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| PERSPECTIVE |
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| Year : 2016 | Volume
: 5
| Issue : 1 | Page : 44-47 |
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An approach to diabetes prevention and management: The Bhutan experience
Tandin Dorji1, Pemba Yangchen2, Chencho Dorji3, Tshering Nidup4, Kinley Zam5
1 Health Care and Diagnostic Division, Department of Medical Services, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan
2 Diabetes Prevention and Care Programme, Health Care and Diagnostic Division, Department of Medical Services, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan
3 Gidakom Hospital, Thimphu, Bhutan
4 Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan
5 Planning and Policy Division, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan
| Date of Web Publication | 18-May-2017 |
Correspondence Address:
Tandin Dorji
Health Care and Diagnostic Division, Department of Medical Services, Ministry of Health, Royal Government of Bhutan, Thimphu
Bhutan
  | Check |
DOI: 10.4103/2224-3151.206552 PMID: 28604397 
Bhutan has been witnessing a trend of increasing diabetes in recent years. The increase is attributed to a rise in risk factors such as overweight, high blood pressure, unhealthy diet and sedentary lifestyle among the population. To address the rising burden, the health-services response has been to establish diabetes clinics in all hospitals and grade one basic health units. People visiting the health centres who have high risk factors and symptoms for diabetes are screened using the World Health Organization cut-off level for blood glucose. They are then classified into prediabetes and diabetes. Accordingly, diet, medicine and physical activity are recommended as per their body mass index. To improve prevention and control of noncommunicable diseases, which include diabetes, the country piloted the WHO Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings in 2009, to promote early screening, treatment and follow-up, and adopted it in 2013. The WHO PEN has now been successfully integrated into the primary health-care system nationwide. It is planned that diabetes clinics will be upgraded to NCD clinics.
Keywords: Bhutan, diabetes, noncommunicable diseases, prevention, risk factors, screening, treatment
How to cite this article:
Dorji T, Yangchen P, Dorji C, Nidup T, Zam K. An approach to diabetes prevention and management: The Bhutan experience. WHO South-East Asia J Public Health 2016;5:44-7 |
How to cite this URL:
Dorji T, Yangchen P, Dorji C, Nidup T, Zam K. An approach to diabetes prevention and management: The Bhutan experience. WHO South-East Asia J Public Health [serial online] 2016 [cited 2020 Jul 9];5:44-7. Available from: http://www.who-seajph.org/text.asp?2016/5/1/44/206552 |
| Background | |  |
Bhutan is a small country in South Asia with a landmass of 38 000 km2 and a population of 757 042.[1] Although a small country, Bhutan, like its South Asian neighbours, is witnessing an increasing trend in diabetes. Administrative data show an increasing burden of diabetes (see [Figure 1]). According to the 2014 estimates of the International Diabetes Foundation, approximately 77% of people with diabetes live in low- and middle-income countries, and for Bhutan the number of people with diabetes is estimated to be 33 000 (456 per 10 000 population), with one third of this group undiagnosed and the cost of treating diabetes being US$ 143 per person.[2] Further, the national prevalence of diabetes is estimated to be 4.87%, with 124 diabetes-related deaths in 2013.[2]
The nationwide World Health Organization (WHO) STEPwise approach to surveillance (STEPS)[3] survey conducted in 2014 among the age group 18–69 years shows that Bhutanese populations are exposed to increased lifestyle-related risk factors: 39.2% were overweight or obese, 35.7% had raised blood pressure, 32.9% had raised blood pressure but were not on medication, 6.4% had raised fasting blood glucose, 6.4% did not have sufficient physical activity and 48.8% did not engage in vigorous physical activity.[4]
| Health-Care System and Policy in Bhutan | | |
Bhutan has a government-administered free health-care system with a strong focus on primary health care. The country has three tertiary care facilities: one national referral hospital and two regional referral hospitals. These are supported by a network of 28 district hospitals, 20 grade 1 basic health units (BHU-Is), 186 grade 2 basic health units (BHU-IIs) and 562 outreach clinics.[1] Physicians are available at the hospitals but BHUs are staffed by non-physician health workers.
The Bhutan National Health Policy, 2011, states that “the prevention strategy for NCD [noncommunicable disease] within the Ministry of Health will focus on addressing the impact of unhealthy dietary habits/lifestyles/traditional practices on the health of the Bhutanese population and their prevention and control through advocacy, risk surveillance and analysis rather than making specific interventions”.[5] In addition, it also states that the “health promotion, disease prevention and health care services will be incorporated as a vital component in the entire relevant programs, and appropriate measures will be instituted to intensify health promotion interventions that address social determinants causing life style related diseases”.[5]
In order to address the growing burden of NCDs, the Royal Government of Bhutan has adopted a number of population-based strategies. These include the formulation of a national policy for the prevention and control of NCDs, banning the sale of tobacco and smoking in public places, and policies on promotion of a healthy diet and physical activity. In addition to interventions targeted at the population level, the government has also piloted a package of essential noncommunicable (PEN) disease interventions for individual-level risk reduction and risk management, and rolled this out nationwide.[6]
| Diabetes Prevention and Care Programme | | |
To address the growing concern about diabetes, the Diabetes Prevention and Care Programme was established within the Ministry of Health in 2005, with the aim of preventing diabetes in the population, minimizing complications and improving the quality of life among those living with diabetes. In order to manage diabetes, diabetes clinics have been established in the referral hospitals, all district hospitals and BHU-Is. The clinics are managed by a focal health-care provider, who is trained on diabetes management and care. One day each week is observed as “diabetes day” in all the districts. During this day, the patients who are diagnosed with diabetes are given health education on diet and physical activity as per their disease conditions, and foot examination is also carried out.
Diabetes screening
Diabetes screening is done at all levels of health facilities. Depending upon the 10-year risk of a fatal or nonfatal cardiovascular event (low/moderate/high) using the WHO/ ISH [International Society of Hypertension] risk prediction charts,[7],[8] biochemistry services such as fasting blood glucose, postprandial blood glucose and glycosylated haemoglobin (HbA1C) are provided, depending on the level of health facility. At the primary level, diagnostic tests are done using a glucometer to measure random blood glucose. At the secondary, tertiary and referral level, biochemistry tests comprising fasting blood glucose, 2-h postprandial blood glucose and HbA1C are carried out. For diabetes patients at high risk, cholesterol, renal and kidney functions are also assessed. Pregnant women with obesity, a history of gestational diabetes, glycosuria, or family history of diabetes are checked for glucose level, using the oral glucose tolerance test during the antenatal check-up at 24–26 weeks of gestation.[9]
Depending on the results of the diagnostic tests, patients are categorized as having prediabetes or diabetes. The prediabetes stage is one in which the fasting plasma glucose is between 130 and 140 mg/dL and postprandial plasma glucose is between 140 and 199 mg/dL; the diabetes stage is when the random blood glucose is higher than 200 mg/dL with fasting plasma glucose higher than 126 mg/dL; 2-h postprandial glucose is greater than 200 mg/dL and HbA1C is more than 6.5 mg/dL.[10]
Diabetes management
Patients with diabetes are registered in the diabetes clinic and are provided individual prescription booklets, which include guidance on the disease, risk factors, diet and foot care, with a few pages of follow-up sheets. Administrative records for the Diabetes Prevention and Care Programme show that Bhutan has more than 12 000 registered cases of diabetes, with more than 1000 cases registered in 2014 alone. The clinic assesses patients for complications and comorbidities like hypertension (defined as blood pressure of 140/90 mmHg or above).
Patients with prediabetes are prescribed metformin, along with advice on lifestyle modification and physical activity. Patients with diabetes are prescribed oral drugs like metformin, glipezide and insulin - in the form of human (soluble) insulin, human zinc suspension and human mixtard (neutral isophane), which are provided free at the health facility.[11] In addition, patients’ calorie requirements are calculated, based upon their body mass index (BMI), level of physical activity and disease condition. Adjustment of oral drugs is also done as per the laboratory test results.
In follow-up, to prevent complications related to diabetes, patients are assessed every month for fasting blood glucose, postprandial blood glucose and weight; HbA1C is tested every 3 months; waist circumference and BMI are checked every 6 month; lipids, fundus, and microalbuminuria are checked annually; and renal function tests are carried out twice per year. Blood pressure measurement and foot examination are carried out on every visit. Adjustments to oral drugs are also made as per the laboratory test results.[12]
Good practice
There has been a renewed focus to strengthen the Diabetes Prevention and Care Programme. New and follow-up cases of diabetes are recorded and reported from the districts to the Diabetes Prevention and Care Programme on a monthly basis. Further, annual reports are generated to enable the programme to develop evidence-based plans and strategies.
During occasions like national festivals or global days of observation, awareness and education programmes for the general population are conducted. These programmes include free testing of blood glucose, blood pressure monitoring and BMI measurements. In addition, education on the disease and its risks and symptoms, along with the importance of healthy eating habits and exercise are also carried out. These have contributed immensely to raising awareness and knowledge about diabetes.
The Ministry of Health has also developed a Food-based dietary guideline and a Physical activity guideline, which have been circulated to all the health facilities for patient education.[13],[14] The guidelines aim to help people develop and practise healthy eating habits. They are based on current scientific knowledge and best public health practices. The guidelines contain up-to-date information on the relationship between diet and disease, nutrients available in the Bhutanese food supply, dietary habits and the profile of morbidity and mortality in Bhutan.[13],[14]
| Challenges | | |
Like most low- and middle-income countries, Bhutan is also faced with numerous challenges in combating the rising diabetes epidemic. Despite the free health-care services, a country-wide audit of the records of the Diabetes Prevention and Care Programme showed that four in ten patients registered with diabetes were lost to follow-up. The incomplete recording of patient data in diabetes clinics was pointed out to be the commonest cause for the loss to follow-up.[15] Among those who come regularly as per the schedules given, glycaemic control was achieved only in one third of all patients.[16] Although diabetes care guidelines have been developed and are available to health-care providers, unstructured and unmonitored clinical care is still being practised. There is little regular or reliable information about the incidence and prevalence of cases, treatment outcomes, morbidity and mortality. Machine breakdown and shortage of laboratory reagents were also found to be occurring regularly in the health-care facilities.[16] Most of the health facilities do not have an HbA1C testing service; therefore, patients often have to travel to the district and regional referral hospitals, leading to frequent delays in accessing timely treatment.
For patients with diabetes and renal diseases, the government of Bhutan currently pays for the cost of vascular-access placement, medications and dialysis. In 2015, Zam et al. noted that, “Although a time limit for finding a living kidney donor has been set at three months, this plan has been found to be untenable in many cases. In reality, patients started on dialysis with no living-related donor stay on this treatment indefinitely, leading to the growth of the dialysis population”.[16] Only a limited number of dialysis machines and staff are available, owing to financial constraints and limited space at the hospital. In order to provide dialysis to more patients, treatment schedules have been cut to once weekly for some patients, instead of twice a week.[16]
Diabetes and high blood pressure are thought to be the major factors contributing to the occurrence of chronic kidney diseases in the country.[16] Currently, out of the 143 patients on dialysis in the country, 16 have diabetes: 5 of them are in Jigme Dorji Wangchuk National Referral Hospital, 10 in Gelephu Regional Referral Hospital and 1 in Mongar Regional Referral Hospital. As per the records maintained by the Jigme Dorji Wangchuk National Referral Hospital in Thimphu (which handles renal transplant referrals to India), the Royal Government of Bhutan spends an estimated US$ 8200 per person for renal transplants.
The cost of health care due to NCDs in Bhutan is rapidly increasing. Bhutan refers patients who cannot be treated in-country for treatment abroad. Most of these patients have NCDs. Over the last 3 years, the number of patients referred has increased by 15% annually. However, no data on NCDs and their risk factors are collected systematically and there is no information on complications, quality of health care, or health expenditures for NCDs.[17]
| The World Health Organization Package for Essential Noncommunicable Disease (PEN) interventions and diabetes | | |
The WHO Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings (WHO PEN) consists of prioritized interventions that can be delivered to an acceptable quality of care in low- resource primary-care settings.[18] The WHO PEN has been found to be effective in tackling NCDs in an integrated manner, as the PEN protocol covers diabetes, cardiovascular disease, cancer and chronic obstructive pulmonary disease; the pilot was implemented by the health services in real-life conditions through non-physician health workers.[6] The proportion of patients who were followed up was high, owing to the involvement of non-physician health workers, who also conducted home visits. During the pilot in 2009, the implementation of PEN interventions led to the identification of new NCD cases. On average, every month, each BHU registered five new patients and each hospital registered 15 new patients with NCD. Moreover, opportunistic screening of those aged over 40 years resulted in the identification of patients with high blood pressure and high blood glucose.The PEN pilot project empowered primary health-care workers to extend screening, diagnosis, treatment and counselling services to patients with NCD, from a health facility close to their home. The availability of medicines free of cost and close to home, and counselling by health workers who were well known in the community, improved behaviours and encouraged the regular intake of medicines, which led to better control of high blood pressure and high blood glucose, thereby reducing the risk for cardiovascular disease.[6]
Bhutan has been one of the first countries to pilot this intervention, and it has been gradually expanding the intervention to all its health-care facilities. It is hoped that with roll-out of the PEN nationwide, the Diabetes Prevention and Care Programme will be assimilated into the overall NCD prevention and control programme and the health service will have a holistic NCD control strategy based on the WHO Global action planfor the prevention and control ofnoncommunicable diseases 2013–2020[19] and the Action plan for the prevention and control of noncommunicable diseases in the South-East Asia Region, 2013–2020.[20]
Source of Support: Nil.
Conflict of Interest: None declared.
Authorship: TD was responsible for the concept, layout and write-up; PY for the layout and write-up; CD for the write-up on treatment protocol; and TN and KZ for the write-up on policy and health systems.
| References | | |
| 1. | |
| 2. | IDF diabetes atlas, 6th ed. Brussels: International Diabetes Federation; 2014 (https://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf, accessed 25 January 2016).  |
| 3. | World Health Organization. Chronic diseases and health promotion. STEPwise approach to surveillance (STEPS) (http://www.who.int/chp/ steps/en/, accessed 25 January 2016). |
| 4. | Factsheet Bhutan. Non communicable diseases risk factors: STEPS Survey Bhutan 2014. New Delhi: World Health Organization Regional Office for South-East Asia; 2014 (http://www.searo.who.int/entity/ noncommunicable_diseases/data/factsheet-bhutan-steps-survey-2014. pdf?ua=1, accessed 25 January 2016). |
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| 15. | Windus D, Owen R. ESRD care in Bhutan: common themes and unique challenges. Dial Transplant. 2010;39:166-7. doi:10.1002/dat.20435. |
| 16. | Zam K, Kumar AMV, Achanta S, Bhat P, Naik B, Zangpo K et al. A first country-wide review of diabetes mellitus care in Bhutan: time to do better. BMC Health Serv Res. 2015;15:389. doi:10.1186/s12913-015-1026-6. |
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[Figure 1]
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