Why has diabetes reached epidemic proportions in Bermuda?
Diabetes is a multi-factorial disease. A lot of it is driven by genetics here — there are many people who have it who are not obese. But it is also lifestyle driven — if we look at the diet of Bermudians as a whole we have a very sweet tooth. Obesity is a big issue — if we had a slimmer population we would have less diabetes.
Changing people’s habits is very hard. I often have conversations with my patients about food choices — people really like sweet foods here — it is generational. If your grandmother and mother are feeding you this food, then you are going to feed it to your children so education is important. In the U.K. they tax everything — if you taxed fat, salt and starch and sugar you would make those foods more expensive and it could subsidise fruit and vegetables.
Also lack of exercise is an issue — we have quite a sedentary lifestyle here in Bermuda. We can’t change genetics but our lifestyle is something we can focus on.
The cost of health care is a big factor here — in the U.S., where you have excess of amputations is where you have lower access to health care. If you know you are going to get a bill when you see the doctor you are going to put it off until the last minute. That is a barrier.
What are the primary reasons that our amputation levels are so high?
There are lots of factors — the cause of amputation can be because of infection in the feet and it can be because of loss of circulation. With neuropathy — you won’t necessarily feel pain in your feet. That is one of the problems, if it doesn’t hurt you might not go to the doctor to get it checked out. Education is really important in explaining this to people and that physicians check their patients’ feet. If you don’t know you have it, it is very difficult to target people — 20 per cent of people have neuropathy at diagnosis of diabetes here.
There is already a wound care clinic in the hospital with nurses and physicians but the diabetes side of the treatment hasn’t fully been tackled.
The new multi-disciplinary facility will bring together two wound care physicians, a podiatrist, a chiropodist, wound care nurses, a diabetes specialist nurse and a diabetologist as well as hospital surgeons.
We are going to work together to guide referrals so we have earlier investigation and intervention to prevent amputation.
How else will the new diabetes foot clinic help?
We want to try and focus care earlier in the presentation. There are certain investigations we don’t currently do on the island such as specific vascular assessments — looking at the circulation.
They didn’t have a diabatologist before so that will make a big difference. We can help people earlier in their disease process to change their lifestyle, use appropriate medication, have close surveillance and be encouraging.
What is the relationship like between the Bermuda Diabetes Association and the physicians?
I’m on the association’s board, I’m very involved. I am trying to make us best friends. There is a difference between an association and the medical side of things. The association is very valuable for education and as a resource center. They have a pharmacist and pharmacy which is paid for by the association so some of the charges are less because it is a charity. They are not for profit. It is definitely an asset and the association goes into schools and provides education. They also support the Spirit of Bermuda trips for kids with type 2 diabetes and obesity in childhood. They are about prevention and education. They also lobby government to increase awareness and are the ones who got them to take soda machines out of schools. The hospital’s job is to treat. We are working in parallel in the same direction but with different aspects of our remit. Over time, we will work more and more together. All the educational opportunities we have we bring in overseas physicians to educate local — the association often financially supports that. We are not separate.
The Department of Health recently drew up a set of guidelines for physicians in Bermuda. How is that going?
I wasn’t involved in designing the guidelines but they are similar to what I have been using overseas. The guidelines were not there before — if someone was trained in the States they might use the American Diabetes Guidelines and may not want to use the Bermuda guidelines we develop our own preferences — you are not going to change it if it works but it is useful to have them if there are gaps in people’s knowledge.
What else need to be done to improve the diabetes situation in Bermuda?
I’m trying to co-ordinate services and am talking to obstetricians etc. for diabetes in pregnancy.
There are lots of different aspects of diabetes care that I want to co-ordinate so that every aspect ends up being at the right level.
The patient also has a huge responsibility in looking after themselves. They have to go to the doctor to get checked.