she dreamed about KFC and McDonalds.

Then, seven years ago, she moved to New Zealand with her family in search of better education and work opportunities and found herself surrounded by fast food outlets.

"I get tempted and get angry. When I lived in Niue I didn't see these foods at all. Now I live here, this sickness is stopping me from having it."

The 47-year-old mother of six was diagnosed with Type 2 diabetes about 10 years ago and has had to eliminate fatty and salty foods from her diet. That means no more of her favourites - icecream and coconut cream - and takeaways "once in a blue moon".

Foods that were a regular part of her island diet like taro, which is high in carbohydrate, can be eaten only in small amounts.

Diabetes runs in Siono's family. Her mother had it, and two years ago her 27-year-old son, Morconi, discovered he had Type 2 diabetes after collapsing at work.

Now he goes to the gym four times a week, has given up fizzy drinks and weighs about 20kg less. He says it's a struggle being good with so much temptation nearby.

The Sionos are not alone - Pacific Islanders and Maori are three times as likely as Pakeha to develop Type 2 diabetes.

Because about half the Pacific Islanders in New Zealand live in the Counties-Manukau area, the district health board - with Health Pacifica, a Mangere GP practice - has developed a programme to improve the management of those with the disease.

The health board pays for three visits each year on top of the Government-funded annual checkup.

Pacific health workers, fluent in Island languages, work with diabetics who have other risk factors such as smoking, obesity and high blood pressure. Trips to the supermarket help to identify good and bad foods, and there are exercise classes and quit smoking clinics.

Staff try to involve the whole family and solve financial and social problems that could interfere with treatment, such as lack of transport.

A consultant visits the clinic regularly, working with the GPs. This removes any fear patients might have of visiting a hospital and keeps staff up to date. Patient information is collected on computers and is easily available to specialists.

Results a year later show a significant drop in patient blood-sugar levels. The average blood-sugar level of the 330 people on the programme was 9.5 points, but that has dropped to 8.5 points, with each point increasing life expectancy five to 10 years.

In addition, 82 per cent of participants returned for doctor visits.

Dr John Wellingham, director of the Chronic Disease Care Management programme, says the aim is to manage diabetes at community level and lessen the burden on hospitals. About $1.6 million is being spent this financial year and 40 to 50 practices are eventually expected to take part.

Other promising developments include a similar programme at the Clendon Medical Clinic involving 150 Maori and Pacific Island patients and a pilot Pacific people's blindness prevention initiative at Langimalie Clinic in Onehunga. (Untreated diabetes or persistent high blood pressure can cause diabetic retinopathy, which can lead to partial or total blindness.)

Tony Haas, president of Retina New Zealand, a consumer organisation leading the blindness initiative, says some Pacific Islanders will not go to European health services, however well intentioned, for cultural, financial, or practical reasons. Some do not speak English well.

The problem is compounded by a long-running scientific debate over the main cause of the disease - genetics or lifestyle.

Dr Robyn Toomath, president of the Society for the Study of Diabetes, believes that until now people have been cynical about whether exercise and diet could reduce Type 2 diabetes. But a growing body of research indicates that the way people live can make a significant difference.

She cites a recent Finnish study of people with impaired glucose tolerance, which found that those who reduced their bodyweight, cut the fat and saturated fat intake in their diet, ate more cereal fibre and walked for 150 minutes a week did not develop diabetes during the time of the study.

Toomath is optimistic that New Zealanders will change their attitudes towards diet and exercise, as they have towards smoking. The main worry, she says, is that it will take time.

But Dr Garth Cooper, professor of biochemistry at Auckland University, believes that while a healthy life must continue to be a cornerstone of any diabetes strategy, seeing lifestyle alone as the cause is simplistic.

"There's obviously more than an element of truth to it. The problem is there are other people around the world who don't [develop diabetes]," he says. "There's definitely a genetic basis to it as well ... but the genetic mechanisms are not at all clear."

Diabetes and its major risk factors - obesity and physical inactivity - were named among the Government's 13 health priorities in 2000.

Since then, local diabetes teams have been set up in district health board areas, linking health providers to consumers.

Diabetics are now entitled to one free doctor's checkup a year, and retinal screening services are offered in some hospitals and from some mobile units.

The question, say experts, is whether this goes far enough. In 2000 a major report commissioned by Diabetes New Zealand warned that unless more money was spent now to better manage diabetes, costs could balloon to more than a billion dollars a year by 2021.

That figure was based on the projected increase in people developing complications such as blindness, or needing limb amputation and dialysis. If spending remains the same, diabetes services will account for about 12 per cent of health spending by 2021 compared with 2 per cent now.

The report, written by PricewaterhouseCoopers, recommended, among other things, a screening programme to identify undiagnosed Type 2 diabetes and the establishment of a national register.

Toomath believes the mechanisms are already in place to set up a national register through the free annual checkup. The catch is ensuring people use the service.

Last year only 30,000 people with diabetes used the free GP check - about 30 per cent of the people estimated to have the illness. The ministry has set a target of 58,000 this year.

In terms of screening, Toomath says the best value for money is a GP practice where the doctor knows the person's medical and family history.

Russell Finnerty, president of Diabetes New Zealand, says a national register would be invaluable in tracking which programmes work. But he worries that because the responsibility falls to individual health boards, diabetes receives varying priority.

"In some cases what you get depends on where you live."

Toomath agrees. The Government may have set diabetes as a priority, but the challenge is whether district health boards have listened to the message.

"Are they prioritising diabetes and putting the money into diabetes at the level that has been indicated by the Ministry of Health? I think there are serious questions about that."

Dr Sandy Dawson, chief clinical adviser at the Ministry of Heath, says boards are required to report back to the ministry on the number of people using the free checkup, their ethnicity, how well their diabetes is controlled and whether they are getting their eyes checked regularly.

He says the ministry is working with those in the sector to see how information gathered from the free check could be used to build up a national database for research and identifying what works best.

But he acknowledges that more work is needed to publicise the free checkup and to identify those going undiagnosed.

"I think the biggest health gain we can make for people with diabetes is improving access to primary healthcare."

Although there are no plans for national screening, as not enough is known about the overall health benefits, Dawson says some boards are considering targeted screening of Maori and Pacific Island populations.

Not good enough, replies Professor Jim Mann, professor in human nutrition and medicine at Otago University, who predicts that the health system will disintegrate if the Government does not speed up its response to diabetes.

Although he applauds the free annual checkup introduced in 2000, he says he advocated the same idea more than 12 years ago.

He hopes the new New Zealand Centre for Diabetes Research launched at the university last week will not only play an important advocacy role in terms of funding but ensure better co-operation and co-ordination of research.

The focus, he says, needs to be on intervention through lifestyle changes at a local and national level. Overseas gene research can be applied to New Zealand.

"In Europe they are going crazy because their rates are trickling up. They are saying, 'How are we going to cope?' Our rates are escalating and we are paying a lot of lip service ... There's got to be money put into where all this talk is going."

THE SEARCH FOR ANSWERS


New Zealand researchers are part of the worldwide quest for the causes of diabetes and possible solutions. Projects include:

Pancreas failure: Dr Garth Cooper, professor of biochemistry at Auckland University, and a team of more than 50 at Auckland company Protemix are investigating why the pancreas fails, why some people become insulin resistant and why complications such as cardiovascular disease develop. They are also developing medicines to manage diabetes and have had good results in the first clinical trials.

East Coast trial: Next year Otago University researchers will undertake a major project on the East Coast with the district health board to look at whether lifestyle changes can reverse the rate of diabetes among a randomly selected population.

Special diets: Researchers at Otago are also investigating the impact of different diets, from high protein to high fibre.

Nutrition: Dr Elaine Rush, a physiologist at the department of applied science at the Auckland University of Technology, is investigating diabetes and the body shapes of different cultures. She says that if nutrition is not adequate at times of rapid growth - in the womb, as a toddler and as a teenager - that may affect metabolism, making a person susceptible to diabetes.

Pig cells: One of the most controversial treatments, which has attracted worldwide attention. In January Auckland company Diatranz announced a breakthrough in a trial in Mexico, where a teenager with diabetes was able to stop insulin injections after receiving transplanted insulin-producing pig cells. Plans for tests in the Cook Islands were abandoned after the New Zealand Government intervened. Professor Bob Elliott, founder of Diatranz, is now seeking approval for trials in Australia after the Government here banned transplants of animal cells into people, except by special ministerial approval, because of the risk of animal viruses passing to humans.

Automated insulin delivery: This is being tested by researchers at Canterbury University. Dr Geoff Chase, a senior lecturer in mechanical engineering, says diabetics use intuition and experience in determining how much insulin to inject, but even the best make mistakes. Most err on the high side, which can have detrimental long-term effects. Dr Chase says initial tests on hospital patients found the automated system reduced the frequency with which people's blood sugar levels rose. More tests are planned.

DIABETES AT A GLANCE

* New Zealand's diabetes epidemic costs the health system $170 million a year. The annual cost is expected to rise to $1 billion by 2021.

* About 115,000 New Zealanders have been diagnosed with the disease. The same number are thought to have diabetes without knowing it.

* A further 60,000 New Zealanders are expected to develop preventable Type 2 diabetes in the next 20 years.

* Maori and Pacific Island diabetes rates are expected to double to one in six adults.

* Obesity leads to Type 2 diabetes. About 17 per cent of New Zealanders are obese; the figure could reach 30 per cent by 2011.

* For more information phone 0800-DIABETES (0800-3422-3837).

Diabetes NZ


Further reading
nzherald.co.nz/health