An educational message by Novo Nordisk Pharma Malaysia

People with diabetes require ongoing care and support to manage their condition and avoid complications. With universal health coverage practised in the country, all Malaysians are able to obtain the medical care that they need for a very nominal fee in the public healthcare system. The access extends as well to people living with chronic diseases such as diabetes.

According to the National Health and Morbidity Survey 2019, there are some 3.9 million adults aged above 18 living with diabetes in the country – that’s about one in every five Malaysian adults. Just over half of them are diagnosed with diabetes while the remaining are actually unaware they have been living with raised blood glucose levels.

Access to diabetes care

Of the approximately two million adults who have been diagnosed with diabetes, the vast majority (83.2%) receive care at Ministry of Health (MOH) primary care clinics (68.2%) and hospitals (15.0%). The remainder see doctors at private clinics (12.1%) and hospitals (2.8%). A very small minority self-medicate by purchasing their own medications at pharmacies and/or seek the services of traditional and complementary medicine practitioners, while 2.1% do not seek treatment at all.

People with diabetes who attend primary care clinics are usually in the earlier, uncomplicated stage of their disease, and they have access to family medicine specialists who are well-trained in diabetes care. Those who have developed complications would be referred to a hospital to receive care from a physician or endocrinologist.

In Malaysia, there is a wide array of treatment options available to help people living with diabetes manage their condition optimally and to have a good quality of life. These include oral anti-diabetic medications, as well as injectables like insulin and glucagon-like peptide-1 receptor analogues. Some of the newly-available medications today not only help to control blood glucose levels, but also help to decrease complications like kidney and heart disease.

Managing diabetes at home

While clinical care and medications for diabetes are widely accessible in Malaysia, the key challenge is when the patient leaves the healthcare setting and has to self-manage at home. As a lifelong disease that requires significant lifestyle changes, those living with diabetes oftentimes find it challenging to maintain their new diet and physical activity regimen. Other known challenges in homecare and self-management include medication adherence issues such as not taking medications correctly or stopping them altogether, as well as skipping follow-up appointments with their doctor.

In managing diabetes at home, another often-overlooked person in the care of the patient with diabetes is their caregiver. With the frequency of diabetes increasing with age in Malaysia – the most number of cases occur among 65- to 69-year-olds – many people living with this disease often have a family member or domestic helper to help look after them. These caregivers play a particularly crucial role in the management of diabetes as they are the ones seeing and tending to the patient every day. It is therefore important to ensure that the caregiver is empowered with the appropriate knowledge to not only help the patient take their medications correctly, but also assist them in adopting the necessary lifestyle changes. In terms of mental health, both patients and caregivers should be taught how to recognise symptoms of depression, anxiety, and stress in themselves, as well as learn and practise healthy coping strategies.

Holistic management of diabetes

One important factor contributing to poor disease management is diabetes literacy, i.e. the patient’s perception of the disease and how it can affect them. There is often a gap between what the doctor thinks the patient understands about the disease, and what the patient actually understands about the disease. For example, many patients harbour a hope to eventually return to their “normal” pre-diagnosis life, while some feel that diabetes is something they can live with, as many people they know also have it and are managing it well. These feelings can have a significant impact on the acceptance of their condition, and thus, the way they understand and manage it. Even with complete acceptance of their condition, it is not easy for a person who has diabetes to suddenly master having a healthy and balanced diet, getting enough physical activity, monitoring their blood glucose regularly, and taking their medications properly.

This is where the need for a multidisciplinary team comes in. Aside from the specialist or medical officer in charge of the patient, a core diabetes care team includes a dietitian or nutritionist, pharmacist, and diabetes educator. The latter in particular plays an important role in helping each individual patient understand their condition and working together with them to make the necessary lifestyle changes needed, according to their socio-economic and cultural situation. It is easy to become weighed down or overwhelmed by a diagnosis of an incurable, lifelong disease like diabetes. Indeed, a 2013 study involving people with diabetes aged above 30 in the Klang Valley found that around one in 10 (11.5%) such persons suffered from depression. In addition, nearly one-third (30.5%) suffered from anxiety, while 12.5% were stressed. As such, the role of psychologists or psychiatrists is also becoming increasingly crucial in the care of people with diabetes to help them manage their mental health and wellbeing.

The diabetes policy landscape

Diabetes is one of the three NCDs prioritised in government policies, with the other two being heart disease and cancer. This is reflected in the National Strategic Plan for Non-Communicable Diseases 2016-2025. The aim of this 10-year plan is to prevent and control the three NCDs, as well as four of the risk factors common to these three NCDs, namely, tobacco use, an unhealthy diet, physical inactivity and harmful consumption of alcohol.

Diabetes is also one of the NCDs targeted for increased efforts in awareness programmes and screening efforts in the 12th Malaysia Plan (2021-2025). Sugar, which is one of the contributors to the progression of diabetes, also received attention in the recent Budget 2022. It was announced that the tax on sugar – first announced in 2019 – would be extended to premixed sugary beverages as well.

Many other government policies have an indirect impact on diabetes as they focus on preventing and controlling risk factors for diabetes, like obesity, an unhealthy diet and physical activity. The Komuniti Sihat Pembina Negara (KOSPEN) initiative is one such programme where community members volunteer to be trained in how to introduce and facilitate healthy lifestyle practices in their own communities. These volunteers are also trained to conduct basic health screenings, including for blood glucose levels, and to refer those with abnormal results to the local clinic or hospital.

Overall, access to diabetes care in Malaysia is notable, but the current gap lies in the lack of optimal management of Malaysians living with diabetes. At the core, the patient is the most important member of their own healthcare team, and their beliefs and attitudes will shape the outcome of their treatment and disease.

-- BERNAMA