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Diabetes mellitus – Prevention and Control

Mauritian studies

 

 

 

 

Summary of Discussions

 

Seminar held on 18 January 2005

at the

Mauritius Research Council

 

 

Organised by

 

Association of Biomedical Analysts

in collaboration with

Ministry of Health and Quality of Life

and

Mauritius Research Council

 

                       

Title:

Diabetes mellitus – Prevention and Control:  Mauritian Studies

Venue:

Mauritius Research Council

Date:

Tuesday 18th January 2005

 

 

Programme

Time

Details

09:00 – 09:30

Registration of participants

09:30 – 10:15

Opening Ceremony:

Welcome Address:       Prof S Bhoojedhur, Chairman, Mauritius Research Council

Address           :                       Mr A Seeburuth, President, Association of Biomedical                                                 Analysts

Opening Speech:         The Hon. A Jugnauth, Minister of Health & Quality of Life

10:15 – 10:30

Tea/Coffee Break

10:30 – 10:55

Mauritius:  Type 2 diabetes or Metabolic Syndrome or both? (Dr F Hemraj, Central Laboratory)

10:55 – 11:15

Search for the genetic factors underlying susceptibility to the metabolic syndrome  (Dr (Mrs) M Manraj, Department of Medicine, University of Mauritius)

11:15 – 11:35

HbA1c and Hb variants  (Mrs N Joonas, Central Laboratory)

11:35 – 12:00

The role of anaerobes and defensin in the diabetic foot (Mrs R Jauhangeer, University of Westminster, UK)

12:00 – 13:00

Panel Discussion

Panelists:         Dr C N Bissoonauthsing, Liaison Officer, WHO Mauritius Office

                        Dr S Manraj, Consultant Pathologist, Victoria Hospital

13:00 – 13:45

Lunch

13:45 – 14:05

Use of glycated haemoglobulin as a glycaemic index of diabetic patients (Mr H Ramuth, Association of Biomedical Analysts)

14:05 – 14:20

Assessment of a semi-quantitative dry immunochemical screening method to detect low levels of urinary albumin in diabetics (Mr A Seeburuth, Association of Biomedical Analysts)

14:20 – 14:45

New trends in the management of the diabetic patients (Dr K Pauvaday, J Nehru Hospital)

14:45 – 15:10

Mauritian Diet for diabetes patients (Ms R Dhookhun, Dietician)

15:10 – 15:35

Care of the diabetic patient (Mrs R Balloo, NovoCare)

15:35 – 16:00

Panel Discussion and Recommendations

Panelists:         Dr C D Bundhun, Consultant Medical Specialist, Victoria Hospital

                        Mrs S Joganah, Principal Nutrionist, Ministry of Health & Quality of Life

                        Dr (Mrs) Pathack, NCD Coordinator, Victoria Hospital

16:00

Tea/Coffee Break

 

 

Morning sessions                                                                                         

 

Type 2 diabetes or Metabolic Syndrome, or both?

 

Dr F Hemraj

 

Dr Hemraj introduced his topic and described diabetes in terms of a chronic and progressive disease. Definitions were given with regard to Type 1 and Type 2 diabetes.

 

Type I diabetes was described as being chronic, consisting of groups of disorders, which contribute to an increase in blood sugar level.

 

In the case of Type 2 diabetes, it was explained that cells cannot respond, and this is accompanied by complications in the kidneys and nerves. The metabolism is also affected. The hallmark of Type 2 diabetes is typically an increase of blood sugar level.

 

Some of the underlying factors involved in diabetes were discussed, including:

 

  • Hormonal problems (insulin)
  • The prevalence: 60% of the population is affected
  • Pancreas destroyed by own cells
  • Insulin not enough
  • Insulin tolerance – resistance of cells to the action of insulin
  • Other substances that contribute to offering resistance to the action of insulin
  • Other conditions
  • Accompanying risk factors
  • Complications

 

It was explained that gaining of weight leads to obesity and insulin resistance. There is an increased tendency for people to go for fast food. Together with lack of exercise, there is growing concern for both young and elderly people.

 

The general background of research carried out to help in detecting the Metabolic Syndrome (MS) was discussed. The challenge posed by screening for MS was explained, drawing attention to the some of the underlying variables, namely impaired glucose tolerance (IGT), central metabolism and blood pressure. The inclusion of genetic abnormalities in relation to fat metabolism as a further variable was also discussed. The general sequence of Type 2 diabetes preceded by MS, which is itself preceded by endothelial dysfunction, was explained.

 

Dr Hemraj also elaborated on various aspects involving retinopathy, inflammation, prevention strategies targeting b-cells, and methods of treatment being introduced.

 

The presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt1.pdf

 

 

Search for genetic factors underlying susceptibility to the metabolic syndrome (a common factor to Type 2 diabetes and to premature coronary heart disease) in Mauritius

.

 

Dr (Mrs) M D Manraj

 

Dr Manraj started by asking the question: Why do young people have these problems?

 

It was explained that in Mauritius, the population is drawn from people originating from different parts of India, Africa and Europe.

 

Several factors leading to complex diseases in the population were mentioned, for example ageing, genetic factors that determine susceptibility, and environmental factors (e.g., lifestyle).

 

Dr Manraj indicated that genetic studies are usually carried out by comparing the DNA between groups of affected patients with groups of healthy individuals.  Further family studies are carried out by comparing the DNA from family members.  The study being described during this presentation was designed to verify whether the candidate genes studied contribute to Type 2 diabetes and premature coronary heart disease. Chromosomal defects and markers located near the disease genes also had to be found, including the phenotypic traits and the ranking of families according to their mean Body Mass Index (BMI) and lipid values.

 

It was also explained that chromosome 8 indicates coronary heart disease, high blood pressure and Type 2 diabetes.  The chromosomal 8q23 region was clearly elaborated and was found particularly interesting as microsatellite markers.  The gene encoding oxidation resistance-1 (OXR-1) maps to 8q23 functions associated with protection against oxidative damage. Oxidative stress has been shown to precede the development of endothelial dysfunction and insulin resistance. 

 

The presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt2.pdf

 

 

HbA1c and haemoglobin variants.

 

Miss N Joonas

 

Miss Joonas explained that problems associated with control of diabetes affect around 60% of the population. She added that HbA1c constitutes one of the main markers used to monitor diabetic status and the control of diabetes over time, and that measurement of HbA1c is currently an established procedure in many countries.

 

The mechanism of the glycosylation process was described briefly, together with an explanation of some of the terms involved (e.g., labile linkage, reversible reaction, rearrangement reaction).

 

Reference was made to the Diabetes Control and Complications Trial (DCCT) and UK Prospective Diabetes Study (UKPDS), conducted over periods of 9 and 20 years, respectively.  They included the measurement of HbA1c, which is used as an estimation of glycemic control.  Reference was also made regarding work done for the estimation of haemoglobinopathies.  It was mentioned that there is an increase in the number of haemoglobinopathies, and that many haemoglobin variants are due to point mutations in the b-chain.

 

The importance of having in place methods for the control of hypoglycaemia was discussed.  It was explained that methods that are susceptible to interference by variants (e.g., sickle cells) can be unreliable.  In the case of the Mauritian population, it was mentioned that further investigations need to be carried out in this area.

 

Some of the methods used to measure glycated haemoglobin were discussed:

  • Ion exchange chromatography
  • Affinity chromatography and immunoassay
  • Spectrophotometry

It was explained that as a reference, measurement of HbA1c using high performance liquid chromatography (HPLC) is used.

 

The presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt3.pdf

 

 

The role of anaerobes and defensin in the diabetic foot.

 

 

Rehana Jauhangeer

 

Mrs Jauhangeer commented about the role of anaerobes and defensin in the diabetic foot.  It was explained that together with the diabetic foot, there can be several related problems.  Complication of the disease can lead to amputation. Foot ulcers are also found due to neuropathy.  There is an indication that the majority of those affected are male, and since most patients are poorly controlled this leads to a proportionately larger number of male diabetics with neuropathy.

 

Details regarding defensin, which forms part of a major family of antimicrobial peptides, were provided.  Defensin is used as a barrier to bacteria in the case of wounds. However, in diabetic patients there is a defect in defensin production, which results from a defect in the gene itself. Illustrations were provided describing the mode of action of defensin and the role of antimicrobial peptides. 

 

A list of what is currently being done to alleviate problems associated with the diabetic foot was given, and includes:

 

  • Patient education at the diabetic clinic
  • Wound treatment at the ward and surgery
  • Wound treatment at the Area Health Centres (AHCs) and Community Health Centres (CHCs)
  • Hyperbaric oxygen therapy

 

The presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt4.pdf

 

 

 

Panel discussion

 

A short summary of the previous presentations was made. It was agreed that carrying research in Mauritius requires continued support and that efforts should be made to create an enabling environment, especially for biomedical research.

 

Some of the types of research that needs to be carried out were discussed, including:

 

  • Epidemiological research
  • Cost/Benefit research
  • Operational and health services research

 

Issues relating to the benefits that patients currently derive from the public and the private sector were raised. Participants agreed that research should be allowed and encouraged both within the public hospitals and private sector health institutions.

 

More information was requested with regard to the clustering factors mentioned by Dr Hemraj during his presentation. Dr Hemraj explained that Type 2 diabetes does not exist in isolation, but as a cluster of risk factors commonly known as the Metabolic Syndrome (MS). He added that the identification of affected people, as well as those at high risk, is of significant importance.

 

An explanation was given regarding the method of determination of insulin sensitivity, and it was pointed out that projects need to be developed that include the use of reliable laboratory markers to identify people who are affected by MS, as well as those who are not currently affected but at high risk. In this context, it was mentioned that in addition to biochemical markers, physiological parameters related to for example, the fingers, and the neck, should also be considered during the identification process.

 

With regard to work under way at the SSR Resource Centre (University of Mauritius), participants were of the view that in the long run, a diagnostic tool could be defined and adapted for use in the Mauritian context.

 

Mrs Joonas elaborated on HbA1c methodology, the potential interference caused by the presence of variants and why the HPLC approach is recognised as the reference method. It was explained that strong support for the use of HPLC comes from the fact that previous studies, such as the DCCT and UKPDS, have used this approach and demonstrated its validity. It was suggested that future studies in Mauritius would benefit from using the same methods and that this would help towards standardisation of diagnostic testing for diabetes throughout the country. 

 

Dr Gareeboo highlighted some of the main differences between the private and public health sectors.  It was suggested that standardised guidelines should be produced for diabetes, which will then be applied to all Community Health Centres (CHCs). The management of diabetic patients should be improved and better utilisation should be made of the available technical and human resources.

 

Participants were of the opinion that accessibility to appropriate medication is a must for every diabetic individual and remarked that there is a slow on-going improvement in the utilisation of manpower and technical resources. However, it was agreed that better monitoring and evaluation procedures are needed. It was pointed out that data are being collected but are currently not used and analysed properly. It was suggested that the best solutions may not only come through improved biomedical processes, but in combination with social and behavioural research. Participants agreed that diabetes often brings about profound psychological changes and were of the view that some element of support could be made available, probably through referral of patients back to CHCs.

 

The need for good education and counselling was identified as important in strengthening the preventive measures being adopted to combat diabetes in Mauritius. Training and counselling should form part of patient education, especially where a combination of risk factors is present (e.g., obesity, cardiovascular disease, poor lifestyle and eating habits, smoking, excessive alcohol consumption).

 

 

 

Afternoon sessions

 

Glycated molecules as indicators of glycaemic level in diabetics

Mr H Ramuth

 

This presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt5.pdf

 

 

Assessment of a semi-quantitative dry immunochemical screening method to detect low levels of urinary albumin in diabetics

Mr A Seeburuth

 

 

This presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt6.pdf

 

 

Type 2 Diabetes Mellitus – an update

 

 

Dr K Pauvaday

 

This presentation addressed the following issues:

 

  • Current perspectives
  • Mortality and morbidity associated with Type 2 diabetes
  • The way forward
  • Re-organisation of diabetes services
  • Prevention of Type 2 diabetes
  • Metabolic control
  • Screening and management of complications

 

The presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt7.pdf

 

 

Diabetes and dietary education in Mauritius

Ms R Dookhun

 

Ms Dookhun commented on the extent of poor diabetic control in Mauritius and the current practice involving the use of diet sheets for diabetes.  Discussions focused on the control of blood sugar level and the significant role of proper dietary education aimed at facilitating control from the perspective of the diabetic patient.

 

The term Glycaemic Index (GI) was explained in accordance to diabetic control and a definition of GI was given. Diets for diabetic patients were proposed and the balance of these diets according to high, intermediate and low GI was specified.

 

The presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt8.pdf

 

 

Patient-centred diabetes care and education
Mrs R Balloo

 

Mrs Balloo outlined the problems associated with non-adherence to protocol diet, emphasising the psychological aspects of the disease. The reasons for having a diabetes educator were discussed, pointing out that due to the complexity of the disease and its effects, proper planning was needed for their inclusion alongside medical treatment. 

 

It was explained that many people are not aware of the symptoms and that this may be linked to social issues. Participants were reminded that to deal with diabetes, family involvement is essential and that strategies need to be developed and put in place to encourage and support the necessary changes in behaviour that are required to manage the disease effectively.

 

It was remarked that patients undergoing treatment need to be explained about the disease, the treatment possibilities and the expected outcomes, in a language they are familiar with and according to their level of understanding. The term ‘bio-psycho social care’ was discussed.

 

The presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt9.pdf

 

 

Panel discussion and recommendations

 

A summary of the presentations was made. Discussions addressed laboratory-based research, clinical findings and their possible applications, education, physical education, and the importance of prescribed physical exercise. Participants agreed that the wide-ranging implications of the growing incidence of diabetes in Mauritius calls for all stakeholders to join forces and act concertedly.

 

At the conclusion of this one-day seminar, recommendations made were to:

 

  • Encourage more collaboration between stakeholders
  • Promote multi-disciplinary approach to research in diabetes
  • Encourage regular dissemination of information relating to the education and prevention of diabetes and related complications