Diabetes is a rising threat to the Portuguese people, the country’s healthcare system, and its economy. Portugal’s National Diabetes Observatory observed that 1.1 million Portuguese people between the ages of 20 and 79.5 (out of a total population of just 10.3 million) were living with diabetes in 2021.
This is being driven by a rapidly ageing populace – 2.2 million citizens are over the age of 65 – and the increase of overweight and obesity prevalence; 67.6 percent of the total population (and nearly 90 percent of people with diabetes) are overweight or obese in Portugal – long a pioneer in diabetes treatment – is going to require new and joined-up approaches, and potentially expensive new therapeutic options, to confront this seismic issue.
A Costly Crisis
Dr João Filipe Raposo, clinical director of patient society APDP – Diabetes Portugal, outlines the seriousness of the situation. “Diabetes in Portugal has one of the highest prevalences in Europe and around 40 percent of type two diabetics are undiagnosed. A big chunk of the budget is allocated to hospitalisation and acute care and treatment of the condition,” he states.
Paula Barriga, VP and GM for Novo Nordisk adds that “despite advancements in diagnostics and treatment and substantial investments in diabetes care, patient outcomes remain less than optimal here in Portugal. There is a growing weight of diabetes in hospital admissions, an increase by almost 20 percent in in-hospital mortality, and high numbers of lower limb amputation linked to diabetes. As indicated by the National Diabetes Observatory, the direct costs related to diabetes in 2021 were estimated to be between EUR 1.4 to 1.7 million, emphasising the need for a comprehensive and collaborative approach.”
An Ounce of Prevention
There is broad stakeholder alignment that fighting the diabetes epidemic will require earlier intervention on its root causes. “The surge in diabetes, pre-diabetes, and congestive heart failure is driven by two primary factors,” explains Pedro Moura, managing director of Merck’s operations in Portugal. “Firstly, the lack of sufficient emphasis on prevention contributes to the rapid evolution of these conditions. Greater investments in preventive measures and early diagnosis could potentially curb the prevalence. Secondly, lifestyle habits, including dietary choices, stress levels, and sedentary lifestyles, play a substantial role in the increasing prevalence of cardiometabolic diseases.”
Raposo adds that “Diabetes as a societal health concern is well known in Portugal, so building awareness is not the issue. People know that a healthy diet and exercise is a good step in prevention, but there is a disconnect between knowledge and behaviour. We are possibly missing a more strategic approach for higher risk populations, and this could be something to undertake in the future.”
He continues, “the lack of resources required to combat individual disease areas will become an even greater burden, and diabetes prevention is a good way of countering this. We must promote areas like physical education in school and university and offer better food options. We cannot make people make better decisions, but we can push them in the right direction and change their thoughts and daily habits.”
For Dr Carolina Neves, deputy clinical director of the APDP, diabetes’ link to overweight and obesity is the most important issue to tackle. “We need the whole society to be shaped around preventing diabetes, and a big part of that is preventing obesity,” she proclaims. “The increasing prevalence of obesity and weight problems are responsible for most cases of type two diabetes. If we were to eliminate obesity, 80 percent of diabetes cases would not exist. Therefore, one of the pillars of diabetes treatment and prevention is weight reduction and control.”
Fresh Approaches Needed
In addition to working on the lifestyle-based causes of diabetes, overweight and obesity, some are calling for a more radical overhaul of the nation’s approach to this pressing issue. “Are we treating all patients according to the most updated evidence and guidelines available?” asks Barriga. “Facing persistent national and regional asymmetries in diabetes care outcomes, are we capitalising on the learnings of the most successful? Are there different approaches to explore?”
Portugal has historically been a pioneer in the diabetes field and could position itself as a modern leader with a refreshed approach. The APDP, for example, is the oldest diabetes association in the world, being founded shortly after the discovery of insulin in 1926. It has adopted a unique model as a patient society that also provides clinical services for patients and acts as the nation’s largest diabetes outpatient clinic, as well as conducting clinical research and generating patient data.
Raposo advocates for greater integration of patient input across all stakeholders. “Private companies are definitely changing how they approach care, but it is still quite superficial, and they are engaging the patient less than they should,” he claims. “Many look at the patient’s needs at the end of the process and not throughout.”
He continues, “Regulators must also use the patient’s voice more. For example, INFARMED is currently taking a broad approach to treating people living with diabetes, rather than groups such as high and low risk, young and old. Each diabetes patient group needs a different approach. Saying that, it is not easy to help all patients in a broad sense, while still having a personalised system of care. Resources can only go so far.”
A New Armoury of Therapeutic Options
Insulin, which recently celebrated its 100th birthday, has long been the standard of care for diabetics, and insulin-based products continue to be so today. However, in addition to more well-established treatments, a new era of therapies are now coming online with the potential to move the dial on diabetes and its causes. “While some drugs in the market have been integral to treatment protocols for over two decades, there is a continual need for innovation and adaptation,” says Merck’s Moura.
“Portugal is open to new innovations, not only with respect to insulin, but also for many other new drugs that are causing a change in prognosis for this chronic disease, addends the APDP’s Neves. “We should distinguish type one diabetes, which is totally dependent on insulin therapy, from type two diabetes that is the target for many efficient and safe new molecules.”
The high prevalence of diabetes in Portugal has created a burgeoning market for related products, as Marco Dietrich, managing director & country division head for Bayer notes. “In the cardiovascular space, we’re entering an exciting phase with the recent launch of two products – one targeting heart failure and the other patients with diabetes and chronic kidney disease. The latter has demonstrated unique efficacy in slowing down kidney deterioration and improving cardiovascular health. With global projections indicating blockbuster potential, we anticipate a strong market presence in Portugal, given the prevalent issue of diabetes.”
French firm Sanofi is also getting in on the act, albeit with a different focus. “Our efforts are directed towards identifying type one diabetes,” declares Country Lead Helena Freitas. “This innovative approach aims at preventive measures and delaying the onset of the disease, offering a unique solution to potentially save years of treatment and improve patient outcomes.”
GLP-1s To the Rescue?
Perhaps the highest profile of the new therapeutic options available are the Glucagon-like peptide-1 (GLP-1)-based treatments that have generated global headlines (and soaring profits) for companies like Eli Lilly and Novo Nordisk. However, as of publication of this report in February 2024, these products have not achieved reimbursement in Portugal and therefore remain unavailable to patients via the national health system.
The APDP’s Neves hopes that this situation will soon change. “We should consider the reimbursement of obesity treatment and prevention of obesity as part of the diabetes strategy. We do have programs for nutrition and physical activity, but we need to attack obesity at an earlier stage before the problems progresses to later complications.”
Novo Nordisk’s Barriga understandably agrees but does acknowledge the burden that costly new treatments can place on an already overstretched health budget. “We need to have open and evidence-based conversations to find the right balance, considering that obesity already accounts for an estimated EUR 1.1 million in direct costs to the Portuguese NHS every year,” she opines. “The process involves careful consideration and strategic discussions with regulatory bodies, healthcare authorities, and other stakeholders, accepting that advocating for reimbursement for a vast population may not be feasible in its entirety.”
Learnings & Prospects
The eventual reimbursement of next-gen treatments will no doubt be important in tackling Portugal’s diabetes and obesity epidemic. Whether this will be accompanied by a unified approach to early detection and prevention, however, remains to be seen. Regardless, diabetes and obesity look set to stay on the agenda for the coming years, and Portugal’s approach to the issue could have a big impact on the system at large, as Raposo explains.
“Diabetes is a good area to focus on in terms of how patients interact with the healthcare system,” he concludes. “For example, people living with type one diabetes are diagnosed at an early age, so we can monitor how they interact with the healthcare system and how we respond throughout their lifetime. If we can understand this interaction at a deeper level, then we can then adapt the healthcare model for other diseases through these findings.”
