Diabetes mellitus
Prevention and Control
Mauritian studies
Summary of Discussions
Seminar
held on
at the
Organised by
Association of Biomedical Analysts
in
collaboration with
Ministry of Health and Quality of
Life
and
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Diabetes
mellitus Prevention and Control:
Mauritian Studies |
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Venue: |
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Programme |
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Time |
Details |
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Registration of participants |
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Opening Ceremony: Welcome Address:
Prof S Bhoojedhur, Address : Mr A Seeburuth,
President, Association of Biomedical Analysts Opening
Speech: The Hon. A Jugnauth,
Minister of Health & Quality of Life |
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Tea/Coffee Break
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Search for the genetic
factors underlying susceptibility to the metabolic syndrome (Dr (Mrs) M Manraj, Department of
Medicine, |
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HbA1c and Hb variants (Mrs N Joonas, Central Laboratory) |
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The role of anaerobes and defensin in the
diabetic foot (Mrs R Jauhangeer, |
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Panel Discussion Panelists: Dr
C N Bissoonauthsing, Liaison Officer, WHO Mauritius Office Dr
S Manraj, Consultant Pathologist,
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Lunch
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Use of glycated
haemoglobulin as a glycaemic index of diabetic patients (Mr H Ramuth,
Association of Biomedical Analysts) |
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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) |
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New trends in the
management of the diabetic patients (Dr K Pauvaday, J |
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Mauritian Diet for diabetes patients (Ms R
Dhookhun, Dietician) |
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Care of the diabetic patient (Mrs R Balloo,
NovoCare) |
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Panel Discussion and
Recommendations Panelists: Dr
C D Bundhun, Consultant Medical Specialist, Mrs
S Joganah, Principal Nutrionist, Ministry of Health & Quality of Life Dr
(Mrs) Pathack, NCD Coordinator, |
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Tea/Coffee Break
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Type
2 diabetes or Metabolic Syndrome, or both?
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:
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
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Dr Manraj started by asking the question: Why do young people have
these problems?
It was explained that in
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
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:
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.
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:
The
presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt4.pdf
A short
summary of the previous presentations was made. It was agreed that carrying
research in
Some of
the types of research that needs to be carried out were discussed, including:
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 (
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
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
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
This
presentation addressed the following issues:
The
presentation can be downloaded from the MRC website at www.mrc.org.mu/Documents/DPpt7.pdf
Ms
Dookhun commented on the extent of poor diabetic control in
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
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
At the
conclusion of this one-day seminar, recommendations made were to: