Mia’s opinion- For years I have written about the cost emotionally physically and financially and obviously medically on the world from morbid obesity, and the food related illnesses it causes. Everytime I do I get flamed as being anti largesse or fat hating? My question is this, when this is the first generation in recorded history to live a shorter life than their parents from food related illnesses and in this generation more amputations happen world wide from diabetes related complications than from all wars and auto accidents combined WHY WOULD YOU WANT TO YOURSELF OR YOUR LOVED ONES TO BE FAT AND EVEN WORSE STAY FAT WHEN YOU HOLD THE ANSWER?
The New York tmes and the World Health Organization looked to latin america and found pandemic illness from over of it’s budget on the treatment of diabetes. Below are the people and their lives ruined by morbid obesity that has for generations been ignored as “our ethnic right”
HOME THERAPY Teresa Sánchez of Mexico City, who lives on $400 a month and supports three children, recently bought a blood sugar meter after having had diabetes for 10 years.
MEXICO CITY, June 11 — Ten years after she learned she had Type 2 diabetes, Teresa Sánchez bought her first blood sugar meter, a small, hand-held device that cost $100, a quarter of her monthly pension.
Times Topics: Diabetes
She says she “would have taken better care of myself and eaten less had I known what would happen to me.”
Before she got the meter, Ms. Sánchez, 52, had to go to a low-cost laboratory or a doctor’s office to have her blood sugar tested. Sometimes months passed without a test, and then she would discover that the level had crept to 400 or 500 milligrams per deciliter, two to four times normal.
Those years of hyperglycemia, or high blood glucose levels, have led to extensive complications: nerve damage in her legs and feet, feeble vision and glaucoma, and incontinence from the strain on her kidneys and bladder. She also complains of frequent nausea and weakness.
For diabetics in the developing world, the most basic tools necessary to keep their illness in check represent a major expense. Yet doing without them can be far more expensive in the long run, and harmful to their health.
Many diabetics in Mexico and other developing countries are finding themselves unable to work, jeopardizing their families’ livelihood. Ms. Sánchez once supplemented her pension by selling clothes to her neighbors, but her painful feet now restrict her mobility.
“I am worried about the future,” she said. “I am raising three children and everything has changed in my life because of this disease.”
Even now, controlling her blood sugar might have remained beyond her reach if not for the intervention of a doctor she met after being hospitalized in December with a bladder infection.
The doctor, Marco Reynoso, is a rare visionary in Mexico’s vast and often inept public health system. An internal medicine specialist, Dr. Reynoso, 49, has intervened in the lives of the scores of working-class diabetics who pass through the Mexican government’s Darío Fernández Fierro General Hospital.
For 23 years, Dr. Reynoso has counseled diabetics like Ms. Sánchez, imploring them to invest in blood sugar meters and keep meticulous daily charts of their levels. He also runs educational courses and fairs for diabetics at the hospital, though he receives no resources or extra pay for his efforts and sometimes has to hold his classes in the hallways.
“We need to re-educate people and reform their habits, particularly their food and exercise plans,” he said. “It’s easy to control diabetes, and not that expensive, yet the disease so often becomes problematic.”
Diabetes is Mexico’s leading cause of death, with 138 deaths per 100,000 adults aged 20 to 84 in 2000, compared with 82 per 100,000 in the United States, according to data from the National Institute of Geographic and Statistical Information. And the prevalence rate here is among the world’s highest — 10.7 percent among adults aged 20 to 69.
The Mexican Diabetes Federation estimates that 6.5 million to 10 million Mexicans have diabetes, and that 2 million of those cases have not been diagnosed. Only 10 percent of diabetics have blood sugar meters and are in good control of their disease, the federation said.
According to a 2003 study by the World Health Organization, the total combined annual direct and indirect costs associated with diabetes in Latin America and the Caribbean in 2000 were estimated at $65.2 billion. In Mexico, direct and indirect costs were $15.1 billion.
Diabetes is also impoverishing families at the household level. According to the International Diabetes Federation, families in Latin America pay 40 percent to 60 percent of the cost of diabetes care from their own pockets. In Mexico, where medical care is financed by an amalgam of public and private sources, half the population is uninsured.
“When diabetics in their 40s and 50s have complications like foot problems or congestive heart failure, they’re going to be less productive and their families may go bankrupt taking care of them,” said Jonathan Brown, a health economist and a senior investigator at the Kaiser Permanente Center for Health Research. “Instead of the money going toward raising the kids, it goes toward taking care of the parents.”
Ms. Sánchez, whose husband died several years ago, has three children. Though she has government-paid health insurance, thanks to her former job as a janitor for a state university, she must pay out of pocket for her monitor and some of her medicine, all of which come to about $200 a month.
While her insurance should cover her insulin, it was out of stock at the hospital pharmacy one recent week, so she had to go to a private drugstore and buy it with her own money. And her insurance does not cover the lancets she uses to prick her finger to draw blood, the blood test strips, the syringes to inject insulin, the rubbing alcohol or the cotton swabs. “It’s very hard economically,” she said.
One remedy, experts say, is self-management education, which teaches diabetics how to regulate their blood sugar levels, avoid complications and keep costs down.
Ms. Sánchez said that in her 10 years with the disease, she rarely received practical advice on what to eat and how to monitor her blood sugar levels.
“I was told to take my pills and not eat so much bread and tortillas, that was all,” she said. “They never told me my levels were far too high, and never explained the risks of complications. I would have taken better care of myself and eaten less had I known what would happen to me.”
Dr. Reynoso’s educational approach is tailored for people with resources stretched thin: he understands they cannot join a gym, so he gives them tips on how to exercise at work. And he advises them on how to find affordable ingredients to prepare low-fat, sugar-free meals.
Mexico’s state-run health institutions are developing educational programs for diabetics.
“Mexico is making an effort to improve quality of care and educational programs for diabetics,” said Alberto Barceló, regional adviser for the Pan-American Health Organization’s noncommunicable diseases unit. “There is a lot of effort from the government to prioritize the disease, especially compared with other countries in Latin America.”
But Enrique Manero, executive director of the Mexican Diabetes Federation, says that fewer than 10 percent of Mexican diabetics are receiving self-management education.
“Many people don’t know the resources exist, but others don’t attend the workshops because of indolence or indifference,” Mr. Manero said. “They hear about the complications but don’t think they will happen to them.”
Ms. Sánchez says she will attend Dr. Reynoso’s diabetes course once her feet improve. And once she can maintain her blood sugar levels over the long term, her costs should go down.
“For now I can’t buy my children shoes or books because the medications are so expensive,” Ms. Sánchez said. “But I want to get better and I want to work again.”
Diabetes: the cost of diabetes
As the number of people with diabetes grows worldwide, the disease takes an ever-increasing proportion of national health care budgets. Without primary prevention, the diabetes epidemic will continue to grow. Even worse, diabetes is projected to become one of the world’s main disablers and killers within the next twenty-five years. Immediate action is needed to stem the tide of diabetes and to introduce cost-effective treatment strategies to reverse this trend.
Diabetes: the size of the problem
A diabetes epidemic is underway. An estimated 30 million people world-wide had diabetes in 1985. By 1995, this number had shot up to 135 million. The latest WHO estimate (for the number of people with diabetes, world-wide, in 2000) is 177 million. This will increase to at least 300 million by 2025. The number of deaths attributed to diabetes was previously estimated at just over 800,000. However, it has long been known that the number of deaths related to diabetes is considerably underestimated. A more plausible figure is likely to be around 4 million deaths per year related to the presence of the disorder. This is about 9% of the global total. Many of these diabetes related deaths are from cardiovascular complications. Most of them are premature deaths when the people concerned are economically contributing to society. This situation is increasingly outstretching the health-care resources devoted to diabetes.
For WHO and the International Diabetes Federation (IDF), sponsors of World Diabetes Day, this increase can and must be prevented with the right measures.
What are the costs of diabetes?
Because of its chronic nature, the severity of its complications and the means required to control them, diabetes is a costly disease, not only for the affected individual and his/her family, but also for the health authorities.
Studies in India estimate that, for a low-income Indian family with an adult with diabetes, as much as 25% of family income may be devoted to diabetes care. For families in the USA with a child who has diabetes, the corresponding figure is 10%.
The total health care costs of a person with diabetes in the USA are between twice and three times those for people without the condition. It was calculated, for example, that the cost of treating diabetes in the USA in 1997 was US$ 44 billion.
In WHO’s Western Pacific region a recent analysis of health care expenditure has shown that: 16% of hospital expenditure was on people with diabetes. In the Republic of the Marshall Islands, this figure was 25%. 20% of “offshore expenditure” on health by Fiji was on diabetes related complications – instances where facilities for care were not available in Fiji, so patients had to travel elsewhere. These represent considerable sums for countries who can ill afford such massive expenditure on preventable conditions. The costs of diabetes affect everyone, everywhere, but they are not only a financial problem. Intangible costs (pain, anxiety, inconvenience and generally lower quality of life etc.) also have great impact on the lives of patients and their families and are the most difficult to quantify.
The costs of diabetes affect everyone, everywhere, but they are not only a financial problem. Intangible costs (pain, anxiety, inconvenience and generally lower quality of life etc.) also have great impact on the lives of patients and their families and are the most difficult to quantify.
Direct costs to individuals and their families include medical care, drugs, insulin and other supplies. Patients may also have to bear other personal costs, such as increased payments for health, life and automobile insurance.
Direct costs to the healthcare sector include hospital services, physician services, lab tests and the daily management of diabetes – which includes availability of products such as insulin, syringes, oral hypoglycaemic agents and blood-testing equipment. Costs range from relatively low-cost items, such as primary-care consultations and hospital outpatient episodes, to very high-cost items, such as long hospital inpatient stays for the treatment of complications.
Recent cost estimates, denied by similar methods to that quoted above for the USA, include those for Brazil (US$ 3.9 billion), Argentina (US$ 0.8 billion) and Mexico (US$ 2.0 billion). Each of these is an annual figure and is rising as diabetes prevalence increases. Overall, direct health care costs of diabetes range from 2.5% to 15% annual health care budgets, depending on local diabetes prevalence and the sophistication of the treatment available.
For most countries, the largest single item of diabetes expenditure is hospital admissions for the treatment of long-term complications, such as heart disease and stroke, kidney failure and foot problems. Many of those are potentially preventable given prompt diagnosis of diabetes, effective patient and professional education and comprehensive long term care.
Costs of lost production (“indirect costs”)
A number of diabetes patients may not be able to continue working or work as effectively as they could before the onset of their condition.
Sickness, absence, disability, premature retirement or premature mortality can cause loss of productivity.
Estimating the cost to society of this loss of productivity is not easy. However, in many cases where estimates have been made, these costs of lost production may be as great or even greater than direct health care costs. For example, the US estimate of direct costs of US$ 44 billion mentioned above needs to be set against an estimated US$ 54 billion of loss of productivity during the same year (1997). Combining the cost estimates for 25 Latin American countries suggests that costs of lost production may be as much as five times the direct health care cost. This may be because there is limited access to high quality care with, consequently, a high incidence of complications, disability and premature mortality. Families too, of course, suffer loss of earnings as a result of diabetes and its consequences.
Pain, anxiety, inconvenience and other factors which decrease quality of life are intangible costs, which are just as heavy. Some activities may have to be foregone in favour of treatment, discrimination may be experienced in the workplace, obtaining jobs may be more difficult, and professional life may be shortened because of complications leading to early disability and even death.
Personal relationships, leisure and mobility can also be negatively influenced. Diabetes treatment, particularly insulin injection and self-monitoring, can be time-consuming, inconvenient and uncomfortable.
Prevention and diabetes:
Effective prevention also means more cost-effective healthcare. This may be the prevention of the onset of diabetes itself (primary prevention) or the prevention of its immediate and longer-term consequences (secondary prevention).
Primary prevention protects susceptible individuals from developing diabetes. It has an impact by reducing or delaying both the need for diabetes care and the need to treat diabetes complications. Reliable examples of this measure come from studies undertaken among susceptible groups in China. Lifestyle modifications (appropriate diet and increased physical activity and a consequent reduction of weight), supported by a continuous education programme, were used to achieve a reduction of almost two-thirds in the progression to diabetes over a six-year period. This type of measure is not easy, but is likely to be cost effective if it can be implemented on a population scale. It should be considered particularly in the poorest regions of the world where resources are severely limited. Similar results have also been achieved recently in Finland and the USA.
Such preventive measures will have benefits above and beyond diabetes since improvements in diet and day-to-day physical activity will reduce obesity, cardiovascular disease and some cancers.
Secondary prevention includes early detection, prevention and treatment. Appropriate action taken at the right time is beneficial in terms of quality of life, and is cost-effective, especially if it can prevent hospital admission.
Secondary prevention measures:
The treatment of high blood pressure and raised blood lipids, as well as the control of blood glucose levels, can substantially reduce the risk of developing complications and slow their progression in all types of diabetes.
Another cost-saving strategy is the prevention of foot ulceration and amputation. Effective foot-care reduces both the frequency and length of hospital stays and the incidence of amputation in diabetes patients by as much as 50%.
Screening and early treatment for retinopathy is also very cost-effective, given the devastating direct, indirect and intangible costs of blindness.
Screening for protein in urine is another valid preventive measure to prevent or slow down the inevitable progression to kidney failure. Furthermore, there is evidence that screening for traces of protein is cost saving, as it allows even earlier intervention in the natural course of kidney disease.
Measures to reduce the consumption of tobacco will also assist in the management of diabetes. Cigarette smoking has been found to be associated with poor control of blood glucose and it is also strongly causally related to hypertension and heart disease in people with diabetes as well as those without.
WHO and IDF are committed to working for access to high quality health care for people with diabetes wherever they live and for primary prevention to reduce the impact of diabetes and its complications in the future