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  • Obesity is one of the most serious global public health challenges of the 21st century and a major cause of type-2 diabetes (T2DM), a life-threatening illness, which costs billions
  • 60% of adults in the UK are either overweight or obese, 74% in the US
  • Low calorie diets and exercise are difficult to sustain and therefore tend to fail as treatment options 
  • Conventional treatments for T2DM have failed to dent the vast and escalating burden of the condition, so interest is increasing in alternative treatment options
  • Bariatric (stomach reduction) surgery is a therapy for obesity, which has been shown to “cure” T2DM
  • In 2016, 45 international health organizations called for bariatric surgery as a treatment for T2DM
  • Is bariatric surgery the biggest step forward in T2DM treatment in 100 years?
 

Weight loss surgery to treat T2DM


It is five minutes to midnight for healthcare systems struggling in vein to reduce the vast and escalating burden of type-2 diabetes (T2DM). Doing more of the same is no longer an option. Given the lack of alternatives, experts are calling for an increase in bariatric surgery because it has been shown to “cure” T2DM.
 
Bariatric surgery not only reduces weight, it also improves glycemic control by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion with a consequent reduction in the symptoms of T2DM.
 
In the video below Kenneth D’Cruz, Senior Consultant Gastroenterological Surgeon at Narayana Health, India describes bariatric surgery, which refers to a range of procedures including gastric bypassgastric sleeve, gastric band, and gastric balloon. Such procedures are often performed to limit the amount of food that an individual can consume, and are mainly used to treat those with a body mass index (BMI) of above 40, and in some cases where BMI is between 30 and 40, if the patient has additional health problems such as T2DM.
 
 
Epidemiology of obesity

Overweight and obesity are principal risk factors of T2DM. In the UK, the number of people classified as obese has doubled over the past 20 years and continues to rise. According to data from the 2014 Health Survey for England, 24% of adults in England are obese and a further 36% are overweight. In 2015, there were 440,288 admissions to England's hospitals for which obesity was the main reason or a secondary factor.
 
Data from the National Child Measurement Programme (NCMP), suggest 10% of children in the UK are obese by the time they start primary school, and 25% are so by the time they finish. 6% of people in the UK are living with diabetes of which 90% have T2DM. Over the past decade the incidence rate of T2DM has increased by 65%.
 
The situation is similar in the US, where 36% of adults are obese, and 6.3% have extreme obesity. Almost 74% of adults are considered either overweight or obese. Over the past 30 years, childhood obesity has more than doubled, and it has quadrupled in adolescents. The percentage of children who were obese increased from 7% in 1980 to nearly 18% in 2012. 9.3% of people in the US are living with diabetes.
 
The World Health Organization warns that obesity is, “one of the most serious global public health challenges of the 21st century”.
 
Causes of obesity

There are many complex behavioural and societal factors that combine to contribute to the causes of obesity. At its simplest, the body needs a certain amount of energy (calories) from food to keep up basic life functions. When people consume more calories than they burn, their energy balance tips toward weight gain, excess weight, and obesity. In the videos below Mohammed Hankir, Department of Medicine, University of Leipzig, Germany, describes what causes obesity, and the relationship between obesity and T2DM:
 
What are the causes of obesity?
 
What is the relationship between obesity and type-2 diabetes?
 
The cost of diabesity

Obesity costs the UK £47bn every year. The medical care costs alone for obesity in the US are estimated to be more than US$147bn. Diabetes treatment and indirect medical costs run to £10.3bn in the UK and US$176bn in the US, representing significant increases over the past five years. The medical costs for an individual with diabetes are typically 2.5 times higher than for someone without the disease. As prevalence of obesity increases these costs will rapidly rise.
 
T2DM prevention and treatment

NHS England, Public Health England and Diabetes UK’s National Diabetes Prevention Program is based upon diet and exercise-induced weight loss, which sometimes remedies insulin resistance. For obese people dietary and lifestyle therapies have limited short-term and almost non-existent long-term success records. According to Professor John Wilding, Head of the Department of Obesity and Endocrinology at the University of Liverpool, UK; the problem with low calorie diets, “is that most people will lose weight, but most people will also regain much of that weight that has been lost.” The UK’s National Institute of Health and Clinical Excellence (NICE) does not support the routine use of low calorie diets.
 
Once an overweight or obese person has T2DM the stakes change. With the limited success of conventional medical therapies, bariatric surgery has become an increasingly popular treatment in the war against obesity and latterly also for T2DM. The 2014 UK National Bariatric Surgery Registry reported that there is good evidence from randomised controlled studies that surgery is superior to medical therapy in improving diabetes control and metabolic syndrome. Surgery lowers the number of hypoglycaemic medications needed, including some people no longer needing insulin. It also means many people living with T2DM going into remission, and it markedly lowers the incidence of T2DM compared to matched-patients not having surgery.
 
NICE guidelines for bariatric surgery as a therapy for diabesity

Concerned about the rising prevalence of diabesity (obesity and diabetes) and the limited success of conventional strategies, in 2011, the International Diabetes Federation endorsed bariatric surgery as a T2DM treatment for obese people. The Federation’s endorsement is a validation of research and medical experience showing that surgery to reduce food intake can alter the biochemistry of the entire body. It also marked the beginning of a major new assault on diabetes.

In 2014, NICE introduced guidelines for bariatric surgery as a treatment option for obese adults, and suggested that it would greatly help T2DM. Current NICE guidelines state that bariatric surgery should be offered to anyone who is morbidly obese (a BMI of 40 or over), to those with a BMI over 35 if they have another condition, such as T2DM, and to those with a BMI of at least 30 with a recent diagnosis of diabetes.
 
In the UK only about 6,500 people each year have bariatric surgery. This is significantly lower than other European countries, which perform on average about 50,000 stomach reduction surgeries each year. Under the NICE guidelines, up to 2m people would be eligible for free bariatric surgery on the NHS, which would cost the taxpayer £12bn.

 
Biggest breakthrough in diabetes care since the introduction of insulin
 
In 2016 a review written by a group of researchers led by David Cummings, an endocrinologist at the University of Washington set out guidelines for bariatric surgery as a treatment option for diabetes. Francesco Rubino, one of the experts behind the guidelines and professor of metabolic and bariatric surgery at King's College London, said: “This is the closest that we have ever been to a cure for diabetes. It is the most powerful treatment to date.” Other doctors who drew up the guidelines said such changes could amount to the most significant breakthrough in diabetes care since the introduction of insulin in the 1920s.
 
The modern Roux-en-Y gastric bypass

The ‘gold standard’ bariatric surgical procedure is the Roux-en-Y Gastric Bypass, which is the most commonly performed bariatric procedure worldwide, named after a 19th century Swiss surgeon César Roux, who first performed the surgery to reroute the small intestine. The modern version of the procedure involves reducing the stomach to a little pouch, to curb eating and appetite, and then connecting that pouch to a lower section of the intestine. By using less of the intestine, fewer nutrients are absorbed, and the patient loses weight.
 
Until recently it has been poorly understood why, after bariatric surgery, a significant proportion of patients with T2DM leave hospital either needing no insulin, or lower doses, before ever losing any weight. Re-plumbing the GI-tract appears to reprogram the body’s hormones and resets its metabolism.

 
Advances in bariatric surgery

Thirty years ago there was little interest in bariatric surgery, which was risky, and not widely practiced. It involved a large, bloody incision, the prising apart of the heavy, fatty abdominal walls with metal arms, which then had to be held in place while the surgeon carried out procedures deep in the gut. Patient recovery times were long, and the risk of complications high.

By the first decade of the 21st century, when obesity became an epidemic in advanced economies the relationship between bariatric surgery and T2DM was given more attention. The medical device industry developed new surgical tools to facilitate blood free minimally invasive procedures for obese people, but researchers were still struggling to understand why bariatric surgery “cured” diabetes.

 
Understanding why bariatric surgery cures diabetes

One of the scientists to discover why bariatric surgery cures T2DM is Blandine Laferrère, an endocrinologist at the New York Obesity Nutrition Research Center at St. Luke’s. Our gut hormone ghrelin signals to our brain that we are hungry and to start eating. Receptors in out GI tract signal to our brain that we are full and to stop eating. In obese people such signalling malfunctions, and leaves them perpetually hungry. According to Laferrère, “It just happened that the surgeons did this type of surgery for weight loss, and that turned out to have a spectacular effect on the remission of T2DM.

Further research was undertaken by Laferrère and influenced by Werner Creutzfeldt, a German doctor who published work on gut hormones that increased stimulation of insulin secretion, which he called an “incretin effect”. According to Laferrère, bariatric surgery, rather than actual weight loss, stimulates the incretin effect, which boosts the production of insulin while lowering the symptoms of diabetes. She concluded that the surgery itself triggered the hormone network, which diet-induced weight loss could not provide.
 
Takeaways

Scientists claim that bariatric surgery is the biggest step forward in diabetes treatment in 100 years, and suggest we are no longer talking about the treatment of obesity, but treatment of diabetes.
 
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The Mexican Connection
A Special Report 

 
  • People are eating themselves to death and our healthcare systems and governments are failing to stop it
  • Obesity and type-2 diabetes (diabesity) kills thousands unnecessarily, and threatens the stability of healthcare systems around the world
  • In the UK there is mounting frustration with the diabetes establishment’s failure to make inroads into the prevention and management of diabesity
  • Mexico is re-engineering the way primary care delivers its services in order to prevent and reduce the burden of diabesity
  • There are lessons from Mexico for healthcare systems challenged by the diabesity epidemic
 

Breaking the cycle of ineffective diabesity services
 
People are eating themselves to death, and our healthcare systems are failing to stop it. Not more so than in Mexico, where 70% of the population is overweight and 33% obese; both risk factors of type-2 diabetes (T2DM), which kills 70,000 Mexicans each year.
 
The situation is not that different in the UK, which has the highest levels of obesity in Western Europe: 64% of adults in the UK are either overweight or obese, and the incidence rates of diabetes have more than trebled over the past 30 years. Each year, in the UK diabetes kills 22,000 people unnecessarily, and leads to 7,000 avoidable lower limb amputations.
 
The two countries differ however in their respective responses to the epidemic of obesity and diabetes (diabesity), which is the subject of this Commentary. While the UK’s diabetes establishment appears to be locked into a cycle of ineffectiveness, the Fundación Carlos Slim (FCS), is re-engineering the way Mexico’s primary healthcare system delivers its services in order to prevent and reduce the vast and escalating burden of diabesity. The FCS’s endeavours have important lessons for the UK, and indeed other countries battling with a similar epidemic.  
Diabesity a global challenge
Diabesity is no longer a disease of rich countries; it is increasing everywhere. An estimated 422m adults were living with diabetes in 2014, compared to 108m in 1980. The global prevalence (age-standardized) of diabetes has nearly doubled since 1980, rising from 4.7% to 8.5% in the adult population. This reflects an increase in associated risk factors such as being overweight or obese. Uncontrolled diabesity has devastating consequences for health and wellbeing, and it also impacts harshly on the finances of individuals and their families, and the economies of nations.


Mounting frustration with the UK’s diabetes establishment

Although there is consensus about what needs to be done to prevent and enhance the management of obesity and T2DM, and although each year NHS England spends £10.3bn on diabetes care, and £4bn to treat obesity, the prevalence rates of the conditions continue to rise, and the UK’s diabetes establishment seem unable to do anything about it.
 
This ineffectiveness has caused mounting frustration with the diabetes establishment on the part of the UK government’s National Audit Office (NAO) and the Public Accounts Committee (PAC). Numerous official inquiries into adult diabetes services have found no evidence to suggest that T2DM prevention and care are effectively managed, and failure to do so leads to higher costs to the NHS as well as less than adequate support for at risk people and those with the condition.
 
Damning official inquires into adult diabetes services
A 2015 NAO report into adult diabetes services found, “that performance in delivering key care processes and achieving treatment standards [recommended by the National Institute for Health and Care Excellence (NICE)], which help to minimise the risk of diabetes patients developing complications in the future, is no longer improving . . . . There are significant variations across England in delivering key care processes, achieving treatment standards and improving outcomes for diabetes patients, (and)  . . . There are still 22,000 people estimated to be dying each year from diabetes-related causes that could potentially be avoided”. 
The 9 basic processes for diabetes care
The nine NICE recommended basic processes of diabetes care are: (i) blood glucose level measurement (HbA1c), (ii) blood pressure measurement, (iii) cholesterol level measurement, (iv) retinal screening, (v) foot and leg checks, (vi) kidney function testing (urine),  (vii) kidney function testing (blood), (viii) weight check, and (ix) smoking status check.
No strong national leadership and depressingly poor progress
When the Public Accounts Committee (PAC) reported on adult diabetes services in 2012 it found that, "progress in delivering the (NICE) recommended standards of care and in achieving treatment targets has been depressingly poor. There is no strong national leadership, no effective accountability arrangements for commissioners (local healthcare providers), and no appropriate performance incentives for providers." Four years later, a 2016 PAC inquiry into adult diabetes services reported that nothing of significance had changed. The Committee was concerned, “that performance in delivering key care processes and achieving treatment standards is no longer improving”, and it challenged, “the Department of Health, the NHS and Public Health England on their lack of progress in improving patient care and support”.
 
The UK’s cycle of ineffective diabesity services
The NAO and the PAC inquiries appear to have identified a cycle of ineffectiveness among the UK’s diabetes establishment, which manifests itself in a familiar scenario. Here is a stereotypical picture.
 
Each year, after the publication of the latest prevalence data for obesity and diabetes, Diabetes UK, a leading charity, “calls on the government to do more”, the National Clinical Director for Obesity and Diabetes at NHS England makes a defensive statement usually emphasising the positive aspects of diabetes services. NHS England continues to spend £14.3bn each year on the treatment of diabesity. There continues to be little improvement in the 20,000 plus unnecessary annual diabetes-related deaths, and 7,000 avoidable amputations. Diabesity services continue to be inflexible and process, rather than outcomes driven. Nothing of substance changes, prevalence rates and eye-watering costs continue to rise, and no one is accountable.
 
This cycle of ineffectiveness reflects a dearth of national leadership among the diabetes establishment.
 
The Fundación Carlos Slim (FCS) appears successfully to have broken a similar cycle of ineffectiveness for the prevention and treatment of diabesity in Mexico. The Fundación used the weaknesses in Mexico’s primary healthcare system as an opportunity to re-engineer the prevention and treatment of diabesity with an innovative program called Casalud. The name is derived from two Spanish words: “casa” (house) and “salud” (health): ‘Homehealth’.
 
In 2008, when the FCS launched the Casalud program, the primary care services of both the UK and Mexico were similar in in their inflexibility, and in emphasising treatment processes and service delivery rather than value-based healthcare. This emphasis results in weak primary care systems, which contribute to the increased prevalence of diabesity.
 
We will draw lessons from the Casalud program, but before doing so let us consider the grounds for a comparison between the healthcare systems of the UK and Mexico.
 


UK and Mexico compared

In both countries the prevalence of obesity and T2DM are high and increasing. Both governments’ healthcare systems are struggling to effectively cope with the vast and growing burden of diabesity. Mexico’s Seguro Popular, which is roughly equivalent to NHS England, serves about 57m people: which includes 60% - 34m - of Mexico’s poorest non-salaried workers employed in the informal sector. Mexico’s population is younger than the UK’s. The median age of Mexico’s 129m citizens is 29 years, whereas in the UK, which has a population of 65m, the median age is 40 years.
 
Both the UK and Mexico struggle with structural challenges associated with the supply and competence levels of health professionals. These manifest themselves in significant local variations in the effectiveness of diabesity prevention and treatment, and in lengthy waiting times for GP consultations.
 
Annual foot checks in the UK and Mexico
In England for instance, standard annual recommended foot checks for people with diabetes vary as much as 4Xs depending on where you live. Each year 415,000 or 13.3% of people with T2DM do not receive foot checks, which increases their risk of amputation, and fuels the 7,000 avoidable lower limb amputations carried out each year. Similarly in Mexico, 60% of people with diabetes fail to have their feet examined during primary care consultations, and between 86,000 and 134,000 diabetes-related amputations occur each year.
 
Responding to the recent English findings, Professor Jonathan Valabhji, the National Clinical Director for Obesity and Diabetes at NHS England said; “It is very important as many people as possible receive their foot checks at the right time – currently each year 85% of people with diabetes receive these foot checks.”
 

Leadership to break the cycle of ineffective healthcare services
In contrast to the UK’s diabetes establishment, the Casalud program provides strong, well-coordinated national leadership, and effective accountability and performance incentives for local healthcare providers. It does not however, deliver direct healthcare services; these are provided by the state. Instead Casalud concentrates on fostering the implementation and use of innovative technology, which it has designed to enhance patient centred primary care, extend healthcare into communities and homes, encourage self-management, engage in prevention programs, and enhance the competence and capacity of healthcare professionals within Seguro Popular.
 
For the Casalud program to stand a chance of being supported by the Mexican government, and implemented nationally, the FCS understood that it was essential to collect convincing performance data in its pilot program. From its inception therefore, the Casalud program developed and agreed with the relevant healthcare agencies a suite of performance measures, data collection protocols and reporting systems. This helped the Fundación to secure the backing of key national and regional healthcare agencies.
 
The FCS chose a social franchising model for the Casalud program, which uses commercial best practice to achieve socially beneficial ends, rather than profit. This makes the program significantly different to the endeavours of some UK public and non-profit bureaucracies, which provide diabesity services.
Some common aspects of bureaucracies
Here we briefly describe some common aspects of bureaucracies, which suggest that over time, bureaucratic organizations may become ineffective diabesity service providers. Bureaucracies are machine-like organizations characterised by hierarchical authority, a detailed division of labour, and a set of rules and standard procedures, which staff are obliged to follow. Rules provide a means for achieving organisational goals, but the following of the rules sometimes displaces the actual objective of the organisation, and organisational objectives become secondary. This is encouraged by the fact that people in bureaucracies tend to be judged on the basis of observance of rules and not results. For example, in an organisation, say committed to diabetes services, performance may be judged on the basis of whether expenditure has been incurred according to rules and regulations. Thus, expenditure becomes the criterion of performance measurement, and not the results achieved through expenditure. Bureaucracies almost completely avoid public discussion of its techniques, although there may be some discussion of its policies. This secrecy is believed to be necessary to prevent “valuable information” from leaking out, and going to competitors. “Trained incapacity” is a term sometimes applied to bureaucracies to describe training and skills, which have been successful in the past, but are unsuccessful under present changed conditions. Inadequate flexibility, in an evolving environment such as healthcare, will result in ineffectiveness.
 mHealth platform embedded with bespoke tools
The Casalud program avoided bureaucratic traps that result in ineffectiveness by developing a flexible mHeath platform (the use of mobile phones and other wireless technology in medical care) with an embedded suite of proprietary software, which connects patients to health providers, nudges people to self-manage their own health, and to become integral members of local care teams. The platform is used for mobile screening, providing patients with their own individual healthcare dashboards, online healthcare education, supply chain monitoring, standardizing electronic patient records, and big data strategies. It also acts as an entry point for patients, support for health professionals to identify at-risk people, make early diagnosis, and quickly begin diabesity management, and structure follow-up with patients over time.
 


The Casalud program’s successful pilot

In 2009, the FCS began a 3-year pilot of its Casalud program in 7 Mexican states, which resulted in improved patient knowledge about diabesity, enhanced self-management among people with the condition, increased clinician knowledge of diabesity prevention and management, and improved clinical decision-making.
 
The FCS used performance data from its pilot to secure a partnership with the Mexican Ministry of Health to extend the Casalud program to 120 primary care clinics serving 1.3m people across 20 Mexican states - 4 to 10 clinics in each state. Also, the performance data was successful in getting the Casalud program adopted as an integral component of the National Strategy for the Prevention and Control of Pre-obesity, Obesity and Diabetes. So, within three years the Casalud program went from a relatively small charity-backed start-up to a significant component in a nationally supported healthcare system.
 
It is reasonable to assume that this was partly due to the leadership provided by the FCS, and partly due to setting, collecting and reporting appropriate performance indicators. The FCS acted similarly to a lead institution in a commercial endeavour, and successfully recruited key contributing partners who were prepared to share the costs of the program’s national rollout. The FCS covers the cost of all the software development, and the training of healthcare professionals for the Casalud program. All the software is owned by the FCS, and licensed free-of-charge to the Mexican government. The federal government covers the cost of all computer hardware used in participating clinics, and local state governments cover the cost of Casalud’s operations, which include such things as laboratory tests and medications.
 


The 5 components of the Casalud program

To better understand the Casalud program and its contribution to enhanced diabesity services we review its five components: (i) proactive prevention and detection of diabesity, (ii) evidence-based management of diabesity, (iii) supply chain improvements, (iv) capacity-building of healthcare professionals, and (v) patient engagement and empowerment. Each component has an on-going monitoring system associated with it, which informs the FCS on the status of the program’s implementation.
 
1. Proactive prevention and detection of diabesity
Previous attempts in Mexico at community based screening for diabesity have failed. However, the FCS insisted that a national screening strategy was important for reducing the burden of diabesity, but understood its case would need to be supported by appropriate performance data, which would require systematic collection and reporting. To help achieve this the FCS developed two online risk assessment tools, which capture, assess and report data on peoples’ risk factors of diabesity.
 
One of these tools is used in clinics, and the other, which is portable, used in homes and communities. Both screen and categorise people as, (i) healthy, (ii) at risk of diabesity, and (iii) already diagnosed as obese or with T2DM. Screening allows local healthcare professionals to suggest personalised lifestyle changes to individuals either to help them reduce their risk of diabesity or to improve their management of the condition. Each participating clinic has a screening goal. Screening data are collated and reported weekly on a pubic system, which incentivizes the clinics in their screening endeavours.
 
Having a portable device means that populations, which previously did not have access to healthcare are included in the screening. While this increased the number of reported people with diabesity, over time it lowered healthcare costs because early detection reduced the use of urgent care facilities. This proactive component of the Casalud program and the performance data resulted in the support of federal healthcare officials who saw the advantages of using technology to integrate communities, families, and patients into a continuum of care. The tools also extended care to people and communities that previously had little access to healthcare, and encouraged patients to use technology to manage their own health, which health authorities appreciated.
 
2. Evidence-based diabesity management
The second component of the Casalud program is an evidence-based diabesity management system, which is supported by more software developed by the FCS. This includes agreed international best practice protocols for diabesity prevention and management, a digital portfolio for health professionals, electronic monitoring of patients in order to improve the accuracy and reliability of performance measurements and patient data. Such data are used to improve the quality of clinical decision-making.

Examples of the data collected and reported are the percentages of people with T2DM and their corresponding laboratory test results. Casalud’s study found that out of 961,733 patients with T2DM, only 20% had an HbA1c (blood glucose) measurement. Further, only 40.7% of patients with an HbA1c measurement had their HbA1c levels under control (below 7%).  All data are made available at the national, state and clinic levels, and are thereby expected to empower healthcare providers to base their health policy decisions on the areas of most need.
 
3. Supply chain improvement
Mexico like other emerging countries suffers from an inconsistent supply of medicines and laboratory tests, which is a significant obstacle to optimal disease prevention and management. Drug supply decisions in Mexico are centralized and made at a state or federal level. This is different to the UK, and other developed countries.
 
This component of the Casalud program uses a proprietary online information system that standardizes metrics for stock management at the clinic level to improve the supply of medicines and laboratory tests. The software is made available on mobile phones to make it easy for health professionals to ensure that stock levels are adequate for clinics to provide a quality service. In addition, Casalud uses these data to raise awareness with federal and state healthcare officials of inefficiencies in supply chains, which could fuel complications and increase healthcare costs. Prior to Casalud there was no accurate and systematic way to assess and report on the supply of medicines and laboratory tests.
 
4. Capacity building for healthcare professionals
Casalud’s forth component is an interactive platform to develop the capacity of healthcare professionals through online education, which leads to diplomas conferred by national and foreign universities. The FCS partnered with Harvard University’s Joslin Diabetes Center, and Mexico’s National Institute of Medical Sciences and Nutrition to develop courses that certify competence in key areas of diabesity prevention, diagnosis and management. One course is designed to update doctors’ knowledge of diabesity, and the other is a practical course developed by faculty of the Joslin Diabetes Center in which health professionals solve real-life cases to test their knowledge in practical settings.
 
Certificates act as non-monetary incentives for health professionals, and to promote competition between clinics and health professionals. This helps to increase participation in the program, improve the quality of care, encourage openness and transparency, and increase collaboration between clinics.
 
Software developed by the FCS assists local clinics to capture data on the characteristics of the participating healthcare professionals, their baseline knowledge, and improvements after each course. These data are aggregated to choose a clinic of excellence for each state, and a national clinic of excellence; both of which are publicly recognised awards, and help with Casalud’s national rollout strategy.
 
Further, performance data are contributed to the National Strategy for Improving Skills and Capacity of Healthcare Personnel, which obliges all Mexican healthcare institutions to engage in formal online training that is, personalized, linked to a continuing education program, validated by academic institutions and independently monitored. Casalud’s capacity building component fulfils all of these criteria.
 
5. Patient engagement and empowerment
With the help of the Joslin Diabetes Center, the Mayo Clinic, and Mexico’s National Nutrition Institute, this component has two mobile applications, which assess patient engagement, knowledge of diabesity, and confidence and skills in order to help them understand their health, begin to self-monitor their condition, interpret their own results, and implement beneficial lifestyle changes. A specific app for people with T2DM allows them to schedule medicines and appointment reminders, input glucose and weight measurements, and receive immediate personalized feedback and educational messages from health professionals.

However, the FCS changed its approach following evidence from the program’s pilot, which suggested that due to the characteristics of the patient population – elderly, rural, and with limited access to and familiarity with technology – mobile technology alone would not lead to a high percentage of patient engagement. So, Casalud implemented a suite of in-person interactions and activities, which are thought to be more appropriate for the specific patient population.

Such a change may not be necessary in the UK and other developed countries. In the UK for instance, the growth trend in smartphone ownership is present in all age groups, and fastest among 55-64 year olds, which jumped from 39% in 2014 to 50% in 2015. While those aged over 55 are more likely to own a laptop the gap is closing. Among younger age groups, 90% of those aged 16-24 now owns a smartphone.
 


Takeaways

Although the Casalud program has encountered challenges associated with Mexico’s patchy technological infrastructure, entrenched attitudes of some health professionals, and fragmentation and lack of uniformity of its primary healthcare system; the program has been successful; not least because of its flexibility and speed of adjusting to prevailing conditions. In 2015 a Brookings Institution research paper concluded that, “Casalud has made significant strides in transforming care delivery in Mexico”. 

Casalud’s development and implementation continues. It is an innovative program, which employs appropriate technology and evidence-based knowledge to re-engineer Mexico’s public sector primary healthcare system by encouraging patient self-management to reduce the country’s vast and increasing diabesity burden.
 
Casalud provided leadership and seed money to secure financial support from and create consensus between the federal and state governments, and obtain local support from clinics, healthcare professionals and patients. The program is on-going and warrants consideration from the UK’s diabetes establishment, and those of other countries wrestling with the burden of diabesity.
 
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  • Diabetes is closely associated with cardiovascular disease (CVD)
  • Heart attack and stroke cause premature death in people with diabetes
  • People living with type-2 diabetes can prevent or slow the onset of CVD
  • Lower CVD risk by exercising, eating healthily, controlling your weight, and giving up smoking
 
Diabetes and cardiovascular disease

Diabetes is treatable, but people with diabetes have a greater risk of developing cardiovascular disease (CVD) than people who do not have diabetes. Indeed, adults with diabetes are two to four times more likely to develop heart disease or a stroke than adults without diabetes. The reason for this is because people with diabetes, particularly type-2 diabetes (T2DM), may have specific conditions that contribute to their risk of developing CVD. These include high blood pressure, abnormal cholesterol and high triglycerides, obesity, physical inactivity, high and poorly controlled blood sugars, and smoking.

Keeping your diabetes under control by managing the risk factors will help protect your heart health. Most people with T2DM are prone to accelerated atherosclerosis, and could ultimately die of cardiovascular disease (CVD). Many will die prematurely. Overall, the incidence of CVD is declining, but for people with diabetes it is increasing.

Much of diabetes care is the prevention of CVD by modifying blood pressure, blood glucose, and lipids, and this involves both medical therapies, and lifestyle changes, as Dr Roni Sharvanu SahaConsultant in Acute Medicine, Diabetes and Endocrinology at St George's Hospital, London, explains:

 
 
Blood pressure and glycaemic control

Blood pressure and glycaemic control often require multiple drug therapies, which are less likely to produce side effects than a signal agent. Glycaemic control is important for controlling both macro and micro vascular disease. The former includes myocardial infarction and stroke; the prime causes of excess mortality in diabetes. Preventing microvascular complications is important to reduce the risk of retinopathy, and nephropathy. 
 
Insulin therapy

Increasing numbers of people with T2DM are using insulin therapy to achieve tight glycaemic control. The challenge is to reconcile reduced HbA1c with the risk of hypoglycaemia. There is an important debate between tight and adequate glycaemic control.  A 2014 Australian study reported in the New England Journal of Medicine suggests that there is no evidence that tight glucose control leads to long-term benefits with respect to mortality or macrovascular events. 
 
Antihypertensive medication
 
The majority of people with T2DM whose blood pressure is not within the 140/80-range will require antihypertensive medication, which is usually an angiotensin converting enzyme (ACE) inhibitor. If the target blood pressure is not achieved, a calcium channel blocker or diuretic can be taken in combination. ACE inhibitors are inappropriate for pregnant women, and may be a less effective alternative for those of Afro Caribbean descent where a calcium channel blocker may be more effective.
 
Lipid lowering
 
Lipids are fat-like substances in the blood, and cholesterol is one type of lipid. In order for lipids to travel in the blood they must be coated with protein: lipoprotein. Excess cholesterol is detected by measuring lipoprotein. High cholesterol is a major controllable risk factor for CVD. As blood cholesterol rises, so does the risk of CVD. Recommended targets for cholesterol lowering in diabetes are total cholesterol bad cholesterol,

People with high cholesterol may be prescribed a statin, which is a group of medications that can lower bad cholesterol, and thereby reduce the risk of CVD, as Professor Olaf Wendler,Consultant Cardiothoracic Surgeon at King’s College Hospital and  Professor of Cardiac Surgery at King’s College London explains :
 

However, high cholesterol is just one risk, and statins are usually offered to people who have been diagnosed with a form of CVD, or whose personal and family medical histories suggest they are likely to develop CVD at some point over the next 10 years.
 
Side effects

Statins are tablets to be taken at the same time once a day, and in most cases, will need to continue for life, as stopping the medication will cause high cholesterol levels to return within a few weeks.
 
There are significant risks associated with mixing statins and grapefruit, which include muscle breakdown, liver damage and kidney failure. Statins also carry other risks, such as digestive problems, increased blood sugar and neurological side effects, including confusion and memory loss.
 
Lifestyle

In addition to drugs, people with T2DM experiencing hypertension, and high cholesterol are encouraged to eat a healthy diet low in saturated fats, exercise regularly, stop smoking, and reduce salt and alcohol. Smoking is particularly harmful for people with diabetes since it increases the risk of macrovascular disease and microvascular complications.
 
Takeaways

Diabetes is closely associated with CVD. Heart attack and stroke are the major causes of premature death in people with diabetes. With the rising prevalence of diabetes, especially in developed countries, the double jeopardy of diabetes and CVD is set to result in an explosion unless preventive action is taken.
 
Managing T2DM involves a combination of drugs and lifestyle. Self-management is enhanced by increased knowledge of the condition. People living with T2DM can either prevent or slow the onset of CVD by increasing their physical exercise, eating a healthy balanced diet, controlling their weight, and giving up smoking.

 
 
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  • Diabetic kidney disease is an epidemic
  • People with severe kidney disease often do not realize it as its symptoms are non specific
  • People living with the condition need to become more active in its management
  • GPs often do not recognise diabetic kidney disease and fail to refer patients to specialists
  • Kidney failure is one of the most severe and life-threatening complications of diabetes
  • Kidney damage from diabetes accounts for 35% of people with end stage renal disease
  • Chronic kidney disease  (CKD) is diagnosed through specific blood and urine tests
  • CKD can be treated with medicines and lifestyle changes
  • Management of CKD includes glycaemic control, blood pressure control and smoking cessation

Diabetes and kidney disease

Diabetic kidney disease has become an epidemic; people living with diabetes need to become more active in its management in order to either slow the onset of kidney disease or to stabilize it.
 
It is not easy.
 
People with severe kidney disease often do not realize it. Primary care doctors often do not recognise it, and fail to refer patients to specialists. According to the US Renal Data System, 42% of patients with end-stage renal disease (ESRD) had not seen a kidney specialist or nephrologist prior to beginning therapy.  

Kidney failure is one of the most severe and life-threatening complications of diabetes. About 30% of people with type-1 diabetes, and between 10% and 40% of those with type-2 diabetes eventually will suffer from kidney failure. Over the next decade, it is projected that twice as many people will suffer from diabetes related kidney failure.

 
Silent killer

"There is an explosion of kidney disease, but a lot of doctors are not aware of the strong association with diabetes, cardiovascular disease and hypertension," says Dr Robert Stanton, chief of the kidney and hypertension section at Harvard’s Joslin Diabetes Center. "You can slow down kidney disease, and maybe stabilize it. But if you wait too long, very little can be done," says Stanton.
 
Kidney damage from diabetes (diabetic nephropathy) accounts for 35% of people with ESRD. In 2015 some 35,000 people in the UK required kidney dialysis. In the US, more than 100,000 people are diagnosed with kidney failure each year, and an estimated 31 million people have chronic kidney disease (CKD). In India there are some eight million people suffering from chronic kidney failure. Lloyd Vincent, Senior Consultant Nephrologist at Narayana Hrudayalaya, Bangalore, India, here explains how diabetes control is related to kidney function:
 

 
The only way to find out for sure whether you have CKD is through specific blood and urine tests. Once detected, CKD can be treated with medicines and lifestyle changes. These treatments usually decrease the rate at which CKD worsens, and can prevent additional health problems.
 

Your kidneys and diabetes

Your kidneys perform vital functions such as filtering your blood and stimulating your red blood cell production. Diabetes damages small blood vessels in your body, including those in your kidneys. This means your kidneys cannot clean your blood properly, and wastes cannot be removed from your blood, which means kidney failure. Diabetes may also result in nerve damage, which can cause difficulty in emptying your bladder. The pressure resulting from a full bladder can back-up and injure your kidneys. Also, if urine remains in your bladder for a long time, you can develop an infection from the rapid growth of bacteria in urine, and this can affect your kidneys.
 
Early signs

An early sign of diabetic kidney disease (DKD) is an increased excretion of albumin in the urine. Albumin is present long before usual tests show evidence of kidney disease. Weight gain, high blood pressure, ankle swelling, and the need to use the bathroom more at night are also signs. A person with diabetes should have their blood, urine and blood pressure checked at least once a year. Maintaining control of diabetes can lower the risk of developing severe kidney disease.
 
Late signs

As kidneys fail, blood urea nitrogen (BUN) levels rise, as do levels of creatinine in your blood. Signs of late stage kidney disease include nausea, vomiting, appetite loss, weakness, fatigue, itching, muscle cramps (especially in the legs), and anaemia. Also, a person with diabetes might find they need less insulin, which is because diseased kidneys cause less breakdown of insulin.
 
Takeaways
 
Diabetic kidney disease is essentially a microvascular complication, which triggers a vicious circle by promoting macrovascular processes as well. Early intervention is crucial and prevention encouraged. The most effective strategies include: glycaemic control, blood pressure control, and smoking cessation.
 
 
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