Issue 52 en

September 2007 Volume 52
Issue 3
G L O B A L
P E R S P E C T I V E S
O N
D I A B E T E S
From child to adult care A role for physiotherapy Access to quality healthcare
Contents
September 2007 Issue 3 Volume 52 I
L G L O B A
E S E C T I V P E R S P
O N
T E S D I A B E
IDF | Promoting diabetes care, prevention and a cure worlwide Diabetes Voice is published quarterly and is also available online at www.diabetesvoice.org Editor-in-Chief Rhys Williams, UK Managing Editor Catherine Regniers catherine@idf.org Editor Tim Nolan tim@idf.org Layout and printing Luc Vandensteene Ex Nihilo, Belgium www.exnihilo.be Advisory group Pablo Aschner, Colombia Ruth Colagiuri, Australia Patricia Fokumlah, Cameroon Attila Jzsef, Hungary Viswanathan Mohan, India All correspondence and advertising enquiries should be addressed to the Managing Editor: International Diabetes Federation Avenue Emile De Mot 19 1000 Brussels Belgium Phone: +32-2-543127 Fax: +32-2-5385114 catherine@idf.org This publication is also available in French, Spanish and Russian.
International Diabetes Federation, 2007 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permission of the International Diabetes Federation (IDF). Requests to reproduce or translate IDF publications should be addressed to the IDF Communications Unit, Avenue Emile De Mot 19, B-1000 Brussels, by fax +32-2-5385114, or by e-mail communications@idf.org.
re lity healthca Access to qua adult care From child to erapy for physioth A role
DIABETES VIEWS
CLINICAL CARE
.......
Preparing for global urbanization 2

Martin Silink
Access to care and information

Rhys Williams
..............
Michle van Vugt, Raph Hamers, Onno Schellekens, Tobias Rinke de Wit, Peter Reiss
Diabetes and HIV/AIDS in subSaharan Africa: the need for sustainable healthcare systems
.........
23
NEWS IN BRIEF
.......................................................................................................................
HEALTH DELIVERY
Insulin pump therapy in children and adolescents: risks and benefits
......................................................
Karin Lange and Thomas Danne 9

DIABETES IN SOCIETY
27
Guideline for the management of post-meal blood glucose
............................
Antonio Ceriello and Stephen Colagiuri
Prevention and management of diabetes: the role of the physiotherapist
The BRIDGES programme: sharing practical solutions and improving outcomes

Jean-Claude Mbanya
...............................
31
12 Sanjay Kalra, Bharti Kalra, Naresh Kumar

................................................................
Christos Bartsocas
From adolescence to adulthood: the transition from child to adult care 15

.................................................................................
Advocating for the rights of people with diabetes in Kyrgyzstan 34

.....................
Svetlana Mamutova
Taking up the struggle to improve care: a journey with diabetes 37

................
The Jaipur Foot: an effective low-cost prosthesis for people with diabetes
Barbara Elster
.......................................................................
18
Shaukat Sadikot, Anant Nigam, Anil Jain
TIDES: meeting diabetes needs in times of crisis

Debbie Jones
...........................................................
40
MEDIA AND EVENTS
Opinions expressed in the articles are those of the authors and do not necessarily represent the views of IDF.
The Public Library of Science: opening access to medical research

Paul Chinnock
.........................................................................................
42
ISSN: 1437-404
International Diabetes Federation, 2007 Cover photo Isopix
September 2007 | Volume 52 | Issue 3
Diabetes views
Preparing for global urbanization

Martin Silink is IDF President. He is Professor of Paediatric Endocrinology at the University of Sydney and the Childrens Hospital in Sydney, Australia. On 14 November 2007, to mark the first UN-observed World Diabetes Day, the Empire State Building in New York will be lit up in blue, the colour of the World Diabetes Day circle logo the global symbol for diabetes. Built as the centrepiece to one of the worlds greatest cities during the Great Depression of the 1930s, the Empire State Building is seen by many as a testament to the resilience and ingenuity of our species. How fitting then, as we approach a defining moment in our species development, that the global call to unite for diabetes should be beamed from such a beacon: some time during the next few months, humankind will complete its transition from a rural to an urban species. The mind boggles at the speed and scale of ongoing urban growth each week, according to the recent UN State of the World Population Report, the number of people living in cities grows by nearly 1 million. This shift will be led by Africa and Asia, which are expected to add 1. billion people to their cities over the next 25 years. The report carries a foreboding message: most countries will not be remotely prepared for the impact of global urbanization. But our societies must prepare and we in the diabetes community have a key role to play. In developing countries, the urban areas already face grave challenges crime, lack of clean water and sanitation, rapidly expanding slums and obesity-driven type 2 diabetes is set to become a huge additional burden to those that could be raised by future growth. Indeed, a new World Bank report (see News in Brief) predicts that within less than a decade, chronic diseases, including diabetes, will be the leading cause of death in developing countries. The report warns that, left unaddressed, the combination of aging populations worldwide and early-onset lifestylerelated non-communicable diseases affecting a growing proportion of people during their most productive years is set to bankrupt already vulnerable national economies. Urban environments represent the global battle ground between health and economic and social development on the one hand, and spiralling death, disability and decline on the other. In the struggle so far, muscle power has lost ground to engine power. A new report from the Institute for European Environmental Policy categorically confirms that the ongoing increase in car ownership in developed countries, which has led to a dramatic decline in walking as a means of transport, is a key factor in the obesity epidemic as well as having a dramatic environmental impact. In Unfit for Purpose: How Car Use Fuels Climate Change and Obesity, it is calculated that returning to pre-car walking habits would play a significant role in stemming the tide of obesity and achieving important reductions in national CO2 emissions. The promotion of walking as a form of transport would be cheaper in economic and human terms than recklessly awaiting the consequences of the obesity epidemic and climate change. However, urban environments largely are not pedestrianfriendly. According to WHO, motor vehicle accidents are the second-leading cause of death for 5- to 29-year-olds worldwide. Therefore, initiatives to increase physical activity must form a part of wide-reaching urban-planning interventions. Indeed, we must prepare to promote and exploit the benefits of urbanization. Not only do cities present poor people with their best hope of escaping poverty, they provide easier access to healthcare and education. This years World Diabetes Day campaign, backed by UN Resolution 1/225, is an unprecedented opportunity to raise awareness among public policy-makers and planners in a range of government departments of the threat from diabetes the biggest epidemic in human history. Our task is to engender the political will that is required for a comprehensive organizational response: the development and implementation of national diabetes prevention plans, as expounded in the IDF Guidelines for the Prevention of Type 2 Diabetes, exploiting opportunities for early screening (easy access to healthcare professionals and pharmacists) that are offered by urban environments, and creating cities that allow people to choose healthful a lifestyle.
Diabetes views
Access to care and information

Rhys Williams is Professor of Clinical Epidemiology at Swansea University, UK. A 200 Diabetes Voice editorial reminded us that access to high-quality diabetes care is a basic human right. In this issue, that right is highlighted by several articles. These deal with access to high-quality basic care; access to appropriate devices (both low- and high-tech); and access to the research information on which high-quality care is based. In places afflicted by natural and man-made disasters hurricanes, wars and the like local health services and, it seems, some international aid agencies, are still unaware of the urgent need to ensure that those affected have access to insulin and other essential diabetes supplies without undue delay. The TIDES initiative, dedicated to improving such access is described here by Debbie Jones. Capitalizing on the work of organizations such as Insulin for Life, and in line with WHOs policy in this field, TIDES looks towards improvement in diabetes emergency settings. In Kyrgyzstan, the lack of access to appropriate diabetes care is the result, not of acute problems, but of chronically inadequate funding within the healthcare sector. This leads to sporadic insulin supplies, accusations that poor-quality insulin delivery systems are being purchased, and the necessity for some people with type 2 diabetes to pay for their oral therapy despite being entitled to free treatment under the public health system. The situation is by no means helped by the apparent failure, as Svetlana Mamutova describes, of the Kyrgyz Ministry of Public Health to officially recognize the Diabetes Association of Kyrgyzstan as a partner in efforts to improve the situation of people with diabetes living in the country. On another continent, access to high-quality basic care, both for people with AIDS/HIV and those developing diabetes and cardiovascular disease as a result of antiretroviral therapy, is likely to be much improved by initiatives such as the Health Insurance Fund described by Michle van Vugt and colleagues. Dutch insurance companies and Dutch multinationals have joined forces with the Dutch Ministry of Development Corporation to launch the Fund and run it in Africa initially for 10 years. One of the most inspirational contributions to this issue describes Pramod Sethi and Ram Chandras work in making available a culturally acceptable lower-limb prosthesis the Jaipur Foot. How foolish to assume that a prosthesis with an integral shoe would be acceptable in cultures where convention and good manners dictate that people remove their shoes before entering a home or religious building! To develop a prosthesis that can be manufactured by local artisans from locally available components and that enables its wearer to fit in to the local scene almost as well as those having intact limbs was a stroke of sheer genius. Access to this technology and to the much more high-tech insulin pump (also featured in this issue) is life-changing for those who can access it. The final issue of access concerns research information about high-quality care. The traditional forum for the publication of scientific research is professional journals with high subscription rates, online access to abstracts only, and, for those who are not already subscribers, a relatively high cost for a reprint of the complete article. This resource, growing in size and potential every day, is inaccessible to many of those working in low-income locations. The Public Library of Science, described here by Paul Chinnock, has set out to make scientific publications freely accessible to those who need them, while maintaining the quality of these publications by rigorous peer review. Furthermore, all articles have a lay summary so that those who are not well-versed in the language of science can understand the gist of what has been done. Medical science has evolved a vocabulary that not only enables researchers to speak to each other with precision but also serves to create a professional cabal from which are excluded those who are not familiar with this vocabulary. This includes the majority of people most likely to benefit directly from that research.
News in brief
Bones help to control weight and metabolism

Researchers have demonstrated for the first time that the skeleton is an endocrine organ which helps control glucose metabolism and weight (Cell 2007; 130: 45-9). Their finding has important repercussions for our understanding of metabolism and may lead to new ways to prevent and manage type 2 diabetes. This discovery suggests that raising levels An international team of scientists working in the USA discovered previously unknown metabolic processes in laboratory mice. It was found that the hormone osteocalcin, which is released in bone-forming cells known as osteoblasts and regulates mineralization, also regulates blood glucose and the deposition of fat. Usually, an increase in insulin secretion is accompanied by a decrease in insulin sensitivity. However, the researchers found of osteocalcin in people with type 2 diabetes might be a promising avenue for treatment, especially given that people with the condition tend to have low levels of the hormone. The researchers are to continue their work in this area by examining the role of osteocalcin in the regulation of blood glucose in people, continuing their investigations into the relationship between the hormone and the development of type 2 diabetes and obesity. that osteocalcin increases both the secretion and sensitivity of insulin, in addition to increasing the number of insulin-producing beta cells and reducing stores of fat. In the study, an upsurge in osteocalcin activity prevented the development of type 2 diabetes and obesity in mice.
IDF is looking to hire a full-time
for its Executive Office in Brussels, Belgium. The person will be responsible for the overall managemen t and coordination of IDF diabetes education projects worldwide. The candidate should be registered by the Professional Board of his or her country as a General Nurse, Die titia n, Pha rma cist, Med ical Doctor, Psychologist or other hea lth professional. Fluency in English is a pre-requisite for the post; any othe r languages would be an asset. A full description of the ideal cand idates profile, responsibilities and duties can be found on the IDF website: www.idf.org/jobs. The closing date for applications is 2 October 2007.
Diabetes Education Manager
New definition helps identify children at risk of metabolic syndrome

IDF has launched a new definition to identify children and adolescents at increased risk of developing type 2 diabetes and cardiovascular disease in later life. The metabolic syndrome is a cluster of risk factors for type 2 diabetes and cardiovascular disease. Its early identification is important to facilitate preventive action. This first simple, unified definition from IDF for children and adolescents is consistent with that available for adults. The new definition is simple and easy to apply in clinical practice. Waist measurement is the main component. Percentiles, rather than absolute values of waist circumference, have been used to For children aged 10 years or older, the metabolic syndrome can be diagnosed with abdominal obesity (using waist circumference percentiles) and the presence of two or more other clinical features (elevated triglycerides, low HDL cholesterol, high blood pressure, increased plasma glucose). Although some of these change as a child grows, the criteria adhere to the absolute values in IDFs adult definition. The exception is that one cut-off is used for HDL cholesterol rather than the sex-specific values for adults. For children older than 1, the IDF adult criteria can be used. compensate for variations in child development and ethnicity. The definition is divided according to age groups: age to 10 years, 10 to 1, and 1 or older. IDF suggests that the metabolic syndrome should not be diagnosed in children younger than 10 years old; a strong message for weight reduction should be delivered for those with abdominal obesity.
News in brief
Poor countries catching up with rich nations in non-communicable diseases

deaths. It warns of the need to adapt healthcare systems to cope with growing numbers of elderly people who will require long-term care and expensive treatment. In Indonesia, for example, private healthcare spending is projected to more than double by 2020, compared to 2005, as its elderly population grows in size, and needs treatment for chronic diseases. However, non-communicable diseases are not restricted to older people and represent an important cause of illness and death among people of working age: 75% of the burden of disability due to non-communicable diseases in low- and middle-income countries occurs among people between A new World Bank report warns that poor countries are catching up with wealthier nations in terms of diabetes, obesity, heart disease, and cancers. It predicts that by 2015, these chronic diseases will be the leading cause of death in developing regions. The report calls for actions to slow down the trend, and to prepare for subsequent heavy demand on healthcare budgets. According to the new report, Public Policy and the Challenge of Chronic Noncommunicable Diseases, rising life expectancy for all age groups, lower fertility rates, better control of infectious diseases, and changing lifestyles with more smoking, unhealthy diets and lack of exercise mean that poor countries face a future in which non-communicable diseases become a major problem. The report calls for the promotion of healthy aging and the avoidance of premature The report suggests a number of strategies to promote healthy aging and avoid premature deaths in low- and middleincome countries. Economic growth and the subsequent increase of incomes can help families to escape the vicious circle of poor health and poverty by reducing their vulnerability to ill-health and give them treatment options when illness occurs. At the same time, risk factors ie smoking, obesity, and high blood pressure must be reduced throughout societies either through legislation, such as cigarette taxes or mandatory nutrition labelling, or by providing education and facilities for behaviour change relating to diet and exercise, for example. The report also recommends screening for non-communicable diseases during normal medical check-ups, and the provision of timely treatment. the ages of 15 and 9 years at the peak of economic productivity.
Stem cell researchers find almost perfect human match in mice
In two separate studies in the UK, scientists recently found an embryonic stem cell in mice which is a near-perfect match for human cells. It is hoped that the discovery will accelerate research into chronic conditions such as diabetes, Parkinsons and Alzheimers disease. Stem cells taken from an early-stage embryo (the blastocyst) have the potential to develop into almost any kind of body tissue. While embryonic stem cells from mice are widely used as models, these differ markedly from human embryonic stem cells. Researchers at Cambridge University took stem cells from mouse embryos at a later stage in their development (Nature 2007; 448: 191-5). These epiblast stem cells had many of the properties of human embryonic stem cells. A separate team at Oxford University made similar findings (Nature 2007; 448: 19-9). The researchers commented that obtaining embryonic stem cells from rodents instead of humans could speed up research because they would be easier to remove and their use would be less controversial.
News in brief
Vitamin deficiency could cause diabetes complications

According to new research, a deficiency of vitamin B1 (thiamine) in people with diabetes could increase the risk of severe complications such as heart disease, eye damage and kidney disease (Diabetologia 2007 [Epub ahead of print]). Researchers in the UK used a newly developed method to test accurately for levels of vitamin B1 by measuring thiamine levels in the blood. According to the study results, people with type 1 diabetes or type 2 diabetes have a vitamin B1 deficiency of 7% and 75%, respectively, and lose thiamine at an average of 15 times the normal rate. This is the first time a deficiency of the thiamine, which has a role in protecting against diabetes-related complications, has been identified in people with diabetes. Although it was found that this deficiency is not due to diet, but to the rate at which the vitamin is cleared from the body, the researchers suggested that diet supplements might be beneficial to people with diabetes.
HbA1c during gestational diabetes predicts long-term risk
Insulin from genetically modified plants?

US researchers found recently that feeding mice with lettuce and tobacco plants that had been genetically modified to produce the precursor protein of insulin preserved the insulin-producing beta-cells in the animals pancreas (Plant Biotechnol J 2007; 5: 495-510). Having developed the genetically modified plants, the scientists fed leaves in either powdered or untreated form to mice with diabetes over a 7-week period. The treated mice showed lower blood or urine glucose levels than control animals with the condition, which lost a significant proportion of their beta cells over the study period. It is reported that after the encouraging results in animals, testing in people is now underway. The investigators expressed their hope that generating the pro-insulin protein in plants might lead to a low-cost alternative to standard methods of producing the hormone for the treatment of people with diabetes.
Recently published research indicates that high levels of HbA1c in women with gestational diabetes are associated with the development of diabetes in later life (Postgrad Med J 2007; 83: 42-30). Despite previously published findings to the contrary, the research also suggests that gestational diabetes is a risk factor for future diabetes regardless of ethnicity. A follow-up study of 73 women (3 South Asian and 37 Caucasian) who were diagnosed with gestational diabetes between 1995 and 2001 was carried out with oral glucose tolerance testing between 4 and 5 years later. On follow-up, nearly 50% of the South Asian women and 25% of the Caucasian women had developed diabetes. An elevated HbA1c value during pregnancy increased the risk of future diabetes by nearly five-fold in the South Asian women and over nine-fold in the Caucasian women. The researchers called for further examination of the value of HbA1c measurement in women with gestational diabetes as it has the potential to target screening away from those at minimal risk.
People with diabetes at greater risk of infections in hospital

2007; 142: 13-8). According to the findings, people with diabetes also spend more days in intensive care, use more ventilator support and have more complications during hospitalization for trauma than the general population. The researchers compared hospital data on 12 500 people with diabetes with the same number of people without the condition. They found that 11.3% of people with diabetes developed infections in hospital following admission for trauma, compared to .3% for those who did not have the condition.
A study conducted in US hospitals reported that people with diabetes who are hospitalized after a trauma are at almost twice the risk of developing infections compared to people without the condition (Arch Surg
News in brief
Gulf States pledge to make diabetes a priority

The Health Ministers of the Gulf States have thrown their full support behind the UN Resolution on diabetes and have pledged to do their part to reverse the diabetes epidemic. In December 200, the UN General Assembly unanimously adopted Resolution 1/225: World Diabetes Day which recognized the global burden of the diabetes epidemic and encouraged Member States to develop national policies for the prevention, care and treatment of diabetes. It asks nations to do this in line with the sustainable development
IASOSquareAd
account internationally agreed development goals, including the Millennium Development Goals. The Health Ministers for the Cooperation Council States, (United Arab Emirates, Bahrain, Kingdom of Saudi Arabia, Oman, Qatar, Kuwait and Yemen) have taken up the UNs challenge. In a letter to IDF, the Ministers pledged to make diabetes and other non-communicable diseases a top priority on their health agenda. In their Declaration, they recognize the importance of UN Resolution 1/225 and World Health Assembly Resolution 57/17.
Updated International Consensus on the Diabetic Foot
The International Working Group on the Diabetic Foot has published a new update of the International Consensus on the Diabetic Foot and Practical Guidelines on the Management and Prevention of the Diabetic Foot. The 2007 version, which follows on from the previous update in 2003, has been produced as an interactive DVD that features several new chapters on footwear and off-loading, wound management, and osteomyelitis. The revised Consensus document and Guidelines were launched during the 5th International Symposium on the Diabetic Foot that took place in Noordwijkerhout, the Netherlands, in May 2007. In order to support implementation of the Guidelines in developing countries, the DVD contains a step-by-step video guide on providing foot care education for people with diabetes. The DVD can be ordered from the IDF bookshop (www.idf.org/bookshop) at the price of 20 EUR.
of their healthcare systems, taking into

11/7/07 12:09 Page 1
Join us in Geneva for the most important European Obesity event of 2008
16th European Congress on Obesity ECO 2008

14 - 17 May 2008 Geneva Switzerland
www.eco2008.org
Abstract Submission Deadline: 1st December 2007 Earlybird Registration Rate Deadline: 1st February 2008
ECO 2008 Secretariat Obesity International Trading Ltd 231 North Gower Street London NW1 2NR, UK Tel: +44 (0) 20 7691 1900 Fax: +44 (0) 20 7387 6033 Email: eco2008@easoobesity.org
European Association for the Study of Obesity
PROGRAMME TRACKS
From Cells to Whole Body Physiology Clinical Management Track 3: Metabolic Syndrome Track 4: Behavioural Change and Patient Education Track 5: Prevention and Public Health
Track 1: Track 2:
Health delivery
Guideline for the management of post-meal blood glucose

Diabetes is a leading cause of death in most developed countries, and has become a serious epidemic in many developing and newly industrialized nations. Currently, an estimated 246 million people worldwide have diabetes. Poorly controlled diabetes is associated with disabling and potentially life-threatening complications such as eye disease, kidney disease, nerve damage and cardiovascular disease. Until recently, lowering fasting and pre-meal glucose levels was a key focus of diabetes management. However, recent studies have shown a strong relationship between elevated post-meal blood glucose and the risk for diabetes complications. As part of its mission to promote diabetes care, prevention and a cure worldwide, the International Diabetes Federation (IDF) recently formed a committee to develop a guideline that would address the issue of elevated post-meal blood glucose. Antonio Ceriello and Stephen Colagiuri highlight the guideline recommendations.
Significantly elevated blood glucose following a meal is a very common problem in people with diabetes. A recent study showed that over 84% of people with type 2 diabetes experience significantly elevated post-meal blood glucose.1 This is a major concern because of the link between elevated post-meal glucose and diabetes complications, particularly cardiovascular disease2 the leading cause of death in people with diabetes.3 In people without diabetes whose glucose tolerance is normal, blood glucose levels are automatically monitored and controlled by the body. When they eat food, the body
releases enough insulin to keep blood glucose within a narrow range rarely rising above 7.8 mmol/l (140 mg/dl) and usually returning to pre-meal levels within 2 to 3 hours. People with impaired glucose tolerance (IGT) or diabetes have little or no automatic control of blood glucose after they eat. As a result, they often experience extended periods of elevated post-meal glucose levels. This is due to a number of factors, including insufficient secretion of insulin, decreased sensitivity to the action of insulin, an inability to suppress glucose output from the liver, and deficiencies in other digestion-related hormones.
10
Health delivery
Table 1: Medications that target post-meal blood glucose

Glinides (repaglinide, nateglinide) Alpha-glucosidase inhibitors (acarbose, miglitol, vonglibose) Rapid-acting insulins (lispro, aspart, glulisine, inhaled insulin) Regular insulin Exenatide, liraglutide DPP-4 inhibitors (sitagliptin, vildagliptin) Amylin analogues Stimulate a rapid but short-lived release of insulin Reduce post-meal blood glucose levels when taken at mealtime Delay carbohydrate absorption in the intestines to reduce post-meal blood glucose Replace the insulin normally produced in the body Start to work 5 to 15 minutes after administration Replaces the insulin normally produced in the body Starts to work 30 to 0 minutes after administration Act as a replacement for glucagon-like peptide 1 (GLP-1), which controls post-meal blood glucose levels Increase the availability of the hormones in the gut that are needed to reduce post-meal blood glucose levels Replace naturally occurring amylin, a hormone secreted by the pancreas that regulates blood glucose
The benefits of managing blood glucose It is important to understand that post-meal blood glucose is a key contributor to average blood glucose readings as measured by glycated haemoglobin (HbA1c). The HbA1c test is generally performed in a laboratory or clinic, and shows a persons average blood glucose level over a 2to 3-month period. As such, it is a good marker for the specific damage that can lead to diabetes complications. IDF recommends that people with diabetes try to keep their HbA1c levels below .5%. Since HbA1c is derived from both fasting and post-meal levels, it is important to control both types of glucose. Large studies have demonstrated that lowering HbA1c levels reduces the development or progression of diabetes complications.4,5 However, studies have also shown that elevated post-meal glucose is an independent risk factor for cardiovascular disease even when HbA1c is within the normal, non-diabetes range.2 A possible reason for this is that the relative influence of fasting and post-meal glucose on HbA1c levels can vary. For example, when HbA1c levels are between 7.3% and 8.4%, the impact of fasting and post-meal glucose is about the same. However, as HbA1c levels decline, post-meal glucose becomes the main contributor to overall blood glucose control. Goals for post-meal blood glucose The new IDF guideline recommends that people with diabetes try to keep post-meal blood glucose below 7.8 mmol/l (140 mg/dl) during the 2 hours following a meal. This 2-hour
timeframe conforms to guidelines published by most of the leading diabetes organizations and medical associations. Self-monitoring is recommended because it is the most practical method for measuring post-meal blood glucose, allowing people with diabetes to obtain immediate, 'realtime' information about their blood glucose levels. This in turn enables people with diabetes and their healthcare providers to make timely adjustments to their treatment regimens in order to achieve and maintain target blood glucose levels. Where blood glucose self-monitoring is available, it is generally recommended that people on insulin test their blood glucose regularly. The frequency of testing for people using other methods to manage their diabetes (oral medications, diet, physical activity) should be individualized to each persons treatment plan and level of blood glucose control. Even if blood glucose self-monitoring is not available, there are many things that people can do to reduce post-meal blood glucose levels and improve their overall diabetes control. Managing post-meal blood glucose Lifestyle Physical activity, healthy eating and weight control remain the cornerstones of effective diabetes management. Physical activity in general improves the way insulin works and lowers blood glucose, especially after meals. Eating a healthy, low-fat diet which includes fruit, vegetables, and whole-grain foods can also help to reduce post-meal blood glucose levels and improve
Health delivery
11
Eating a healthy diet can help reduce postmeal blood glucose levels and improve blood pressure and cholesterol levels.
people with type 1 diabetes and type 2 diabetes, taking into consideration the available therapies as well as the technology relating to blood glucose self-monitoring. It is widely accepted that targeting both post-meal blood glucose and fasting blood glucose is an important strategy for achieving optimal blood glucose control. However, the impact of elevated post-meal blood glucose is fast becoming an area of concern. Although the research literature provides valuable information and evidence relating to this area of diabetes management, there are still some uncertainties regarding the relationship between post-meal blood glucose and macrovascular complications. Additional research is needed to clarify our understanding in these areas.
Antonio Ceriello is Professor of Diabetes and Metabolic Diseases at Warwick Medical School, University of Warwick, UK. Stephen Colagiuri is Professor of Metabolic Health at Boden Institute of Obesity, Nutrition and Exercise, University of Sydney, Australia.
blood pressure and cholesterol levels. Controlling weight also helps to increase the bodys sensitivity to insulin. Medications There are also a number of medications that specifically target post-meal blood glucose levels, such as alpha-glucosidase inhibitors, glinides, rapid-acting insulin, regular insulin, exenatide, DPP-4 inhibitors and amylin analogues. Table 1 presents a description of how these medications work. These medications may not be available in many parts of the world; it is important to place a strong focus on physical activity, healthy eating and weight control as primary treatment tools. Conclusion Given the significant and growing diabetes epidemic, it is important that people with diabetes and their healthcare providers find ways to better manage this condition. The new IDF guideline is intended to serve as a resource for healthcare providers and diabetes organizations to develop strategies to effectively manage post-meal blood glucose in
The IDF guideline for the management of post-meal blood glucose is available at www.idf.org and can be ordered via the IDF online bookshop at www.idf.org/bookshop.
References
1 Bonora E, Corrao G, Bagnardi V, et al. Prevalence and correlates of postprandial hyperglycaemia in a large sample of patients with type 2 diabetes mellitus. Diabetologia 200; 49: 84-54. 2 Ceriello A. Postprandial hyperglycemia and diabetes complications: is it time to treat? Diabetes 2005; 54: 1-7. 3 Niskanen L, Turpeinen A, Penttila I, Uusitupa MI. Hyperglycaemia and compositional lipoprotein abnormalities as predictors of cardiovascular mortality in type 2 diabetes: a 15-year follow-up from the time of diagnosis. Diabetes Care 1998; 21: 181-9. 4 Diabetes Control and Complications Trial (DCCT) Research Group. The relationship of glycaemic exposure (HbA1c) to the risk of development and progression of retinopathy in the diabetes control and complications trial. Diabetes 1995; 44: 98-83. 5 UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837-53.
12
Health delivery
Prevention and management of diabetes: the role of the physiotherapist

Sanjay Kalra, Bharti Kalra, Naresh Kumar
As the diabetes epidemic grows in size and complexity, there is an increasing realization that physicians alone are unable to provide the care required by people with diabetes. To help them live life to the fullest, people with the condition need the services of a range of healthcare personnel, including diabetes nurses, dietitians, podiatrists, psychologists and eye specialists. The role of most of these is well defined; the multi-disciplinary team approach benefits increasing numbers of people with diabetes worldwide. However, the potential of some specialities, such as physiotherapy, has hardly been explored. The authors of this article consider the importance of physiotherapy as a medical science, and discuss the various roles the physiotherapist can play in diabetes care.
Physiotherapy is an ancient science, which involves physical treatment techniques, such as massage, and the use of electrotherapeutic and mechanical agents rather than drug therapy for the management of a condition. Physiotherapists play an important role in helping people to overcome disability and pain related to orthopaedic, musculoskeletal, neurological and rheumatological illnesses. Any person with diabetes whose aching legs have experienced relief after a massage, or whose painful feet have been relaxed after a soak in cool water will testify to the importance of physiotherapy in relieving their symptoms. However, diabetologists and endocrinologists generally have been slow to exploit the benefits of this science. This may be due to a lack of awareness of its potential for improving health and well-being, or because of the shortage of trained personnel in many countries. Preventing diabetes The Diabetes Prevention Project demonstrated that lifestyle modification, including intensive exercise, is more effective in preventing diabetes than pharmacological therapy, and highlighted the role of trained professionals
Health delivery
13
Physiotherapists can help people to overcome the pain of orthopaedic, musculoskeletal, neurological and rheumatologic illnesses.
in motivating people to follow lifestyle interventions.1 Similar results have been reported by the Malm Study, the Da Qing Study, the Finnish Diabetes Prevention Study and the Wenying Study.1 Physiotherapists are able to help people plan an individualized exercise programme in order to maintain good blood glucose control and achieve optimal weight. Furthermore, physiotherapy leads to metabolic improvements even in the absence of weight loss, reducing the frequency of cardiovascular events and improving life expectancy. Effective exercise counselling ensures both cardio-respiratory and musculoskel-
etal fitness.1 This helps people with diabetes improve their quality of life, and contributes to overall control of blood glucose. The use of alternative therapies, such as yoga, can contribute to the achievement of optimal cardiorespiratory health. Physiotherapists can help people to maintain good blood glucose control and achieve optimal weight. Physiotherapists, with their knowledge of physiology and anatomy, can suggest specific exercises for people with coexisting complications, cautioning against certain movements that might
be detrimental to their health. For example, an isotonic exercise like jogging will benefit a person with high blood pressure and diabetes, but the repeated foot trauma associated with jogging may harm someone with peripheral sensory neuropathy or Charcot foot. Beyond exercise counselling Most people with diabetes suffer from musculoskeletal complications, which might include frozen shoulder, back pain or osteoarthritis. Many people with poorly managed type 1 diabetes develop a syndrome of limited joint mobility. Diabetic amyotrophy is a type of neuropathy that involves muscle
14
Health delivery
wasting and weakening, especially in the thighs. Carpal tunnel syndrome and sciatica are other neurological conditions that are commonly suffered by people with diabetes. In all these conditions, physiotherapy plays a pivotal role in returning people to normal levels of health and well-being. The physiotherapist uses a combination of active and passive exercises, and mechanical and electrical aids to improve musculoskeletal and neurological functions. Pain relief Physiotherapy offers various effective non-pharmacological approaches for pain relief.2 Transcutaneous electrical nerve stimulation (TENS) involves electrical nerve stimulation through the skin, sending a painless current to specific nerves. The mild electrical current generates heat that serves to relieve stiffness, improve mobility, and relieve pain. Interferential therapy (IFT) uses the strong physiological effects of low frequency electrical stimulation of nerves. TENS and IFT are considered goldstandard therapies for the relief of neuropathic pain, and have proven benefits in the management of painful diabetic neuropathy, oedema (build-up of fluid in tissue) and resistant foot ulcers. TENS has been shown to be most effective against burning and stabbing pain, but comparatively less efficient for the relief of painfully sensitive skin and restless legs syndrome. Other modalities, such as ultrasonic therapy and hot wax, are useful for specific conditions in both people with diabetes and people without the condition.
In spite of the benefits safety, lack of drug interactions, efficacy, cost associated with these methods, few centres have adopted TENS/IFT as primary treatments for painful neuropathy. Perhaps this underscores the need to create specialized diabetes physiotherapy units, staffed by qualified physiotherapists specializing in the care of people with diabetes. Physiotherapy can play an important role in preventing and managing foot problems. Improving feet Physiotherapy centres can play an important role in preventing and managing foot problems. Teaching the importance of correct gait and posture, along with the basic principles of off-loading when required, can prevent or stabilize a number of foot complications. In people with trophic ulcers, for example, which are typical in people with diabetes-related foot problems, the effective use of crutches or foot splints can ensure off-loading and early healing. In people who are unfortunate enough to undergo an amputation, the physiotherapist helps with post-operative pain relief, rehabilitation, limitation of disability, and the optimum use of prostheses. Similar rehabilitative measures, exercises and therapeutic aids are available for people who are recovering from heart attack, stroke, peripheral vascular surgery, or other traumas or surgical interventions. Wider benefits Physiotherapeutic interventions, usually delivered on a one-to-one basis,
are patient-centred, in line with the contemporary approach that all providers of chronic medical care, including endocrinologists, try to provide to people in their care. The time spent with the physiotherapist during the course of treatment can strengthen patientprovider bonding and enhance communication. As the number of people with diabetes continues to rise, and as the existing diabetes population ages, the need for efficient physiotherapy services will continue to grow. Including specialized physiotherapists as equal members of the diabetes care team will help us to utilize their services effectively in order to improve the health and well-being of all people with diabetes.
Sanjay Kalra, Bharti Kalra, Naresh Kumar

Sanjay Kalra is an endocrinologist at Bharti Hospital, Karnal, an endocrine hospital in Haryana, India. Bharti Kalra is a gynaecologist trained in diabetology. Naresh Kumar is in charge of the physiotherapy wing, Bharti Hospital, Karnal, India.
References
1 Holman R. Should we treat impaired glucose tolerance and impaired fasting glycemia? In: DeFronzo RA, Ferrannini E, Keen H, Zimmet P, eds. International Textbook of Diabetes Mellitus, 3rd ed. John Wiley. Chichester, 2004: 771-94. 2 Kalra S, Kalra B, Nanda G. Transcutaneous electric nerve stimulation (TENS) in diabetic neuropathy. Diabetologia 200; 49(Suppl 1): 121.
Health delivery
15
From adolescence to adulthood: the transition from child to adult care

Christos Bartsocas
Adolescence, the period of transition from childhood to adulthood, is a key phase of human development. It is characterized by rapid changes physical, sexual, psychological, emotional, cognitive, and social. The psychological imbalance that prevails during adolescence is particularly significant in people with diabetes as it often leads to a decline in self-care. This brings about a deterioration in blood glucose control, and creates difficulties that hamper the development of harmonious relationships between the young person with diabetes and his or her healthcare providers. Christos Bartsocas describes the developmental factors that impact on diabetes and makes specific recommendations to facilitate a smooth transition from paediatric to adult care.
A number of developmental factors can create difficulties for adolescents with diabetes. Adolescents typically strive to overcome anxiety over controlautonomy-dependence issues. This is a critical period for any person with diabetes in terms of achieving independence in general, and optimizing the management of their diabetes in particular. The adolescents anxiety over acceptance by peers a particularly important issue in adolescence may lead to behaviour that impairs blood glucose control, such as skipping insulin injections or eating unsuitable foods in order to avoid being viewed
by peers as 'different'. Adolescence is associated with impulsive, aggressive and risk-taking behaviour, including alcohol and tobacco use; young people with diabetes might experiment with insulin doses and/or reject their treatment regimen. Many children or adolescents with diabetes establish a long-term positive emotional bond with their paediatrician that is not confined to the mere presentation of medical facts and treatment rules. A consultation might focus on the development of efficient problem-solving skills which enable the young person to cope with a wide range of day-to-day problems that are directly or indirectly related to diabetes issues concerning prevention, as well as parents, peers, school, vocation, or family planning.This type of support is usually diminished in the adult care setting; interactions tend to focus more on the medical, rather than the psychosocial components of diabetes care.
1
Health delivery
Adolescents need support to anticipate problems they might face during the transition from child to adult care.
Factors that impede a smooth transition to adult healthcare include: the adolescents separation anxiety concerning the move away from the paediatrician developmental issues a switch in the focus of the relationship they have with their healthcare provider a lack of appropriate preparatory work concerning the transfer to a diabetes clinic. Making complex decisions about insulin doses, lifestyle, and bloodmonitoring are demanding for a young person. Anxiety and dependence Diabetes creates particular problems that can foster dependence. The intricacies of diabetes management often bring about a sense of loss of control and helplessness. Making complex everyday decisions about insulin doses, diet and exercise, and regular monitoring of blood glucose are demanding tasks for a young person. This is commonly compounded by fear of social stigma and uncertainty concerning complications. It is not surprising that young people seek a secure base, such as their family members and the paediatrician, who can provide solutions.
Transition issues The transition of the adolescent with diabetes from paediatric to adult healthcare represents a critical process. Certain difficulties and challenges can decisively affect the young persons capacity to meet everyday needs and achieve optimum blood glucose control. Generally, the age of the transfer from paediatric to adult diabetes care varies depending on the needs of the individual; in many cases the transfer is delayed up to young adulthood.
Furthermore, a considerable proportion of adolescents with diabetes who have been transferred from the childrens to the adults diabetes clinic tend to return to their paediatrician either sporadically or on a regular basis. Consequently, many adolescents who for various reasons do not achieve a smooth transfer are prevented from obtaining proper diabetes care, failing to attend outpatient clinics or seek systematic diabetes care, or even choosing to remain without medical care for long periods of time.
Health delivery
17
For young people with diabetes, the process of progressing from dependence to independence is littered with obstacles that often lead to a state of crisis. During adolescence, certain endocrine factors such as increased insensitivity to the action of insulin contribute to a deterioration in blood glucose control. This accentuates a young persons sense of loss of control, which, in turn, intensifies anxiety and the need for attachment to a secure base. Indeed, for the majority of adolescents, leaving the care of their paediatrician is in fact a passage from security to uncertainty. As mentioned above, it is not uncommon for adolescents to return to the paediatrician when faced with adversity emergencies or vagueness about their regimen. For many adolescents, leaving the care of their paediatrician is a passage from security to uncertainty. Further factors can adversely affect the process of transition. Gaps can appear in terms of personal medical information. Adolescents who return to the paediatric clinic after they have transferred to the adult diabetes clinic often report that their paediatrician, more familiar with the complex aspects of their particular condition, is better able to assume a supportive role and give personalized medical and psychosocial advice. Environmental issues can also arise regarding the ambience and surroundings in the adult diabetes clinic strict time limitations during consultations, for example, due to the larger throughput of people in the conventional clinic.
Preparing for the transition Preparatory work to facilitate the transfer of care should include several interrelated components. Adolescents require support in order to anticipate problems they might face during the transition period. They need to gain a realistic perspective of the emerging situation, eliminating unfounded worries and exploring and evaluating possible courses of action. Each adolescent needs to formulate a concrete workable approach, which is tailor-made to his or her particular needs including, for example, the timing of the transfer. This problem-solving procedure should be initiated by the paediatrician long before the actual transfer, allowing the adolescent enough time to adjust. The participation of parents in the problem-solving process can be very helpful, particularly where the adolescents degree of independence is not adequate. A specialized mental health practitioner psychiatrist or psychologist may also offer valuable support. The same problem-solving approach should also be applied by the adult diabetologist during the initial stage of acquaintance with an adolescent. This will help the physician to become familiar with the problems the adolescent encounters, assume an active role in solving difficulties (by cooperating with the paediatrician, for instance), and develop an effective working relationship with the young person. It is imperative that the paediatrician and the adult diabetologist collaborate concerning, for example, the acquisition of the necessary medical information in order to ensure a seamless transition to diabetes care
which effectively meets each young persons special needs. This might be achieved through the presence of the adult diabetologist in the paediatric diabetes clinic. Uncertainty together with the practical, psychological, and emotional barriers that can hamper the transfer to the adult diabetes clinic can be eliminated through adequate preparation. Key elements include the provision of structure, and sensitivity to the psychosocial as well as medical needs of the adolescent.
Christos Bartsocas
Christos Bartsocas is Emeritus Professor of Paediatrics at the University of Athens and Director of the Mitera Paediatric Hospital in Athens, Greece. He was the founder of the Greek Affiliate of the Juvenile Diabetes Research Foundation, and edits and publishes a diabetes news magazine, Neanikos Diabetes: Ta Nea mas.
Further reading
1 Crosnier H, Tubiana-Rufi N. Modalities of transition of diabetic adolescents from pediatrics to the adult care in the Paris-Ile-de-France region: an appeal to cooperative work for improving quality of care. Paris-Ile-de-France Section of DESG (Diabetes Education Study Group). Arch Pediatr 1998; 5: 1327-33. 2 Dunning T. Moving to adult care. Practical Diabetes International 2005; : 22-8. 3 Songini M. Transfer of IDDM patients from paediatric to adult diabetologist. In: Laron A, Pinelli L, eds. Theoretical and Practical Aspects of the Treatment of Diabetic Children. 5th International ISPAD Course. Editoriale Bios. Cosenza, 1995: 207-11. 4 Tsamasiros J, Bartsocas CS. Transition of the Adolescent from the Childrens to the Adults Diabetes Clinic. J Ped Endocrinol Metab 2002; 15: 33-7. 5 Wysocki T, Hough BS, Ward KM, Green LB. Diabetes mellitus in the transition to adulthood: adjustment, self-care and health status. J Dev Behav Pediatr 1992; 13: 194-201.
18
Health delivery
The Jaipur Foot: an effective low-cost prosthesis for people with diabetes
In people with diabetes, optimal management of their condition, regular examinations, the use of adequate footwear, and education are the best strategies to prevent diabetesrelated foot problems, such as ulceration. If foot problems cannot be prevented, these should be treated as early as possible. However, in many cases, some degree of amputation of lower limbs cannot be avoided. In people who undergo a major amputation, artificial limbs are required to enable them to continue normal daily life. While such prostheses are available, these are costly and beyond the reach of most people living in developing countries. The authors report on the Jaipur Foot, a low-cost, culturally appropriate response to the needs of such people, tracing its origin in India and looking forward to the broadening of its use.
It is estimated that around 70% of people with diabetes live in low-income countries, many of which have an average daily per capita income of around 1 USD and have no universal health care to cover diabetes and diabetesrelated complications. Widely available modern artificial limbs, costing up to 8000 USD, are clearly beyond the reach of the majority of people undergoing a lower-limb amputation in such settings. Moreover, many of the currently available prostheses might not be suitable for the lifestyles and customs of people in many regions. An artificial limb must serve a number of diverse functions, and should be culturally and
Health delivery
19
socially acceptable to people of different ethnicities. In India, for instance, people typically spend long periods of time in a squatting position, or sitting cross-legged on the floor. In such circumstances, the knees have to be able to flex until the soft tissues of the thighs and calf can be flattened against each other. Furthermore, many Indians would disapprove of using shoes inside the home. The use of regionally inappropriate prostheses can also have further negative social and economic repercussions. The 'shoe' attached to many models of artificial limb is made of heavy sponge and is impossible to detach. This renders these prostheses extremely inconvenient for people who wish to observe their religious customs, removing footwear upon entering a place of worship (temple, mosque, Gurudwara); or worthless for rural workers, who need to spend long hours in the rain or in irrigated rice fields. In India, nearly three-quarters of the population lives and works in rural areas. The use of regionally inappropriate prostheses can have negative social and economic repercussions. An artificial limb should be waterproof and not necessarily require the wearing of a shoe. It should allow a person to squat for at least short periods, sit cross legged, and should be sufficiently durable and flexible to permit walking on uneven ground. And, very importantly, it should be cheap and simple to manufacture made out of locally available materials.
Hari Singh demonstrates his treeclimbing skills.
Hari Singh, a young man in his mid-20s, lives in Kehan, a rural region of India. Having lost both his parents to diabetes-related complications, he was forced to take financial responsibility for his siblings at the age of 17 years. His small income came from climbing trees to harvest fruit. At age 24 years, a wound on his left foot developed into an ulcer. The ulceration became severe, but due to the remoteness of his village, he was unable to access adequate healthcare services. The infection spread, and only when his leg was badly swollen and red did he travel to a hospital, where he was diagnosed with diabetes. Medical personnel were unable to stem the infection,
and he had to undergo a below-the-knee amputation. He was advised of the availability of various prosthetic options. However, all of these were well beyond the reach of his finances, the cost representing between 5 and 7 years of his total income. Given his line of work, the loss of his lower leg was tantamount to a death sentence. Fortunately, he was advised by a physician at a rural health camp of the existence of a clinic in Jaipur that could fit him with a low-cost artificial limb the Jaipur Foot. The prosthesis would cost less than 5% of any other option. A charitable organization working closely with the clinic financed the artificial limb. Furthermore, in Jaipur, he underwent training in the manufacture of the Jaipur Foot and started making and fitting these prostheses for others. Currently, he has stable employment, looks after his family financially, and is even able to climb trees again just for fun.
20
Health delivery
The Jaipur Foot meets many of these requirements. First developed in 198, the Jaipur Foot has been further developed and refined, incorporating improved design features and the application of modern bio-mechanical principles, as well as new materials in its manufacture. History The inventors of the Jaipur Foot were an unlikely partnership: Pramod Karan Sethi, an orthopaedic surgeon, and Ram Chandra, an artisan who, although he had received only basic formal education, was a highly skilled craftsman. They met at the Sawai Man Singh Hospital in Jaipur, India, when Sethi was working with people with severe orthopaedic problems and Chandra was teaching people with leprosy to make handicrafts in order to earn a living. Observing people, including lower-limb amputees, struggling in considerable discomfort to become mobile, Chandra became convinced that a good-quality, life-like artificial limb could be made which would improve these peoples quality of life. He spoke to Sethi, who explained to Chandra concepts of bone movements within the feet, and the importance of preventing excessive pressure at contact points leading to further significant problems. They worked together to fashion a variety of limbs out of a variety of materials. However, these failed to meet their expectations. One day, Chandra saw a mechanic re-treading a tyre with rubber. After talking to Sethi, Chandra asked the mechanic if he could cast a rubber foot. The mechanic agreed (refusing to accept any money for the work).
The result was a much improved model, but the rubber shredded after just a few days. Chandra and Sethi proceeded to make the rubber foot around a hinged wooden ankle, wrapping this in a flesh-coloured lighter rubber and vulcanizing the whole limb. This took only minutes to build and fit, and was sturdy enough to last for a number of years. In 1971, Sethi presented the artificial prosthesis to British orthopaedic surgeons in Oxford, UK, who were impressed by its suppleness and durability. But due to opposition from other healthcare professionals, between 198 and 1975, only 59 people were fitted with the Jaipur Foot. The International Committee of the Red Cross discovered that the robust Jaipur Foot was ideal for use in mountainous regions. However, with the advent of the Afghan war in the late 1970s, the Jaipur Foot gained widespread international recognition. Landmines caused thousands of injuries, and the International Committee of the Red Cross discovered that the robust Jaipur Foot was ideal for use by people in mountainous Afghan terrain. Its low cost and use of simple and locally available materials, as well as the simplicity of its manufacture, were also recognized as key features. In Afghanistan, the Jaipur Foot is hammered out of spent artillery shells. In Cambodia, where roughly one out of every 380 people is a war amputee, part of the foots rubber components are scavenged from old tyres.
A farmer, Yogendra Gantara, aged 66 years, having lost his only son to tuberculosis, was left to provide financially for his family single-handed, including his deceased sons three young children. Yogendra was aware of his diabetes, which he tried to manage as best he could. One day he noticed a lesion on his foot. However, the harvest season was fully underway and he was unable to take time off from work to seek hospital treatment, despite the increasing swelling of his leg. By the time he received medical care, the infection was so extended that it was too late to save his leg. His left leg was amputated above the knee. His future well-being and that of his entire family was clearly under threat; it would be impossible for him to continue working in the rice paddies with only one leg. Fortunately, he was being treated in a town close to Jaipur and was fitted with the Jaipur Foot. He has now returned to work in his fields.
Health delivery
21
The Jaipur Foot and diabetes There is little published research validating the use of the Jaipur Foot in people with diabetes-related amputations. However, as early as 1991, it was described in a paper on the suitability of available prostheses in people with diabetes in Trinidad and Tobago as ideal for West Indian amputees due to its light weight, low cost, and the quality of its features (waterproof, well ventilated, good grip, shock absorbent, flexible and cosmetic appearance).1 Yet a number of people still refuse to accept that the Jaipur Foot can be of practical use in people with diabetes, especially for above-the-knee amputations. Whether this reflects a lack of knowledge of the advances made in the design and production of the Jaipur Foot since its invention, or whether it reflects the interests of the manufacturers of costlier artificial lower limbs is not for us to say. The modern Jaipur Foot Today, the Jaipur Foot has two basic components: the foot piece and socket, and the extensions which represent the joints depending on whether the limb is to be used after an above- or belowthe-knee amputation. A misconception persists that the Jaipur Foot can only be used in below-the-knee amputations. It can in fact be used in the entire range of lower-limb amputations from partial foot to hip disarticulation with equal efficiency. Although lightweight aluminium shanks are still available, it is recommended that for people with diabetes, the sockets should be made of ethylene-vinyl acetate and a polypro-
pylene-based material. This is safer and more user-friendly for people with diabetes. The old-fashioned openended sockets are now a thing of the past, and have been replaced by total-contact sockets again improving the user-friendliness. The Jaipur Foot can be used in the entire range of lower-limb amputations with equal efficiency. The Jaipur Foot is light in weight: for an average-sized adult, the socket, belt and Jaipur Foot for a below-theknee limb weighs between 1.3 kg and 1.5 kg; the above-the-knee prosthesis weighs between 2.25 kg and 2.5 kg. The average weight of a persons undamaged leg and foot is between 3 kg and 4 kg. Clearly, this artificial limb does not represent a weight burden. As mentioned above, a good modern lower-limb prosthesis is prohibitively costly to many people. A below-theknee Jaipur Foot replacement costs around 70 USD, and an above-theknee replacement around 150 USD. Promoting the Jaipur Foot Personnel can be trained quickly in the manufacture and fitting of the Jaipur Foot. Even workers such as cobblers and tinsmiths can learn how to make the artificial limbs under the supervision of a trained physician. A number of organizations are involved in promoting the use of the prosthesis, training such personnel around India and in other countries. There is clear justification for increased funding to support their efforts.
More work needs to be done to validate the long-term effectiveness of the Jaipur Foot in diabetes-related amputations. However, as healthcare professionals, we have a responsibility to address the urgent needs of people who want to live full and productive lives.

Shaukat Sadikot is Vice-President of the International Diabetes Federation and President of Diabetes India. Anant Nigam is Vice-President of Diabetes India. Anil Jain is Chief of the Jaipur Foot Centre.
Reference
1 Pooran SV, Naraynsingh, V, Deneash AC, et al. The Jaipur foot: the best option for the West Indian amputee. West Indian Med 1991; 40(suppl 1): 44.
Order online at www.idf.org/bookshop

Subscribe free to Diabetes Voice online at www.diabetesvoice.org or by sending your request to diabetesvoice@idf.org
Free EN ES Free EN FR ES 20 EN
Global Guideline for Type 2 Diabetes

(2005, 80pp)
19th World Diabetes Congress Abstract book
Diabetes Voice Special issue Diabetes in young people

(2007, 44pp)
15
th
EN
12
FR
ES
19 World Diabetes Congress Abstract CD-ROM
Diabetes and Foot care: Time to Act

(CD-ROM, 2005)
Free
EN
ES 35 EN
Diabetes education modules

(CD-ROM, 200)
Diabetes and Foot care: Time to Act

(2005, 20pp)
20
EN
International Consensus on the Diabetic Foot and Practical Guidelines on the Management and Prevention of the Diabetic Foot
(DVD, 2007)
Free
EN Free 90 EN EN
The IDF consensus worlwide definition of the metabolic syndrome

(200, 22pp)
Diabetes Atlas third edition

(200, 384pp)
Guideline for Management of Postmeal Glucose

(2007, 28pp)
These and other IDF publications can be ordered via our online bookshop at www.idf.org/bookshop. All prices are in EUR and include VAT. Prices are exclusive of postage and packaging. Shipping costs will be calculated based on weight and destination.
Clinical care
23
Diabetes and HIV/AIDS in sub-Saharan Africa: the need for sustainable healthcare systems
Chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the leading cause of mortality worldwide, representing 60% of all deaths. Contrary to common perception, 80% of chronic disease deaths occur in low- and middle-income countries. This invisible epidemic is an underestimated cause of poverty and hinders the economic development of many countries. Sub-Saharan Africa carries the highest burden of disease in the world, the bulk of which still consists of the communicable diseases HIV/AIDS, tuberculosis and malaria. However, the prevalence and incidence of diabetes and its long-term complications in sub-Saharan Africa are increasing, and will have a devastating human and economic toll if the trends remain unabated in the future. This report describes the links between two chronic diseases, diabetes and HIV/AIDS, in sub-Saharan Africa and its implications for healthcare systems.
In 200, a total of 24.7 million people in Africa were estimated to be infected with the human immunodeficiency virus (HIV) and 2.1 million were estimated to have died due to acquired immune deficiency syndrome (AIDS). By killing the economically active population in particular, HIV/AIDS is destroying the very fabric of societies throughout the continent. In the industrialized world, the use of antiretroviral combination therapy (or highly active antiretroviral therapy, HAART) has dramatically improved the life expectancy and well-being of people infected with HIV. Recently, the introduction of HAART in developing countries with a high prevalence of HIV has been recognized as a public health priority. This has resulted in a significant reduction in the price of antiretroviral drugs, increased donor funding, and enhanced political commitment as demonstrated by, for instance, the World Health Organization (WHO)s 3 by 5 initiative. The number of people with access to HAART in sub-Saharan Africa is estimated to have increased 10-fold over the last three years, currently covering approximately 28% of those in need (estimated at 1 340 000 of 4 800 000 people).
24
Clinical care
However, the rapidly increasing use of HAART in subSaharan Africa has some important implications. HIV disease requires life-long treatment, meticulous adherence to therapy, and intensive clinical and laboratory monitoring. Therefore, robust and sustainable healthcare systems are needed to provide adequately trained staff, laboratory facilities, and a reliable supply of drugs. Moreover, there are growing concerns about drug toxicity related to the chronic use of the antiretroviral drugs that are most frequently used in sub-Saharan Africa. It can be expected that the increasing use of these particular drugs in sub-Saharan Africa will contribute to the rising incidence and prevalence of diabetes, which has reached epidemic proportions in the industrialized world. The increasing use of HAART in sub-Saharan Africa will contribute to the rising prevalence of diabetes. Epidemiology of diabetes The International Diabetes Federation estimates that currently more than 24 million people have diabetes worldwide. This figure is expected to reach 380 million by 2030. In 2005, an estimated 1.1 million people died from diabetes. Almost 80% of diabetes deaths occur in low- and middleincome countries. The exact genetic markers of diabetes are unknown and only limited studies have been performed in people of sub-Saharan African origin. The effective management and prevention of diabetes in sub-Saharan Africa demand a multidisciplinary approach. There is a need for proper access to diabetes treatment and disease monitoring. Currently, laboratory monitoring, which is routinely performed to guide treatment in the industrialized world, is not routinely performed in sub-Saharan Africa. Besides individual characteristics, social obstacles, such as poor education and illiteracy, low socio-economic status, and lack of access to healthcare, make the prevention and treatment of diabetes in sub-Saharan Africa arduous. Toxicity of HAART For resource-limited countries, WHO has developed simplified treatment guidelines on the public health approach to the delivery of antiretroviral therapy.1 This is based on a standard first-line therapy, consisting of two nucleoside/
nucleotide reverse transcriptase inhibitors (NRTIs) plus a non-nucleoside reverse transcriptase inhibitor (NNRTI); and second-line therapy, consisting of a boosted protease inhibitor (PI) with at least one NRTI with the switch in therapy being guided by the clinical progression of the disease. To date, by far the most common first-line therapy in subSaharan Africa consists of lamivudine (3TC), nevirapine (NVP), and either stavudine (d4T) or zidovudine (AZT). Often, d4T, 3TC and NVP are available in a fixed-dose combination produced generically by pharmaceutical companies in India. WHO recommends the use of the fixed-dose combinations, not only because they simplify the drug regimen and improve adherence, but also because they are available at considerably lower prices than branded drugs. However, the downside of this choice is that metabolic complications, including dyslipidaemia, insensitivity to insulin, and the excessive loss of fat beneath the skin (lipoatrophy) resulting in sunken cheeks, indentations, and hollow eyes , occur more frequently with the use of these therapies. In particular, d4T and to a lesser extent AZT are the cause of these complications. Accelerating the emergence of diabetes The toxicities associated with HIV therapy are directly influencing the emerging diabetes crisis in Africa. Both HIV PIs and thymidine analogue NRTIs contribute to dyslipidaemia and insensitivity to insulin, and thereby to cardiovascular risk. Interrupting HIV treatment may also contribute to a higher risk for cardiovascular disease, suggesting that HIV infection in itself may contribute to the formation of plaques in the lining of the arteries (atherogenesis). Reductions in the cost of alternative and safer antiretrovirals are urgently needed. The use of d4T increases the risk of new-onset diabetes2 and has recently been shown to induce peripheral insensitivity to insulin in healthy people.3 Avoiding d4T as much as possible would thus contribute to avoiding these metabolic complications as well as lipoatrophy. Unfortunately, recent evidence suggests that AZT may also directly contribute to the onset of insensitivity to insulin and lipoatrophy. Thus, the continued
Clinical care
25
2003 EU
Poverty and the lack of access to healthcare complicate the prevention and treatment of chronic diseases.
reduction in the cost of alternative and safer antiretrovirals is urgently needed in resource-limited settings. It should be emphasized that the toxicities associated with HIV therapy should never be used as an argument to withhold these life-saving treatments from anyone with HIV who needs them. But given the rise in diabetes and cardiovascular disease in low- and middle-income countries, and the toxicities of d4T including its association with the development of diabetes WHO notes that it is important to begin planning to move away from d4T-containing regimens in particular so as to avoid or minimize the predictable toxicities associated with this drug.1 The need for an effective health chain Both HIV/AIDS and diabetes are on the rise in sub-Saharan Africa the latter notably amplified by the side effects of HAART. In addition to diabetes and HIV/AIDS, the incidence of other chronic diseases associated with westernization
and urbanization (obesity, respiratory diseases, coronary artery disease, high blood pressure) is also on the rise in sub-Saharan Africa. It remains to be seen exactly which effect HIV/AIDS and diabetes will have on each others epidemiology; but it is clear that for both diseases there is a need for chronic life-long treatment, and the availability of prompt diagnosis and laboratory monitoring. In addition, prevention measurements are crucial to avoid high costs of disease treatment and hospitalization at later stages. However, in sub-Saharan Africa the healthcare infrastructure is underdeveloped, and suffers from a lack of adequately trained professionals, insufficient support for adherence to treatment, and interruptions in drug supply. It is a sad fact that while sub-Saharan Africa carries over 0% of the global burden of diseases, it spends less than 1% of total global health expenditure. In this regard, innovative healthcare delivery and financing models will be needed to ensure appropriate and sustained management of chronic diseases.
2
Clinical care
We propose that one way of accomplishing this is to make chronic diseases, including diabetes and HIV/AIDS, part and parcel of emerging healthcare insurance packages for Africans, as summarized below. A recommendation by WHO to African health insurers to include chronic diseases into their packages will contribute to this approach. While sub-Saharan Africa carries over 60% of the global burden of diseases, it spends less than 1% of global health expenditure. Health insurance in Africa Currently, a multitude of health insurance efforts are being undertaken in Africa. In our view, the establishment of insurances is the best way of dealing with chronic diseases. It should be kept in mind that insurances will require adequate healthcare infrastructure and human capacity to actually deliver treatment and care of chronic diseases. Only when the quality of care is considered consistent and sufficient by the individual, will the willingness to pay for insurance premiums increase. Since in many African settings the state is not strong enough to enforce certain minimum standards of quality, these have to be secured through contractual arrangements and outputbased programmes. The focus should be on strengthening healthcare financing and enhancing the capacity for accountable quality healthcare delivery at the same time. The Health Insurance Fund: a practical example The above considerations, among others, have contributed to the establishment of the Health Insurance Fund. This Fund is basically aiming at breaking the vicious circle of healthcare delivery by subsidizing the health insurance premiums of people living in Africa.4 A non-profit organization that is dedicated to quality healthcare, the Health Insurance Fund puts this innovative business model for healthcare development into practice. The objective of the Health Insurance Fund is to increase access to quality basic healthcare, including care for currently uninsured people in Africa with a low income, through the provision of group-based private health insurance. A start was made in Nigeria in February 2007.
With respect to diabetes, the recommendation would be that any insurance supported by the Health Insurance Fund should comply with an insurance package covering the following: performing diagnostic glucose tests (blood, urine), blood lipid control, blood pressure control and foot care, and screening for early signs of long-term complications. The insurance should reward favourable lifestyle behaviour physical activity of 30 minutes or more per day, maintaining healthy body weight, smoking cessation.
Michle van Vugt is Chief Medical Officer and specialist in infectious diseases at PharmAccess Foundation, Centre for Poverty-related Communicable Diseases, Academic Medical Centre, University of Amsterdam, The Netherlands. Raph Hamers is a PhD fellow on antiretroviral therapy delivery and drug resistance in Africa at PharmAccess Foundation, The Netherlands. Onno Schellekens is Director of PharmAccess Foundation, The Netherlands. Tobias Rinke de Wit is Director of Advocacy, Technology and Research of PharmAccess Foundation and Professor of Sustainable Healthcare in Resource-poor Settings, University of Amsterdam, The Netherlands. Peter Reiss is Professor of Internal medicine at the Department of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, University of Amsterdam, The Netherlands. For more information on the Health Insurance Fund, visit www.pharmaccess.org
References
1 UNAIDS/WHO. Antiretroviral therapy for HIV infection in adults and adolescents: Recommendations for a public health approach, 200 revision. Geneva, 200. Available at www.who.int/hiv/pub/guidelines/artadultguidelines.pdf 2 De Wit S, Sabin CA, Weber R, et al. HIV Program for the DAD Study Group. Relationship between use of stavudine and diabetes mellitus. Abstract during 8th International Congress on Drug Therapy in HIV infection. Glasgow, 200. 3 Fleischman A, Johnsen S, Systrom DM. Effects of a nucleoside reverse transcriptase inhibitor, stavudine, on glucose disposal and mitochondrial function in muscle of healthy adults. Am J Physiol Endocrinol Metab 2007; 292: E1-73. [Epub 2007 Feb ] 4 Schellekens O, van Wijnbergen S. On aid and AIDS in Africa: Alleviating poverty through increasing access to health care and HIV/AIDS treatment in Sub-Saharan Africa. Preadvices 200: New forms of development cooperation. Royal Association of Macroeconomics (submitted).
Clinical care
27
Insulin pump therapy in children and adolescents: risks and benefits

Karin Lange and Thomas Danne
During the last decade, insulin pump therapy has gained widespread acceptance in the treatment of children and adolescents with type 1 diabetes. In some of the European and North American paediatric diabetes centres, more than half of the young people with diabetes try to simulate a normal pattern of insulin secretion by means of an insulin pump (continuous subcutaneous insulin infusion). Karin Lange and Thomas Danne look at the use of insulin pumps among young people of a range of ages, and outline its advantages, potential risks and shortcomings, as well as educational requirements for children and their parents initiating this type of intensive therapy.
With continuous subcutaneous insulin infusion (CSII), children and their parents aim to achieve near-normal blood glucose levels while avoiding severe hypoglycaemia. After starting therapy with an insulin pump, only a small number of young people have discontinued CSII and returned to multiple daily injections.1 As with any form of intensive insulin therapy, a strict differentiation of the substitution of basal and meal-time insulin is necessary. With a pump, at the touch of a button, insulin can be given for each meal, and additionally when elevated blood glucose levels need to be corrected. Children, adolescents and their families have reported
improvements in blood glucose control as well as improved flexibility in their lifestyle, allowing them to adapt their therapy to the age-appropriate developmental tasks of daily life. For children of all ages Initially, insulin pump therapy was offered predominantly to adolescents who appeared to be competent enough to handle such a technically advanced therapy. However, nowadays young children also benefit from CSII.2 Their very low basal insulin rate during the first years of life can be programmed in very small steps in response to requirements that change hourly during the day and especially at night. The risk of severe night-time hypoglycaemia has been shown to be reduced. This may enable parents to be less anxious and have a better and quieter nights sleep. During the day, the opportunity to conveniently give an extra dose of rapid-acting insulin may help children to follow their appetite spontaneously and learn how to eat and drink without restrictions.
28
Clinical care
Insulin pump therapy offers an opportunity to solve specific day-to-day problems for motivated young people.
From a psychological point of view, learning normal eating behaviour without frequent conflicts with parents is particularly important for the youngest children. A quick beep of insulin when a child wants to eat something is clearly less burdensome for the parent-child relationship than five or more daily insulin injections. Robust adhesives for fixing catheters and creative ways of carrying a pump (a small backpack, a pouch worn around the neck, special belts) enable young people to undertake un-
restricted physical activities even in pre-school-age children. Learning normal eating behaviour without frequent conflicts with parents is particularly important for the youngest children. During ongoing exercise, the basal rate can be reduced prospectively to prevent hypoglycaemia. Unwanted playful manipulation of the pumps functions
can be avoided with numerous safety features.3 Young children wearing a pump can attend pre-school day-care facilities as long as carers have received appropriate information. School-age children are often able to master the technical features of an insulin pump indeed they are more competent than many adults are when it comes to programming a new mobile phone or using other new technical devices. However, children still need supervi-
Clinical care
29
Table 1: Requirements for initial insulin pump therapy education

Skills training in pump-related technical abilities Selecting and managing a catheter Managing nutrition (carbohydrate counting/estimation) Principles of basal/bolus therapy (including circadian variation of insulin sensitivity) Insulin kinetics and self-management of insulin dosage Preventing, detecting and treating hypoglycaemia Preventing, detecting and treating hyperglycaemia Adjusting insulin in relation to physical activity and exercise Managing sick days Integrating CSII in everyday life (ie day-care, school, parenting, independence in diabetes care)
a practically oriented introduction to the day-to-day use of the pump, delivered by a multidisciplinary paediatric team with experience in insulin pump therapy. In addition to technical details and proper insulin dosing, the efficient and responsible application of the device need to be learned. Insulin pump therapy needs to be accompanied by regular blood glucose self-monitoring before meals and on several other occasions physical activity, exercise. Estimating carbohydrate intake is a prerequisite for successfully determining meal-time doses. People who hope that using a pump will relieve them from the burden of monitoring or thinking about diabetes will be disappointed. Difficulties with accepting diabetes, lack of motivation, uncontrolled appetite, cravings for sweets, or psychosocial problems counteracting successful therapy will not disappear when using a pump. The first step should be to have an open-minded discussion between the young person, his or her family, and members of the diabetes team on the time, effort, and potential benefits involved. Setting up a written agreement for a trial period can be helpful. This should include statements concerning the expectations of the team regarding the child and family, as well as the degree of continuous support provided by the healthcare team. Benefits Studies giving conclusive scientific evidence for the long-term success of CSII in children are scarce. Systematic comparisons over years of multiple daily injections and CSII in these age
sion in the complex task of calculating their insulin requirements for meal-time doses or correcting high blood glucose levels. Therefore, as with any intensive insulin therapy, clear arrangements for consultation and supervision by adults, teachers or other carers have to be put in place. A dependable contact by mobile phone between child and parent may be useful. Medical and psychosocial indications Compared to a therapy with multiple daily injections, CSII is more expensive, not only because of the pump itself but also the related supplies, such as catheters or insulin cartridges. A reasonable indication should be a prerequisite for reimbursement in healthcare systems where this is an issue. Recently, the following indications for insulin pump therapy were published in an international consensus statement:3 recurrent severe hypoglycaemia wide fluctuations in blood glucose levels, regardless of HbA1c poorly managed diabetes (HbA1c exceeding target range)
microvascular complications and/or risk factors for macrovascular complications good metabolic control but with an insulin regimen that compromises a persons lifestyle. Insulin pump therapy might also be beneficial in very young children, adolescents with eating disorders, children and adolescents who experience an early-morning steep rise in blood glucose levels (dawn phenomenon), and children with needle phobia. Pregnant adolescents can also benefit from CSII, particularly if therapy had started before conception. Young people who are prone to ketosis a possible precursor to diabetic ketoacidosis (DKA) and competitive athletes may also find advantages in the use of an insulin pump. Prerequisites for success Diabetes cannot be managed with an insulin pump alone just as it cannot be managed with a syringe alone. Knowledge, motivation and self-management are most important. Therefore, children, adolescents and parents need
30
Clinical care
groups have not yet been published.3 While considerable improvements in HbA1c readings have not been reported, several observational studies have indicated reductions in severe hypoglycaemia during CSII. However, systematic studies in large groups of children are lacking. This said, performing randomized controlled trials may be hampered by ethical objections. Nobody will expose a child to a therapeutic regimen over years if this treatment does not fit well with his or her individual lifestyle and when an alternative treatment is available. In the end, it is unlikely that one therapy exists to suit all; there will be as many different individual concepts as there are children with diabetes.4 Safety The experience of several thousand children on CSII worldwide has shown that there is no cause for the many objections regarding possible technical malfunctions in these devices. The safety and alarm features together with continuous adult supervision offer ample protection from insufficient insulin supply. Furthermore, the theoretical increased risk for DKA can be minimized by proper education, careful placement of the catheter, and frequent self-monitoring of blood glucose and ketones. Moreover, young people with diabetes and their parents need to know exactly what to do when ketone bodies are detected. An emergency plan must form part of all CSII education. Following these principles in a Norwegian study, no increase in the rate of DKA was found.5 Likewise, irritations or infections at the site of the catheter placement can be prevented by careful training.
Education for parents and children Table 1 contains a list of the requirements for initial insulin pump therapy education for parents and children. Depending on their stage of cognitive development, children should be involved in the educational courses. Long-term care for children and adolescents should be delivered by a paediatric team with knowledge and experience of technical aspects, correct dosing, and the practical aspects of implementing this therapy in everyday situations, as well as continuous followup education for the family. Limitations As with any other form of intensive diabetes therapy, successfully implementing CSII relies heavily on the resources of parents or other carers that are available for providing continuous support to their children. The same is true for older children and adolescents. If regular self-monitoring, correct changes of catheters and reservoirs, and appropriate insulin dosing, food intake and physical activity cannot be maintained, metabolic control is likely to be unsatisfactory. Unwillingness to perform these necessary tasks or a lack of continuous support from an experienced paediatric team does not justify the extra costs of this type of therapy.3 Nevertheless, insulin pump therapy offers an opportunity to solve specific problems of day-to-day insulin delivery for a large group of motivated young people and their families. This chance should be made available for as many children and adolescents with type 1 diabetes as possible in order to reduce their risk of long-term complications.
Karin Lange and Thomas Danne

Karin Lange is Head of the Department of Medical Psychology, Hannover Medical School, Germany. She is a member of the Diabetes and Psychology Working Group of the German Diabetes Association. Together with several paediatric diabetes teams in Germany, she developed and evaluated structured diabetes education programmes for children, adolescents and parents. Thomas Danne is Professor of Paediatrics and Chief Physician, Department of General Paediatrics at the Childrens Hospital Auf der Bult, Hannover Medical School, Germany. He is a member of the IDF Consultative Section on Diabetes in Children and Adolescents and the current Secretary General of the International Society for Paediatric and Adolescent Diabetes (ISPAD). He is a member of the PedPump Study Group.
References
1 Wood JR, Moreland EC, Volkening LK, et al. Durability of insulin pump use in pediatric patients with type 1 diabetes. Diabetes Care 200; 29: 2355-0. 2 Danne T, Battelino T, Kordonouri O, et al; for the PedPump Group. A cross-sectional international survey of continuous subcutaneous insulin infusion in 377 children and adolescents with type 1 diabetes mellitus from 10 countries. Pediatr Diabetes 2005; : 193-8. 3 Phillip M, Battelino T, Rodriguez H, et al. Use of insulin pump therapy in the pediatric agegroup: consensus statement from the European Society for Paediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2007; 30: 153-2. 4 Hanas R. CSII in children with diabetes. Acta Biomed 2005; 7 (Suppl 3): 3-8. 5 Margeirsdottir HD, Larsen JR, Brunborg C, et al. Nationwide improvement in HbA1c and complication screening in a benchmarking project in childhood diabetes. Pediatr Diabetes 200; 7(Suppl. 5): 18.
Diabetes in society
31
The BRIDGES programme: sharing practical solutions and improving outcomes

Jean-Claude Mbanya
Diabetes is now the worlds fourth leading cause of death by illness, and the global epidemic shows no signs of abating. In recent decades, a revolution in science has contributed to a greater understanding of diabetes and the development of new cutting-edge therapies. However, diabetes prevalence, and diabetes-related death and disability have continued to grow rapidly. In order to identify, test and publish practical solutions to improve outcomes for people with diabetes throughout the world, the International Diabetes Federation (IDF) and Eli Lilly and Company have forged a partnership to fund and support translational research in the field of diabetes through IDFs new grant research programme, Bringing Research in Diabetes to Global Environments and Systems (BRIDGES). The Chair of the BRIDGES Executive Committee, Jean-Claude Mbanya, outlines the aims and functions of the programme.
Diabetes is complex in its aetiology and management. There are numerous challenges involved in preventing the disabling and life-threatening complications of diabetes: it is a life-long condition which requires the combined efforts of people with the condition, healthcare providers, and healthcare systems. The good news is that there is a large and growing bank of knowledge for effectively managing diabetes and preventing its complications. Indeed, there is overwhelming evidence that type 2 diabetes is preventable. Furthermore, currently available treatments can be implemented in real-life settings, which can significantly reduce cardiovascular events.1 However, despite the recent revolution in scientific knowledge and the introduction of many new diabetes
32
Diabetes in society
BRIDGES will test and communicate the translation of research findings into improved outcomes for people with diabetes.
tic ways of achieving better outcomes for people with diabetes in order to help halt the progression of the condition, particularly in low-resource developing countries. The lessons learned through the supported research projects will provide the opportunity to steer, for example, the development of treatment routines and effective behavioural interventions, leading to relevant, evidence-based healthcare and improved outcomes for people with diabetes. The programme will rely on collaboration and cultural context. Under BRIDGES, researchers will be able to share insights and advice for improving their projects, leading to findings that can be applied in different settings. This global research programme will help communities worldwide to identify their specific needs related to intervention and prevention, and develop programmes that directly benefit people with diabetes in their region. Managing BRIDGES An Executive Committee, appointed by the Executive Board of Management of IDF, met in April 2007 to determine the structure of the programme, criteria for eligibility of the projects, and the duration and maximum amounts available for each. A representative of Eli Lilly and Company took part as an observer (without voting rights).
treatments, there remains a major gap between what we have learned through clinical research and what we do in clinical practice to successfully support behaviour modification. Translational research aims to close the gap between knowledge and practical know-how by converting the available scientific knowledge into effective measures for clinical and public healthcare practice.2 Translational research aims to close the gap between knowledge and practical know-how. Through an educational grant from Eli Lilly and Company of 10 million USD over the next seven years, the IDF BRIDGES grant programme will fund translational research projects.
The funding will support research to identify, test and publish new non-pharmaceutical strategies for combating diabetes and improving outcomes for people with the condition. Over several years, IDF will issue calls for proposals from investigators who are interested in community-based research around the world for innovative programmes that are designed to help improve the lives of people with diabetes. The goal of the BRIDGES programme is to test, communicate and implement worldwide the translation of research findings into practical diabetes care strategies and solutions for people with diabetes. Building BRIDGES Through the BRIDGES grant research programme, IDF aims to identify realis-
Diabetes in society
33
All applications will be peer reviewed and prioritized by a cross-disciplinary review group. Eli Lilly and Company will not be represented in the Review Committee. Strict ethical guidelines underpin the programme. Projects involving basic science research, and those designed to test pharmaceuticals or disease mechanisms are not eligible for funding through BRIDGES. Projects which could be construed as project development, marketing or sales interventions will also be excluded from funding. Proposals will be evaluated based on the strength of their hypotheses and the ease with which these can be replicated. The review committee will evaluate proposals, based on the strength of their hypotheses and the potential ease with which these can be replicated in other settings. The review committee will then select from among the submitted proposals and award funding. Crossing BRIDGES Over the coming years, BRIDGES will offer three cycles of funding, and support two types of project: Short-term projects defined as a study in translational research which will generate initial data to reproduce this on a larger scale Long-term projects for researchers who have generated clinically significant findings in pilot projects. Pilot projects should have a maximum duration of two years and may be eligible for funding of up to 5 000 USD;
outcome projects will have a maximum duration of three years and may receive up to 450 000 USD. If a short-term project provides strong evidence for the testing of a hypothesis, the findings will need to be replicated, extended or implemented for the benefit of people with diabetes. In this case, BRIDGES will encourage the applicants to apply for a larger threeyear long-term study grant. The first round of applications opened in June 2007. Applications will be accepted until 2 November 2007. Submissions received after the deadline will be considered for the next round of funding. The announcement of the first grant awards will be made at the beginning of 2008. Funding will be made available in instalments: up to 50% following the signing of the agreement up to 40% approximately half way through the project upon acceptance of the mid-term project report 10% on acceptance of the final report. Researchers whose projects are awarded funding will be required to submit a progress report and final report to the Executive Committee for evaluation of the significance of their research findings, and the potential for regional and/or global replication. These findings will be evaluated, based on how applicable they are in real-life situations to local and regional populations. Successful projects that meet the specified evaluation criteria and are per-
ceived to have significant regional and/or global impact will be considered for dissemination. Key study results will be submitted for acceptance as oral or poster presentations at major international diabetes meetings, in published scientific and non-scientific journals, and will be communicated through media announcements. Conclusion In taking responsibility for BRIDGES, IDF is for the first time developing a programme of these dimensions which is oriented towards research in diabetes. In doing so IDF hopes to strengthen relations with its Member Associations. Furthermore, if BRIDGES is successful, it will open new developmental perspectives for IDF, reinforce the Federations image in the international diabetes community and further promote diabetes care, prevention and a cure worldwide.
Jean-Claude Mbanya
Jean-Claude Mbanya is PresidentElect of IDF and Chair of the , Executive Committee of BRIDGES. For more information, visit the website www.idfbridges.org or contact Ronan LHeveder, ronan@idf.org.
References
1 Lindgren P, Lindstrom J, Tuomilehto J, et al; DPS Study Group. Lifestyle intervention to prevent diabetes in men and women with impaired glucose tolerance is cost-effective. Int J Technol Assess Health Care 2007; 23: 177-83. 2 Narayan KMV, Benjamin E, Gregg EW, et al. Diabetes Translation Research: Where Are We and Where Do We Want To Be? Ann Intern Med 2004; 140: 958-3.
34
Diabetes in society
Advocating for the rights of people with diabetes in Kyrgyzstan

Svetlana Mamutova
Kyrgyzstan is a landlocked, largely mountainous country, bordering Kazakhstan, China, Tajikistan and Uzbekistan, and is therefore sometimes referred to as the Switzerland of Central Asia. But the dramatic beauty of its snow-capped mountains and Alpine gorges hides a terrible potential for destruction: heavy winter snow often leads to spring floods, provoking serious damage in valleys and lowlands. The President of the Diabetes Association of Kyrgyzstan, Svetlana Mamutova, likened the destructive flow of the mountain rivers to the epidemic of diabetes in her country and worldwide leaving no region or territory unaffected. In this article, she describes the status of diabetes in Kyrgyzstan and reports on the efforts of the Kyrgyz diabetes community to improve the provision of care and diabetes supplies.
Diabetes is of growing concern to healthcare institutions worldwide, and its societal impact is exacerbated in low- and middle-income countries. Kyrgyzstan is a case in point: diabetes and its complications are an established and growing burden to families and society as a whole. Currently, more than 25 000 people are officially registered as having diabetes in the country. However, estimates put the number of people with diabetes far higher than these official figures: according to the latest figures from the IDF Diabetes Atlas, there are 132 000 people with diabetes (a prevalence of 4.3%).
The Diabetes Association of Kyrgyzstan (DAK) is a non-profit, non-government organization, and a member of IDF. It was founded in the late 1990s by stakeholders in diabetes care, including people with the condition and healthcare providers, in order to consolidate and coordinate efforts in the fight against diabetes. DAKs mission is to provide medical and social support for people with diabetes in Kyrgyzstan, and to enhance quality of life by advocating for peoples rights and interests. DAK strives to improve the performance of statecontrolled national and regional healthcare provision. DAK is active on a number of fronts in partnership with a range of groups, including state agencies, healthcare institutions, public organizations, pharmaceutical companies, and national and international aid organizations. Alongside its fundraising activities and hands-on involvement in the collection and distribution of humanitarian aid (diabetes
Diabetes in society
35
In Kyrgyzstan, young people with diabetes do not receive insulin delivery systems in sufficient numbers.
supplies), DAK strives to improve the performance of state-controlled national and regional healthcare provision. Shortcomings in care In Kyrgyzstan, the Ministry of Public Health purchases insulin, insulin delivery systems, and oral blood glucose-lowering medications. DAK cooperates with the Ministry in an unofficial capacity at various levels, advocating improvements in the provision of diabetes services. Unfortunately, however, the Ministry of Public Health does not officially recognize DAK as a social partner, limiting our impact on the development and implementation of public health initiatives. Indeed, when public health policy is developed, neither the opinions and interests of people with diabetes nor those of their healthcare providers are taken into consideration. Under the Kyrgyz constitution, the public healthcare system should provide diabetes supplies insulin, delivery systems, oral blood glucose-lowering medications to people with diabetes free of charge. Insulin is purchased centrally by tender and should be distributed among people with diabetes throughout the country. In practice, inadequate funding within the healthcare sector leads to irregular insulin supplies. Given that it is an essential life-saving medication, insulin should
EU/J Silva Rodrigues
3
Diabetes in society
be accessible to those whose health and life depend on it. The irregular supply of insulin violates the constitutional rights of people with diabetes. Although oral medications ought to be bought using local public health budgets, this is frequently not the case. Consequently, many adults with type 2 diabetes are forced to pay for their medication out of pocket again, a violation of their constitutional rights. Defending rights DAK campaigns directly to ensure that people with diabetes receive the insulin they require, raising awareness among the general public and policy-makers when the threat of failed insulin supply arises. Press briefings and public events ensure coverage of the problem in local and regional media. The Ministry of Public Health is accused of repeatedly violating the law on public procurement of medical supplies. Charges have been brought against a number of Ministry officials, accused of lobbying for the purchase of poorquality insulin delivery systems. In response to insecure purchasing of diabetes medications, DAK applied to the UK Department for International Development (DFID) for funding. In March 2007, DFID selected DAKs project proposal, Transparency of budget funds and effective use of funds for people with diabetes in Kyrgyzstan, for an award of 11 000 EUR. Subsequently, DAK along with 1 other NGOs, all DFID grant holders, established the Alliance For Transparent Budgeting, with the objective of fighting corruption and financial infringements in public spending.
DAK was involved in the development of national legislation on diabetes (the 2004 Model Law on Diabetes). However, although the legislation was passed by Parliament and signed by the President of the Republic, it appears to lack real force. The current situation with regards diabetes supplies is far from ideal. Limited funds in the country prevent the stockpiling of vital supplies. People with diabetes, in particular children and teenagers, do not receive insulin delivery systems in sufficient numbers. Furthermore, the state does not supply test strips to measure levels of glucose in blood or urine essential for the effective management of diabetes. Other activities World Diabetes Day (WDD) celebrations have become the highpoint of DAKs awareness-raising efforts. Exhibitions, conferences and public meetings are organized to coincide with WDD, and national media newspapers, radio, television are engaged to publicize the campaign and events. One such initiative involved a 2003 campaign to diagnose diabetes among high-risk groups. Around 10 000 people were tested and as result, some 900 people were diagnosed with diabetes. Diabetic foot care guidelines for health practitioners, and booklets containing recommendations for people with diabetes were produced and distributed in 2005. Diabetes education is not only one of the cornerstones of effective diabetes management, it is the key to relieving the economic burden of diabetes on the state and society. Since its inception,
DAK has actively promoted diabetes education for people with the condition and healthcare providers alike. DAK organizes seminars in many parts of the country for healthcare providers, including nurses, which focus on improving diabetes education for people with type 2 diabetes. Educational material has been produced to specifically ensure effective training. Diabetes education is the key to relieving the economic burden of diabetes on society. International partnerships Since 1999, DAK has enjoyed a close supportive relationship with the German charity organization, Kinderhilfe. The German group has provided children and teenagers with diabetes in Kyrgyzstan with glucometers and test strips, insulin and insulin delivery systems to the value of 350 000 EUR. Recently, DAK received a training grant from IDF Europe. The funding, worth 8000 EUR, supports an educational project for people with diabetes in Talas oblast. DAK will continue to seek effective partnerships within our borders and internationally in order to continue supporting people with diabetes and to protect and enhance the Kyrgyz healthcare system.
Svetlana Mamutova
Svetlana Mamutova is President of the Diabetes Association of Kyrgyzstan and Director of the Endocrinology Centre, Bishkek, Kyrgyzstan.
Diabetes in society
37
Taking up the struggle to improve care: a journey with diabetes

Barbara Elster
During a meeting halfway through a 24-month project for the UK National Institute for Health and Clinical Excellence (NICE), surrounded by well-known health professionals, Barbara Elster was asked her opinion on one of the subjects under discussion. Having expressed her views, she contemplated how she, a person with no formal medical training, had come to be in such esteemed medical company, involved in producing national guidelines on diabetes for the UK Government. In this article, she describes her journey with diabetes as the mother of a child with the condition and a person with type 2 diabetes and underlines the importance of a central role in diabetes care for people with the condition and recognition on the part of healthcare professionals of the importance of peoples real-life experience.
At the turn of the 19th century, the US author Mark Twain famously described physicians as wanting you to: eat what you dont want, drink what you dont like, and do what youd rather not. While Twains words are typically humorous, they encapsulate the experience of generations of people, and refer to themes that are highly relevant to people with diabetes: the attitudes of healthcare professionals towards the people in their care, and the impact on peoples health and well-being of the traditional doctor-patient relationship. I am pleased to say that my experience of health professionals today differs greatly from Twains vision. But reaching this point has required a great deal of commitment, dedication, and support and the work continues. Thirty seven years ago, at the Great Ormond Street Hospital in London, I had my first meeting with the physician in charge of the care of my 2-year-old son, BradleyMarc, who had just been diagnosed with type 1 diabetes. This was not a positive experience for me. Although I was new to the world of diabetes, I was no stranger to parenting: Bradley-Marc was my fourth child. Yet I was being instructed as to how I should react to my sons dislike for the food he had been given, which I was told he must finish as part of his treatment. It was clear to me that my feelings meant little to this healthcare professional.
38
Diabetes in society
For all parents, their childrens lifelong health and happiness is the ultimate goal.
Starting the journey My interaction with the senior nurse in my sons ward was an entirely different story. She was patient and supportive, taking time to explain to me the importance of food in balancing the effects of insulin. After many hours of conversation, my mission in life became clear: to learn as much as I could about diabetes, control my emotions, and work with other parents of children with diabetes, raising our collective voice in order to become involved in and improve the care of our children. One of my first steps was to organize a national conference for the parents of children with diabetes the first of its kind in the UK. While the parents were in sessions, our children were taken to the zoo in the care of young doctors and nurses. For the first time, parents had a forum where they could draw on their real-life knowledge and experience in order to present facts from a non-medical point of view, effectively challenging the healthcare professionals.
National support Having formed a number of parents groups, I sought the support of our national diabetes organization, Diabetes UK (then known as the British Diabetic Association). Doubts remained, however, as to whether health professionals and public health administrators could be convinced to take our needs seriously. Would they understand that emotions take hold of parents when their child is diagnosed with diabetes? Often, anger, disbelief, and bewilderment combine to make parents fear for the future. All parents want more than just survival for our children; their lifelong health and happiness is our ultimate goal. In order to achieve this, it is essential that healthcare professionals offer families care, support and knowledge in the context of encouragement and understanding. Diabetes UK recognized the importance of children in their work to improve diabetes care. A Childrens Committee
Diabetes in society
39
was formed, and the organization undertook to organize holidays for young children. My participation in both of these projects brought me into contact with many parents and dedicated health professionals, and my own diabetes journey continued in question-and-answer sessions around the country, alongside doctors, dietitians, specialist nurses and researchers. When I became a Trustee of Diabetes UK, I was able to bring the knowledge I had accumulated from the many parents groups across the UK to the formal setting of monthly meetings. Interestingly, during these meetings, the health professionals somehow all managed to sit together, with the non-medical Trustees sitting opposite. Contributions had to be invited by the Chair, and any Trustee showing strong emotions were politely asked to conclude. I very quickly learned to ensure that my observations were brief and very well informed. Although initially I felt uneasy in the company of consultants and professors, fearful of not being taken seriously, I was encouraged by key officers to continue fighting and work with the remarkable healthcare professionals that did want to listen to people like me. Recognizing the specific problems faced by adolescents with diabetes, I was instrumental in organizing weekend camps for teenagers. A surprising and encouraging number of healthcare professionals were delighted to be invited to take part in these informative events. The young people chose the subjects they wanted to discuss including sex, alcohol, driving, travel and the groups were free to express their own ideas and feelings. One of the most frequent comments went along the lines of: our health professionals were fantastic why cant clinic times be like this? Why indeed. My work with Diabetes UK continued to focus on engendering respect for the needs and wishes of people with diabetes adults and elderly people as well as children and adolescents. It was apparent to me that elderly people represented one of the most underserved groups in our society, and I made every effort to convince healthcare professionals to insist on a more realistic approach to care. Denying an 85-year-old woman a small piece of her own birthday cake because it is not good for her diabetes, for example, is insensitive, humiliating, and potentially counter-productive.
A few years ago, I was diagnosed with type 2 diabetes, which did not come as a complete surprise to me as I had had gestational diabetes while pregnant with my first daughter many years previously. At that time, however, I had no idea of the real significance of my condition; after the birth of my daughter, I thought I was cured! Now, of course, I understand the many challenges involved in living with diabetes in the real world. Ignorance is not bliss In order to improve their health outcomes and quality of life, people with diabetes must remain at the centre of their care. People who live with diabetes must be encouraged to ask questions about their condition, to learn as much as possible in order to feel at ease with the healthcare professional who will offer them advice and support. Healthcare professionals can, and do, become experts in diabetes management; but only people with diabetes can become experts in the organization of their everyday lives. Health professionals must carry out their work with compassion, concern and compromise always with patience and understanding. Diabetes is not just a medical condition as described in a text book. It is a way of life. The real-life experiences of those affected by diabetes must be taken seriously into account. With the help and determination of everyone involved in diabetes care, we will win our battle with diabetes. There must be no losers in this game.
Barbara Elster
Barbara Elster is Vice-President of Diabetes UK and participates in numerous diabetes-related groups at local and national level, including the UK National Institute for Health and Clinical Excellence (NICE) Guidelines Development Group for Type 2 Diabetes.
40
Diabetes in society
TIDES: meeting diabetes needs in times of crisis

Debbie Jones
It is estimated that over 3 million deaths each year are directly related to diabetes. Of greatest concern is that diabetes prevalence appears to be highest in the low- and middle-income countries. Managing diabetes, a complex task in ideal circumstances, can be made extremely difficult in emergency situations. Millions of people around the world live under constant threat from armed conflict or natural disasters, such as floods, hurricanes and earthquakes. The difficulties faced by poor and underserved people in accessing diabetes care are exacerbated in times of catastrophe. Debbie Jones reports on an International Diabetes Federation initiative which aims to ensure care for people with diabetes in emergency situations.
Thousands of homes were severely damaged or completely destroyed, which provoked terrible uncertainty and fear of losing homes and possessions for many thousands of people; many people were separated from their loved ones. Ensuring access to medication for people with diabetes who were temporarily housed in emergency shelters proved extremely difficult. Greatly increased levels of stress and anxiety resulted in rising blood glucose levels. Medical records had been lost. Many of the patients had no knowledge of their medication: a number of emergency clinics reported that people with diabetes, in need of medication, were only able to describe their prescription as a blue or yellow pill. Ensuring access to medication for people housed in emergency shelters proved extremely difficult. While the geographical context varies, the experiences of disadvantaged
In the wake of Hurricane Katrina in 2005, many of the evacuees with diabetes in the New Orleans area had low incomes, low rates of home ownership, and no health insurance coverage. Co-morbidities, such as heart disease and asthma were common. Large numbers of people encoun-
tered extreme difficulties accessing and maintaining diabetes supplies. Prior to Katrina, many people relied on the network of hospitals and clinics of New Orleans public hospital system; Charity Hospital, which served thousands in the New Orleans area, was completely demolished.
Diabetes in society
41
people are depressingly similar around the world after events like the Indian Ocean earthquake, hurricanes affecting the Caribbean, war in Iraq, Lebanon, and Afghanistan, or the recent earthquakes in Pakistan and Peru. Stress-induced hyperglycaemia was a severe problem after the 2004 tsunami provoked by the Indian Ocean earthquake on December 2. Many people with diabetes had high blood pressure and elevated lipid levels. The lack of available water and, in many cases, access only to sweetened drinks exacerbated the threat of hyperglycaemia provoked by the lack of blood glucose-lowering medications. In emergency situations, diabetes supplies, including blood or urine glucose testing equipment and medications, must be up to date and constantly available. Sadly, large numbers of people with diabetes around the world can testify to the failure of healthcare services to guarantee these supplies in the aftermath of a catastrophe. Many people with diabetes can testify to the failure of healthcare services to guarantee supplies in the aftermath of a catastrophe. Daily diabetes management tasks often take second place in the daily struggle for survival. The lack of equipment, shelter and hygiene make the task of glucose testing almost impossible; food shortages complicate dietary management, and opportunities for physical activity might disappear when peoples local environment is severely damaged. The threat of diabetes and
its symptoms are compounded by the effects of armed conflict or natural disasters: many people with diabetes present with severe injuries to their hands and feet, which increase the risk of diabetes-related ulceration and subsequent amputation. International response Despite the achievements of aid organizations like Insulin for Life and the Red Cross and Red Crescent Movement, there is an important lack of knowledge about how to respond in support of people with chronic disease in emergency situations particularly regarding the specific needs of people with diabetes. Although people with type 1 diabetes depend on insulin for survival, there have been reports of dismissal by aid organizations of the need for an urgent response which recognizes diabetes as a life-threatening condition. In order to avert preventable death and disability beyond the immediate effects of a disaster, it is essential to ensure that people with diabetes have the knowledge they need to obtain medical care after a disaster, and that those ancillary services have been previously prepared to cope with an emergency event. Turning the tide IDF recognizes the need to bolster the capacity to respond to emergency situations. Staff and resources have been earmarked for improving outcomes via an initiative that was launched at the end of 200, known as Towards Improvement In Diabetes Emergency Settings (TIDES). Organizations involved in emergency aid, such as Insulin for Life and WHO,
stress the need to address chronic disease in the aftermath of a disaster. Low educational levels and resistance to outside aid from domestic administrations are cited as obstacles to ensuring adequate emergency care for people with diabetes. TIDES, in line with the UN Resolution on diabetes, embraces awareness, education, and effective partnerships. TIDES deserves attention from all sectors. The project, in line with the UN Resolution on diabetes, embraces awareness, education, and effective partnerships. Moreover, TIDES might serve also to open a dialogue with countries around the world regarding the importance of provision for chronic diseases in national disaster plans. IDF Member Associations will play an important role in identifying the key government and healthcare agencies that are relevant to this initiative. Emergency relief organizations will be identified and contacted in order to establish and protect effective channels of communication. Workshops are planned to raise diabetes awareness and increase diabetes knowledge among these agencies.
Debbie Jones
Debbie Jones is Coordinator of the Diabetes Centre and Coordinator of clinical trials at King Edward VII Memorial Hospital, Hamilton, Bermuda. She is a Vice-President of the International Diabetes Federation.
42
Media and events
The Public Library of Science: opening access to medical research

Paul Chinnock
There are thousands of medical journals worldwide, many of them publishing articles that report diabetes-relevant research. The growth of Internet publishing has made this knowledge universally available in theory. However, the contents of peer-reviewed medical journals are beyond the reach of most of the worlds healthcare providers and indeed most people with diabetes. Publishers limit access to the latest research findings to those institutions and individuals that can afford to pay for it. Paul Chinnock puts forward the case for open access publishing, and describes the principles and achievements of the open access movement, focusing on one of the key players the Public Library of Science.
People with diabetes are obviously interested parties when it comes to knowledge about their condition, and should surely have the right to see published articles that report diabetes research. Given that much research is funded by governments or charities, tax payers and anyone who has ever subscribed to a medical charity can argue that they have a right to see what they helped pay for. Furthermore, many people with diabetes have participated in research projects themselves and have thus made an important contribution of another kind. Medical journals used to be held only in specialist libraries, making it difficult to access published medical research. Since the launch of the Internet, however, most of the important journals have been published online, so that
technically it is possible for anyone to reach them. However, the majority of these journals charge a substantial subscription fee, which must be paid before their content can be read either in print or online. For example, the journals Diabetes and Diabetes Care each have annual subscription rates of 30 USD. Access to single articles also can be costly: access to a single article in Diabetes Self-management costs 28 USD; Pediatric Diabetes is more expensive at 55 USD. The substantial subscription fees charged by most publishers close the door on the potential for open access. Stifling research Scientists working in a research establishment in a developed country will have access to many of the journals they need to see via their institutions library, which of course requires a very large budget to pay for institutional subscriptions. Anyone who does not
Media and events
43
PLoS Medicine covers the complete range of medical specialties with diabetes a priority.
articles, edit, and print or publish them online. However, it might be argued that this is a relatively small contribution compared to that of the researchers and those who funded the investigation or participated in it. An alternative to charging the reader is for those funding the research to meet the publication costs. If a one-off fee is paid for publication, the research can be made available online free of charge for anyone to see. This is the basis of open-access publishing. have the services of such a library at their disposal would have to find other ways of meeting the costs. Most journals allow free access to short summaries (abstracts) online. However, an abstract alone is of limited value, and might even give a misleading impression of the research and its findings. These financial restrictions to scientific knowledge appear to be exacerbating the existing imbalance in resources between the wealthy developed world and the resource-limited developing countries. The former Director General of the Indian Council of Medical Research pointed out that an Indian [researcher] is often unaware of the latest trends in science publishing [because] hardly 10% of our libraries get the top journals.1 As well as limiting the potential for research in developing countries, the lack of access poses problems for huge numbers of people who might have reason to consult published research on diabetes: healthcare providers, health policy-makers and planners, people with diabetes and their families, the public at large. Ironically, there is a wealth of freely available diabetes information on the Internet that is of dubious origin and quality. Much of it is misleading and potentially dangerous. There is a wealth of freely available diabetes information on the Internet much of it misleading and potentially dangerous. Clearly, there are considerable costs involved in producing a peer-reviewed, edited, and formatted article for online publication, and hosting it on a server that is accessible around the clock. Publishers arrange the expert review of The Public Library of Science Many people and organizations are part of the open-access movement. The Public Library of Science (PLoS), a non-profit organization of scientists and physicians committed to making the worlds scientific and medical literature a freely available public resource, is playing a key role. We promote the concept of open-access publishing and publish open-access journals. All PLoS material is published under the Creative Commons license, which allows unrestricted use, distribution, and reproduction in any medium. This means more than just free access: articles can be printed freely, passed on, and used (in whole or in part) in other publications, provided the original work is properly cited. Diabetes organizations, for example, are welcome to reprint any material from a PLoS journal; permission is not required
44
Media and events
Journals published by the Public Library of Science

PLoS Biology PLoS Medicine PLoS Genetics PLoS Pathogens PLoS Computational Biology PLoS Neglected Tropical Diseases PLoS ONE
to translate into local languages. An example of the creative use of articles that bring research closer to people with diabetes can be seen on the website of Children with Diabetes: www. childrenwithdiabetes.com. PLoS believes science is international, and aims to provide access to scientific literature to anyone, anywhere, publishing work from all regions and territories, and engaging a geographically diverse group of scientists in the editorial process. Scientific quality and importance are the sole considerations in editorial decisions. PLoS believes science is international, and publishes work from all regions and territories. PLoS Medicine, launched in 2004, is one of the flagship journals of PLoS. We cover the complete range of medical specialties; diabetes is a priority area. With the ultimate aim of improving human health, we encourage research and comment that address the global burden of disease. Quality and equality Open access as a whole and the PLoS journals in particular have received a
degree of negative criticism, much of it from established publishers. It has been claimed that open-access articles will always be of lower quality than those in the traditional journals. PLoS argues that the quality of articles is not related to the method of publication; everything we publish passes a rigorous expert peer-review process. Most of the research submitted to PLoS Medicine is in fact rejected; only articles of the highest quality are accepted. PLoS asks those researchers whose work we accept for publication to pay a publication fee currently 2500 USD out of their research budget. It has been alleged that such fees might make it impossible for some researchers to publish their work. However, PLoS recognizes that many researchers might have a limited budget, particularly those working in developing countries. We therefore operate a feewaiver policy. Importantly, members of the editorial team do not know who can afford to pay and who cannot. A firewall effectively separates the editors from our colleagues who deal with finances, which prevents any influence on publishing decisions. Enhancing understanding Some would argue that the very technical language used in scientific and medical reports makes these unsuitable reading for the public, reinforcing the argument in favour of maintaining limited access to published research. PLoS Medicine strives to promote wider understanding as well as open access. The editors write a 500- to 750-word summary of each article, using plain language to explain what has been done and set it in context. Our maga-
zine section contains articles which help put research in perspective, and we have a rapid electronic readerresponse system, enabling our readers to comment on published material. Making progress Many scientists now submit their work to the PLoS journals; the quality of these publications is widely recognized. Open access is supported by many of the organizations that fund research, most notably the US National Institutes of Health. The Wellcome Trust, one of the worlds largest financers of medical research requires that all research funded by the Trust is published with open access. Others are taking up a similar position. Recently, three major funding agencies in the UK the Department of Health, the British Heart Foundation and Cancer Research UK announced policies on open access. A few of the established publishers are taking steps to make some of their research articles available through open access.
Paul Chinnock
Paul Chinnock is a Senior Editor of PLoS Medicine.
Reference
1 Gibbs WW. Information have-nots: A vicious circle isolates many third world scientists. Scientific American 1995; 272: 12-4.
For more about PLoS, its aims and core principles, visit www.plos.org To read PLoS Medicine, go to www.plosmedicine.org
International Diabetes Federation
Executive Board
President
Martin Silink, Australia
Regions
Africa
Chair: Alieu Gaye, Gambia Chair-Elect: Maria Mupanomunda, Zimbabwe Office Manager: Nancy Njie
Phone: +220-4224174 idfafrica@mill.gm www.idf-africa.org
Corporate Partners
Long Term Partner (Lawrence Circle)
Eli Lilly and Company Novo Nordisk A/S Roche Servier
President-Elect
Jean-Claude Mbanya, Cameroon
Vice-Presidents
Anne-Marie Felton, United Kingdom Michael Hirst, United Kingdom Nigishi Hotta, Japan Debbie Jones, Bermuda Massimo Massi-Benedetti, Italy Marg McGill, Australia Valentina Ocheretenko, Ukraine Kaushik Ramaiya, Tanzania Shaukat Sadikot, India Denis Taschuk, Canada Brian Wentzell, Canada Wim Wientjens, The Netherlands
Eastern Mediterranean and Middle East
Corporate Partners (Mayes Circle)

AstraZeneca Bayer Corporation Becton Dickinson Eli Lilly and Company GlaxoSmithKline LifeScan Merck KgaA Merck and Co. Novo Nordisk A/S Pfizer Roche Diagnostics Sanofi-Aventis Servier Takeda
Chair: Morsi Arab, Egypt Chair-Elect: Amir-Kamran Nikousokhan Tayar, Iran Office Manager: Ali El Sherif
Phone: +203-5433505 Fax: +203-5431698 alyshrf@hotmail.com www.idf-emme.org
Europe
Chair: Tony OSullivan, Ireland Chair-Elect: Eberhard Standl, Germany Office Manager: Lex Herrebrugh
Phone: +32-2-5371889/6392094 Fax: +32-2-5371981 lex@idf-europe.org www.idf-europe.org
Executive Office
Luc Hendrickx, Executive Director Marleen Vanden Berghe, Executive Assistant Alain Baute, e-Project Manager Delice Gan, Special Project Manager Olga Greenwood, Office Assistant Chlo Harkness-Pierre, Programme Manager Olivier Jacqmain, Project Coordinator Ronan LHeveder, Project Manager Kerrita McClaughlyn, Media Asha Nartus, Office Assistant Tim Nolan, Editor Vivian Okonkwo, Congress Assistant Lorenzo Piemonte, Communications Coordinator Anne Pierson, Press Events Manager Marcel Pirlet, Finance Manager Jol Quenum, Accounting Assistant Catherine Regniers, Project Manager Celina Renner, Congress Manager Philip Riley, Communications Manager Dominique Robert, Special Project Coordinator Kari Rosenfeld, Special Project Manager
Relations Coordinator
Contributor
Abbott Amylin Medtronic Novartis
North America
Chair: Frank Vinicor, USA Chair-Elect: Lurline Less, Jamaica Office Manager: Linda Cann
Phone: +1-703-5491500 Fax: +1-703-5491715 lcann@diabetes.org www.idf-na.org
South and Central America
Chair: Susana Feria de Campanella, Uruguay Chair-Elect: Manuel Vera Gonzalez, Cuba Office Manager: Vasco Campanella Lemes
Phone: +598-2-7095457 Fax: +598-2-7072963 susanafe@adinet.com.uy www.saca-idf.org
South-East Asia
Chair: Mahen Wijesuriya, Sri Lanka Chair-Elect: Dhruba Lall Singh, Nepal Office Manager: Farzana Hameed
Phone: +94-11-2872951 Fax: +94-11-2872952 dasl@sltnet.lk www.idf-sea.org
Western Pacific
Chair: Gordon Bunyan, Australia Chair-Elect: Yutaka Seino, Japan Office Manager: Esther Ng
Phone: +65-64587172 Fax: +65-65531801 idf_wpr@diabetes.org.sg www.idf-wp.org
The International Diabetes Federation (IDF) is not engaged in rendering medical services, advice or recommendations. The material provided in this publication is therefore intended and can be used for educational and informational purposes only. It is not intended as, nor can it be considered or does it constitute, medical advice and it is thus not intended to be used or relied upon to diagnose, treat, cure or prevent diabetes. Readers should seek advice from and consult with professionally qualified medical and healthcare professionals on specific situations and conditions of concern. Reasonable endeavours have been used to ensure the accuracy of the information presented. However, the International Diabetes Federation (IDF) assumes no legal liability or responsibility for the accuracy, currency or completeness of the information provided herein. Any views, opinions, and/or recommendations contained in this publication are not those of IDF or endorsed by IDF, unless otherwise specifically indicated by the IDF. The International Diabetes Federation assumes no responsibility or liability for personal or other injury, loss, or damage that may result from the information contained within this publication. Acceptance of advertisements in Diabetes Voice should not be construed as an endorsement by IDF. IDF does not test advertised products and, therefore, cannot ensure their safety and efficacy. Acceptance of advertising does not imply that IDF has conducted an independent scientific review to validate product safety and efficacy of advertising claims. The Federation reserves the right to reject any advertisement for any reason which need not be disclosed to the party submitting the advertisement.

Issue 52 en

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Issue 52 en

Uploaded by

Copyright:

Available Formats

September 2007 Volume 52

September 2007 Issue 3 Volume 52 I

Preparing for global urbanization 2

Access to care and information

Insulin pump therapy in children and adolescents: risks and benefits

Karin Lange and Thomas Danne 9

Guideline for the management of post-meal blood glucose

Antonio Ceriello and Stephen Colagiuri

Prevention and management of diabetes: the role of the physiotherapist

The BRIDGES programme: sharing practical solutions and improving outcomes

12 Sanjay Kalra, Bharti Kalra, Naresh Kumar

From adolescence to adulthood: the transition from child to adult care 15

Advocating for the rights of people with diabetes in Kyrgyzstan 34

Taking up the struggle to improve care: a journey with diabetes 37

Shaukat Sadikot, Anant Nigam, Anil Jain

TIDES: meeting diabetes needs in times of crisis

MEDIA AND EVENTS

The Public Library of Science: opening access to medical research

September 2007 | Volume 52 | Issue 3

Preparing for global urbanization

September 2007 | Volume 52 | Issue 3

Access to care and information

September 2007 | Volume 52 | Issue 3

Bones help to control weight and metabolism

IDF is looking to hire a full-time

Diabetes Education Manager

New definition helps identify children at risk of metabolic syndrome

September 2007 | Volume 52 | Issue 3

Poor countries catching up with rich nations in non-communicable diseases

Stem cell researchers find almost perfect human match in mice

September 2007 | Volume 52 | Issue 3

Vitamin deficiency could cause diabetes complications

HbA1c during gestational diabetes predicts long-term risk

Insulin from genetically modified plants?

People with diabetes at greater risk of infections in hospital

September 2007 | Volume 52 | Issue 3

Gulf States pledge to make diabetes a priority

Updated International Consensus on the Diabetic Foot

of their healthcare systems, taking into

16th European Congress on Obesity ECO 2008

European Association for the Study of Obesity

September 2007 | Volume 52 | Issue 3

Guideline for the management of post-meal blood glucose

September 2007 | Volume 52 | Issue 3

Table 1: Medications that target post-meal blood glucose

September 2007 | Volume 52 | Issue 3

September 2007 | Volume 52 | Issue 3

Prevention and management of diabetes: the role of the physiotherapist

September 2007 | Volume 52 | Issue 3

September 2007 | Volume 52 | Issue 3

Sanjay Kalra, Bharti Kalra, Naresh Kumar

September 2007 | Volume 52 | Issue 3

From adolescence to adulthood: the transition from child to adult care

September 2007 | Volume 52 | Issue 3

September 2007 | Volume 52 | Issue 3

September 2007 | Volume 52 | Issue 3

September 2007 | Volume 52 | Issue 3

Hari Singh demonstrates his treeclimbing skills.

September 2007 | Volume 52 | Issue 3

September 2007 | Volume 52 | Issue 3

Shaukat Sadikot, Anant Nigam, Anil Jain

September 2007 | Volume 52 | Issue 3