World Report
Russia’s gaps in diabetes control The incidence of diabetes is increasing in Russia, and problems with data collection, care, and access to educational programmes are hampering improvements. Fiona Clark reports from Moscow.
www.thelancet.com Vol 385 May 23, 2015
University, isn’t overly concerned. “There are two things affecting the growth rate: the real incidence and the growth of incidence. These days’ diagnostics are better, so we are finding more people. The other thing that affects the figures is that people are living longer. So I’d say the incidence we’re seeing is generally about the same as Europe.”
“...public health campaigns have been introduced to encourage a healthier lifestyle...” And although statistics show there has been a rise in the prevalence of type 1 diabetes, Fadeyev believes it too is attributed to better longevity and the reclassification of some patients from type 2 to type 1. “There is no real increase in incidence in type 1”, he says.
Education centres One thing that has changed, according to Marina Kalashnikova, assistant professor of endocrinology at the IM Sechenov First Moscow State Medical University, is the age at which people are being diagnosed with type 2 diabetes. Traditionally, people were diagnosed at around 50 years of age or older, but now she says more patients are turning up in their 30s and 40s, and lifestyle is to blame. A 2008 WHO report said 59·8% of Russian adults were overweight and 26·5% were obese. Women were almost twice as likely to be obese than men (32·9% vs 18·6%), which is far higher than the average in 2012 in countries of the Organisation for Economic Co-operation and Development of 15·2% and 15·5%, respectively. Several public health campaigns have been introduced to encourage a healthier lifestyle, including healthy eating guidelines and a fitness scheme
inspired by the young pioneers of Soviet times, which gives a medal to those who can pass a basic fitness test, but there is no current programme that specifically targets diabetes awareness and prevention. Under the Federal Targeted Program, which ended almost a decade ago, more than 1000 education centres were set up across Russia to help educate people with diabetes as well as 150 foot, 100 ophthalmology, and 20 dialysis clinics. Fadeyev believes that any “motivated person” can find a programme. Mamaev says that might be the case in very large cities but in his home town of 1·2 million, access to classes isn’t easy. “There is no education for adults. If you’re under 16, yes, but if you’re over 16 there is no information for you. You can make a request [for a class]…but you need 20 or so people and that can take time to organise.” But when they are available they can be quite effective. A 1997 study of two education centres (Kransnogorsk and Balashika) showed that 12 months after the programme, glycaemic control improved from an average fasting plasma glucose of 11·3 to 8·7 mmol/L in Kransnogorsk and both towns also experienced a substantial
For the DAWN 2 study see http://www. changingdiabetesbarometer. com/docs/dawn/DAWN2%20 CP%20Russia_Eng.pdf For the Novo Nordisk report see http://annualreport2009. novonordisk.com/web-media/ pdfs/Novo-Nordisk-AR-2009en.pdf
Ullstein bild/Contributor
The scars on Danny Mamaev’s head are a lasting testament to the vagaries of insulin supply in Russia today. Patients can usually get the drug, but getting a continuous supply of the brand you’ve been prescribed is the problem. “The pharmacist will tell you they’ve run out of your brand and they won’t have any more for another 2 months and they’ll offer you a cheaper version. And of course you have to take it, but every time you change brands it’s difficult to maintain your glycaemic control. Twice I’ve ended up with holes in my head from passing out and woken up in a pool of blood”, he says. Now in his 30s Danny is the founder of Moi Diabet (My Diabetes), a patients’ advocacy and support group based in Nizhny Novgorod, 400 km east of Moscow. He has type 1 diabetes, as did his father, who died of a heart attack when Danny was a child. According to the State Register of Diabetic Patients, Danny was one of 9·6 million Russian’s with diabetes in 2013, but the 2012 DAWN 2 study puts the figure at around 12·7 million. There are two main reasons for the discrepancy: many people might have the disorder but aren’t yet diagnosed and because the register itself is still relatively new, set up in 2002 as part of a Federal Targeted Program to tackle diabetes, it may not yet have all the statistics from across the country. The result is that, on paper, Russia’s rate of diabetes isn’t that bad. Prevalence is 6·2%, which is below the European average of 8·5%, but the number of cases is growing rapidly. The global average growth rate is 2·7% per year but in Russia it is more than 6%. Valentin Fadeyev, affiliated president of the Federal Research Centre of Endocrinology and head of the endocrinology department at the IM Sechenov First Moscow Medical
Unhealthy lifestyle habits have driven up obesity rates in Russia
2033
Photoagency Interpress/Global Look/Corbis
World Report
A World Diabetes Day 2013 event in Saint Petersburg, Russia
drop in the number of days spent in hospital, down from 2170 and 2176, respectively, to 460 and 523. The DAWN 2 study showed that of the 910 Russians surveyed (507 with diabetes, 120 family members, and 283 health-care professionals), 37% of those with diabetes had been educated about it, 22% below the median of other countries surveyed. The courses are usually presented by endocrinologists but “there simply aren’t enough of us”, Fadeyev says, and while there is a push to encourage primary care physicians to take a greater role in diabetes care, they are reluctant to do so. “They don’t want to do it, but we have to develop this step as it could solve many problems”, he says. But ensuring they’re up to scratch is another challenge. “I work in the university and there are many aspects of concern about the quality and quantity of staff and their education, especially at this first level of care. Patients, by the time they get to my clinic, have so many problems that could have been solved much earlier if they’d received proper information at the first step of care”, he says. Hypertension and cholesterol are two examples he cites as not well managed, resulting in poorly controlled comorbidities and premature death.
Lost in translation According to Kalashnikova’s 2014 study of almost 50 000 people in Moscow with diabetes, the mortality 2034
rate from diabetes in Russia is quite low at 5·4 per 100 000 people, but it is severely underestimated. The reason? An incorrect translation of WHO’s International Classification of Diseases, which said primary causes of death “should be accepted” as opposed to “must be accepted”. Because of this error, deaths that should have been recorded as diabetes were marked down as strokes or heart attacks. One area of improvement has been in foot care. The 2009 annual report by health-care company Novo Nordisk said 22 000 amputations were done but Kalashnikova says the number is declining annually. Among the Moscow cohort less than 1% had a limb amputated.
“...it’s very difficult to convince people to change the habits of a lifetime, especially if they don’t feel sick.” Unfortunately, this decrease hasn’t resulted in more free time for Vitaly Tsvetkov, professor of surgery at the First Moscow Medical University, but he has noticed two differences: these days he sees only the most serious cases—those with acute infection or severe complications, and, the number of above-the-knee amputations has substantially decreased. “When I finished university, gangrene of the toes in diabetic patients would in most cases have resulted in an above the knee amputation. That was 30 years ago. Now there’s been a great improvement in surgical techniques and the only time we’d amputate a diabetic foot above the knee now is if there’s severe ischaemia due to unreconstructable vascular occlusion.” The problem though is that he often sees the same patient twice. “Patients treated for complications go nowhere. They go home and get no support and they forget about what they should be doing and end up back here again…The system of rehabilitation doesn’t work well.” He says that unless patients are handed
from one specialist to another for ongoing care, many fall through the cracks. Kalashnikova adds that there is no system to recall patients for tests, so unless they are self-motivated, they only seek care when they have acute problems. The cost of drugs, glucometers, and testing strips is also an issue for patients. The average cost per type 2 patient for basic hypoglycaemic therapy is about RUB7500 per year. The state subsidises medicines and provides patients with Russian-made glucometers and 720 test strips, enough for two tests per day for a year, but according to Mamaev there are some serious problems with this system. The Russian glucometer, he says, is “dangerous” and Kalashnikova concurs. “You virtually have to chop your hand off”, to get enough blood for a sample Mamaev says. It is also notoriously inaccurate. He says suits have been brought against the manufacturers. He adds that getting clinics to dispense the 720 test strips is also a challenge, with staff saying they’ve never heard of the ruling. Sometimes, he says, patients have brought police into the clinic to get them. The result is that glycaemic control isn’t the best, but it is improving. In 2008, 75% of patients weren’t achieving glycated haemoglobin HbA1c targets of less than 7 mmol/L; the Moscow study puts the figure at 48%. Fadeyev says all diabetes drugs are available in Russia; the Moscow study showed 80% of type 2 patients were prescribed oral hypoglycaemics and 20% received insulin. It also showed that just 1·5% of people were using diet to control their condition. Fadeyev explains that it’s very difficult to convince people to change the habits of a lifetime, especially if they don’t feel sick. He adds that aggressively lowering HbA 1c without getting cholesterol and hypertension under control won’t make a substantial difference to the long-term outcomes.
Fiona Clark www.thelancet.com Vol 385 May 23, 2015
Russia’s gaps in diabetes control The incidence of diabetes is increasing in Russia, and problems with data collection, care, and access to educational programmes are hampering improvements. Fiona Clark reports from Moscow.
www.thelancet.com Vol 385 May 23, 2015
University, isn’t overly concerned. “There are two things affecting the growth rate: the real incidence and the growth of incidence. These days’ diagnostics are better, so we are finding more people. The other thing that affects the figures is that people are living longer. So I’d say the incidence we’re seeing is generally about the same as Europe.”
“...public health campaigns have been introduced to encourage a healthier lifestyle...” And although statistics show there has been a rise in the prevalence of type 1 diabetes, Fadeyev believes it too is attributed to better longevity and the reclassification of some patients from type 2 to type 1. “There is no real increase in incidence in type 1”, he says.
Education centres One thing that has changed, according to Marina Kalashnikova, assistant professor of endocrinology at the IM Sechenov First Moscow State Medical University, is the age at which people are being diagnosed with type 2 diabetes. Traditionally, people were diagnosed at around 50 years of age or older, but now she says more patients are turning up in their 30s and 40s, and lifestyle is to blame. A 2008 WHO report said 59·8% of Russian adults were overweight and 26·5% were obese. Women were almost twice as likely to be obese than men (32·9% vs 18·6%), which is far higher than the average in 2012 in countries of the Organisation for Economic Co-operation and Development of 15·2% and 15·5%, respectively. Several public health campaigns have been introduced to encourage a healthier lifestyle, including healthy eating guidelines and a fitness scheme
inspired by the young pioneers of Soviet times, which gives a medal to those who can pass a basic fitness test, but there is no current programme that specifically targets diabetes awareness and prevention. Under the Federal Targeted Program, which ended almost a decade ago, more than 1000 education centres were set up across Russia to help educate people with diabetes as well as 150 foot, 100 ophthalmology, and 20 dialysis clinics. Fadeyev believes that any “motivated person” can find a programme. Mamaev says that might be the case in very large cities but in his home town of 1·2 million, access to classes isn’t easy. “There is no education for adults. If you’re under 16, yes, but if you’re over 16 there is no information for you. You can make a request [for a class]…but you need 20 or so people and that can take time to organise.” But when they are available they can be quite effective. A 1997 study of two education centres (Kransnogorsk and Balashika) showed that 12 months after the programme, glycaemic control improved from an average fasting plasma glucose of 11·3 to 8·7 mmol/L in Kransnogorsk and both towns also experienced a substantial
For the DAWN 2 study see http://www. changingdiabetesbarometer. com/docs/dawn/DAWN2%20 CP%20Russia_Eng.pdf For the Novo Nordisk report see http://annualreport2009. novonordisk.com/web-media/ pdfs/Novo-Nordisk-AR-2009en.pdf
Ullstein bild/Contributor
The scars on Danny Mamaev’s head are a lasting testament to the vagaries of insulin supply in Russia today. Patients can usually get the drug, but getting a continuous supply of the brand you’ve been prescribed is the problem. “The pharmacist will tell you they’ve run out of your brand and they won’t have any more for another 2 months and they’ll offer you a cheaper version. And of course you have to take it, but every time you change brands it’s difficult to maintain your glycaemic control. Twice I’ve ended up with holes in my head from passing out and woken up in a pool of blood”, he says. Now in his 30s Danny is the founder of Moi Diabet (My Diabetes), a patients’ advocacy and support group based in Nizhny Novgorod, 400 km east of Moscow. He has type 1 diabetes, as did his father, who died of a heart attack when Danny was a child. According to the State Register of Diabetic Patients, Danny was one of 9·6 million Russian’s with diabetes in 2013, but the 2012 DAWN 2 study puts the figure at around 12·7 million. There are two main reasons for the discrepancy: many people might have the disorder but aren’t yet diagnosed and because the register itself is still relatively new, set up in 2002 as part of a Federal Targeted Program to tackle diabetes, it may not yet have all the statistics from across the country. The result is that, on paper, Russia’s rate of diabetes isn’t that bad. Prevalence is 6·2%, which is below the European average of 8·5%, but the number of cases is growing rapidly. The global average growth rate is 2·7% per year but in Russia it is more than 6%. Valentin Fadeyev, affiliated president of the Federal Research Centre of Endocrinology and head of the endocrinology department at the IM Sechenov First Moscow Medical
Unhealthy lifestyle habits have driven up obesity rates in Russia
2033
Photoagency Interpress/Global Look/Corbis
World Report
A World Diabetes Day 2013 event in Saint Petersburg, Russia
drop in the number of days spent in hospital, down from 2170 and 2176, respectively, to 460 and 523. The DAWN 2 study showed that of the 910 Russians surveyed (507 with diabetes, 120 family members, and 283 health-care professionals), 37% of those with diabetes had been educated about it, 22% below the median of other countries surveyed. The courses are usually presented by endocrinologists but “there simply aren’t enough of us”, Fadeyev says, and while there is a push to encourage primary care physicians to take a greater role in diabetes care, they are reluctant to do so. “They don’t want to do it, but we have to develop this step as it could solve many problems”, he says. But ensuring they’re up to scratch is another challenge. “I work in the university and there are many aspects of concern about the quality and quantity of staff and their education, especially at this first level of care. Patients, by the time they get to my clinic, have so many problems that could have been solved much earlier if they’d received proper information at the first step of care”, he says. Hypertension and cholesterol are two examples he cites as not well managed, resulting in poorly controlled comorbidities and premature death.
Lost in translation According to Kalashnikova’s 2014 study of almost 50 000 people in Moscow with diabetes, the mortality 2034
rate from diabetes in Russia is quite low at 5·4 per 100 000 people, but it is severely underestimated. The reason? An incorrect translation of WHO’s International Classification of Diseases, which said primary causes of death “should be accepted” as opposed to “must be accepted”. Because of this error, deaths that should have been recorded as diabetes were marked down as strokes or heart attacks. One area of improvement has been in foot care. The 2009 annual report by health-care company Novo Nordisk said 22 000 amputations were done but Kalashnikova says the number is declining annually. Among the Moscow cohort less than 1% had a limb amputated.
“...it’s very difficult to convince people to change the habits of a lifetime, especially if they don’t feel sick.” Unfortunately, this decrease hasn’t resulted in more free time for Vitaly Tsvetkov, professor of surgery at the First Moscow Medical University, but he has noticed two differences: these days he sees only the most serious cases—those with acute infection or severe complications, and, the number of above-the-knee amputations has substantially decreased. “When I finished university, gangrene of the toes in diabetic patients would in most cases have resulted in an above the knee amputation. That was 30 years ago. Now there’s been a great improvement in surgical techniques and the only time we’d amputate a diabetic foot above the knee now is if there’s severe ischaemia due to unreconstructable vascular occlusion.” The problem though is that he often sees the same patient twice. “Patients treated for complications go nowhere. They go home and get no support and they forget about what they should be doing and end up back here again…The system of rehabilitation doesn’t work well.” He says that unless patients are handed
from one specialist to another for ongoing care, many fall through the cracks. Kalashnikova adds that there is no system to recall patients for tests, so unless they are self-motivated, they only seek care when they have acute problems. The cost of drugs, glucometers, and testing strips is also an issue for patients. The average cost per type 2 patient for basic hypoglycaemic therapy is about RUB7500 per year. The state subsidises medicines and provides patients with Russian-made glucometers and 720 test strips, enough for two tests per day for a year, but according to Mamaev there are some serious problems with this system. The Russian glucometer, he says, is “dangerous” and Kalashnikova concurs. “You virtually have to chop your hand off”, to get enough blood for a sample Mamaev says. It is also notoriously inaccurate. He says suits have been brought against the manufacturers. He adds that getting clinics to dispense the 720 test strips is also a challenge, with staff saying they’ve never heard of the ruling. Sometimes, he says, patients have brought police into the clinic to get them. The result is that glycaemic control isn’t the best, but it is improving. In 2008, 75% of patients weren’t achieving glycated haemoglobin HbA1c targets of less than 7 mmol/L; the Moscow study puts the figure at 48%. Fadeyev says all diabetes drugs are available in Russia; the Moscow study showed 80% of type 2 patients were prescribed oral hypoglycaemics and 20% received insulin. It also showed that just 1·5% of people were using diet to control their condition. Fadeyev explains that it’s very difficult to convince people to change the habits of a lifetime, especially if they don’t feel sick. He adds that aggressively lowering HbA 1c without getting cholesterol and hypertension under control won’t make a substantial difference to the long-term outcomes.
Fiona Clark www.thelancet.com Vol 385 May 23, 2015
