Press releases rarely make me drool. But the recent announcement from the International Diabetes Federation (IDF) on their new Global Guidelines for Treating Type 2 Diabetes did. Why? Because this was trumpeted as more than a scientific manifesto of the best practices for treating diabetes; it was put forward as a working solution to an imperfect world.
Wow. Finally. Someone influential was acknowledging that the world is not black and white, but a million shades of gray. I was excited to see what the global experts had come up with to help the most needy get care. I expected innovative, out-of-the-box thinking. Maybe even some tricks I could steal for my own resource-scarce service area in New Mexico. According to the World Health Organization (WHO), fully 80% of the 346 million people in the world who have diabetes live in low and middle-income countries. And these people are less healthy and die earlier than those of us in wealthier nations.
Did the IDF figure out a way to address this glaring global health disparity?
I got more exited still as I scanned the lengthy guidelines' table of contents and saw that "psychological care" and "older people" and "education" and "lifestyle management" where all subjects that got their own chapters. Finally someone was assembling all the pieces. Mind and body and circumstance.
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Sadly, when I dug into the meat of the document I was disappointed, to say the least. But before I proceed to blast the IDF, let me quickly review what the 123-page document (PDF here) is all about.
Poor, Richer, and Super-Rich
Each chapter first provides a brief bullet-point-like summary of the recommendations. This is followed by an explanation of the rationale behind the recommendation, and a discussion of the evidence base. Each section wraps up with considerations, implementation, evaluation, and references.
Rather innovatively, on the surface at least, the document defines three levels of care:
Recommended care. This is the core care needed to treat diabetes. The IDF says they choose approaches that are cost-effective in "nations with a well-developed service base and with healthcare funding systems consuming a significant part of their national wealth." In other words, in developed countries. And following the trend in the USA, their recommendations are "evidence-based," meaning they stand behind only treatments and modalities that have been well-studied and validated by science.
Limited care. These are the shortcuts for the poorest countries. How do you care for PWDs when your country has little to go on? In the IDF's verbiage, you use "care that seeks to achieve the major objectives of diabetes management, but is provided in healthcare settings with very limited resources — drugs, personnel, technologies and procedures."
Comprehensive care. This third level of care is ironically pictured at the bottom of the pyramid, rather than the top, while it is actually "the icing on the care cake." It's the best of the best for those who can afford it. It even includes yet-to-be-fully-proven approaches in "healthcare settings with considerable resources."
As an example of how these three levels of care overlap, but differ, let's start at the beginning: The Guidelines for screening for diabetes. (Note: the document recommends against universal screening.) Recommended Care states that high-risk folks should be screened using any of the WHO criteria, which are old-fashioned fasting glucose test results or random glucose fingersticks, oral glucose tolerance tests, or A1C tests. It goes on to say "People with screen-detected diabetes should be offered treatment and care." Ya think?
So, what should we do in a Limited Care environment? First, detection programs should be "opportunistic and limited to high-risk individuals in very limited settings." Screening should be done using send-out labs, rather than point-of-care testing. The lack of faith in the ability of field personnel in Third World countries to accomplish anything of note is a theme we see repeated again and again in the document. In this sense, I found the Guideline to be Imperial, Paternal, and frankly, quite insulting. It reflects the totem-pole hierarchical attitude typical of Western Medicine.
And what should we do in a wealthier Comprehensive Care environment? Well, of course, we should also run islet antibody tests, C-peptide tests, and genotyping to ferret out the proper classification of diabetes.
This gives you some idea of how the three levels pan out: Recommended actions generally make sense, the Comprehensive suggestions are nice if you can afford them... but the Limited Care recommendations fall absolutely flat.
Creative Thinking, Anyone?
While the concept of a Limited Care component for diabetes guidelines is a fantastic idea in principle, I found the limp-dick approach of the IDF to be pathetic. Take education for example. No CDEs in the central Amazon Basin region of Mosquitovilla? I expected the IDF to advocate for ways of getting peer educators into the field, use radio or cell technology to leverage limited manpower, drop leaflets from airplanes, or use tribal drums to send diabetes education "tweets" if need be. Or maybe something really innovative that I would never have thought of in a million years. What do we get instead? "...education may be provided by a smaller team (physician and educator) or in very limited situations by an appropriately skilled individual."
OK. All-righty then. We'll get right on that. If we had any idea what the IDF considers "appropriately skilled"...
In care delivery, we find that Recommended Care advises a "multidisciplinary care team with specific diabetes expertise maintained by continuing professional education." And even better, it suggests: "Consider how people with diabetes, acting as expert patients, and knowing their limitations [Huh? Oh, right, we PWDs don't know squat about living with diabetes, after all], together with local/regional/national associations, might be involved in supporting the care delivery of their local health-care team."
That sounds like peer-educators to me. And I think that's a super idea. In the education consideration section the IDF even admits that, "Recent studies have demonstrated the benefits of innovative approaches that include using peers, community workers, and technology to support diabetes self-management education. Great! Now we're getting somewhere! Let's do it in the Third World, it would be an awesome force multiplier.
But no. Wait. The All-Knowing IDF doesn't appear to trust the intelligence, drive, and ingenuity of Third World PWDs. The Limited care protocol, knowing a multidisciplinary care team won't be on the savanna any time soon, says "use an appropriately trained healthcare professional to deliver diabetes care." They do offer the helpful suggestion that "Redeployment of underused resources (such as leprosy clinics)" may "offer opportunities for improved care in some countries." No shit. I couldn't have made that up if I tried.
And on it goes. A lot of official language. So little creative thinking...
Writing Off the Third World?
No registered dietitians on the remote island of Udun-wana-live-here? Make sure the docs are trained to double up.
No test strips in sub-Saharan Africa, where we know diabetes is currently diagnosed by having patients pee on an ant hill? The IDF suggests only giving meters and what few test strips that might be available to people who use insulin and insists that blood glucose strips should only be used in emergency situations.
In fact, the guidelines totally diss urine glucose strips. I agree, they're sub-standard, but in a resource-poor area, where every penny counts, wouldn't it be better to use them rather than having only the insulin users test their blood sugar, like the guideline suggests? To my way of thinking, it would be better to have the type 2s on orals use the strips for some sort of glucose control feedback than none at all. But what do I know? I'm not the IDF.
It almost feels like the IDF is writing off the Third World, which means it's writing off 80% of the people with diabetes on the planet. Just in time for World Diabetes Day. For instance, the guideline notes that kidney dialysis or transplantation is "severely limited in a global context," and that "it has been estimated that once a dipstick test is positive, time to kidney failure is about 9 years, but that this time interval can be doubled though appropriate treatment of blood pressure."
And what are the Guideline's thoughts on how to treat blood pressure in a Limited Care environment? While they admit that lifestyle change is "generally insufficient" and that even at full dosage, any single medication is "not particularly effective" at controlling blood pressure, the front-line advice for blood pressure control in the Third World is "initiate a trial of lifestyle modification... with appropriate education."
Recommended foot care takes up seven bullet points with a total of 25 sub-points spread over two full pages. But even in remote Up-river Congo-wongo the guideline insists that checking feet requires a doctor. In northern New Mexico, where I work, we use Promotoras (community health educators) extensively to do foot screenings. We often joke that our state is a Third World Country. I had hoped I could learn from the IDF. Maybe the IDF should be learning from us instead.
Sadly, the guideline is a Western Medicine standard of care document, heavily credential-laden and full of medical bluster, which to me shows that the IDF is clueless about how to help the 277 million PWDs in the Third World. As noted, there's almost no creative thinking. No consideration of using Mid-levels, Para professionals, or trained laypeople. There's nothing new in the "new guidelines."
Maybe the people who wrote it should have been sitting on a piece of canvas in the jungle, not in some air-conditioned wood-paneled boardroom in glass high rise.
Wait a sec. Just who did write this Guideline, anyway?
The Guideline was crafted by a "broadly based group" uncluding health professionals from "diverse disciplines," representatives of non-governmental organizations, and also some PWDs (!). The introduction to the Guidelines tells us the group was global in scope, including folks from "countries in very different states of economic development."
The members came from the UK, USA, Argentina, Australia, Belgium, Colombia, Cameroon, Denmark, India, Italy, Switzerland, Tanzania, and The Netherlands.
UK and USA members dominate the list.
But according to a WHO-funded study published in The Lancet, Oceania had the largest rise in diabetes prevalence, closely followed by Asia, Latin American, the Caribbean, North Africa, and the Middle East. All parts of the globe rather poorly represented (if at all) on the committee that developed the Guidelines.
You can see for yourself what parts of the world have the lowest and highest fasting glucose rates globally here. Cambodia seems to be doing something right, while the Marshall Islands seem to have a problem. If I were working on the Guidelines, I would have invited someone from each place to the table. And an analysis of the growing global diabetes epidemic published in the journal Diabetes Care predicts the greatest relative increases in diabetes will be in the Middle Eastern Crescent. Again, missing from the table.
The IDF intends to review and revise these Guidelines again in five years. I hope they do better next time. Because if the IDF can't figure this out, who can?