Dr Wannee Nitiyanant, president of the Diabetes Association of Thailand and Dr Supawadee Likitmaskul, president of the Siriraj Diabetes Center of Excellence, highlight the crucial importance of educate the public, patient and the healthcare professional in the diabetes field. They feature the priority of having more collaboration between the multi stakeholders in the country in order to reduce the number of diabetes patients as well as a better control of diabetes in those who have it.
Could you both introduce yourselves to our global audience and tell us why did you decide to pursue a career in Diabetes field?
Dr Supawadee Likitmaskul (SL): After the graduation of my residency training of pediatrics, I had the opportunity to become a clinical fellow in pediatric endocrinology and diabetes, The Children’s Hospital in Sydney for two years (1992-4). I was studying paediatrics diabetes with Professor Martin Silink former president of the International Diabetes Federation (IDF). I came back to Thailand as a pediatric endocrinologist doctor and started to focus on diabetes in children and adolescents. I launched an education program for a new patient, and different educations days for patient’s family to educate them and raise the awareness of the necessity to have a good lifestyle and good medication. In 1997, we created pediatrics diabetes clinic in order to continue self-management education, follow up, complications screening and also to prevent diabetes.Dr Wannee Nitiyanant (WN): After my six years of training in the United States, I came back to Thailand. I started to have a strong interest in thyroid diseases and diabetes. I wanted to focus on those fields due to a lot of patients suffering from that in Thailand. I have been working in Siriraj Hospital since 1979. Thanks to my teachers for their support and encouragement while working on improving education and care projects for patients with diabetes.
One of the missions of the Siriraj Diabetes Center of Excellence is actually the patient-centered education. What other initiatives do you do in regard to education for the patient?
WN: First of all, in the center we are not providing any treatment services, we are doing a screening of chronic complications and education for diabetic patients. The center is a site for gathering data base of diabetes service providing in the hospital. Many research questions can be initiated and solved by center’s staffs. With the leadership of Dr Supawadee, the center is very well established and has many ongoing diabetes projects.
SL: The first mission of the center is to educate the patient, but also, we are trying to register every patient in our hospital to track their result and use the data to understand and improve the treatment. Another project is a diabetes expertise for doctor and healthcare professionals who wish to learn more about how to treat a diabetes patient. At the beginning of this project, we were thinking of creating a master’s degree, but it was too difficult. In the end, we decided to put in place the certification to become a diabetes educator (Certified Diabetes Educator Program). And finally, we are able to put together the collaboration between the different departments within the hospital and building a strong network and involve more doctors, and clinics and work closely all together.
SL: During my entire career, I followed the work of Drs Wannee Nitiyanant and Chanika Tuchinda, (Founder of Siriraj Diabetes Education program 1989), I carry on their visions which was since the beginning of improving the patient education. We believe that the patient with the fundamental knowledge about their chronic disease, are able to manage themselves. One objective is the patient’s education, we conducted a camp for teenagers, and families to be more confident in their self-care treatment. Another objective is to build a strong teamwork by working closely in the camp among the nurses, doctors, dietitians, pharmacists, care professionals, patients and families.
In 2016, we conducted a survey about diabetes education activities in hospital setting both private and public hospitals in the country, and one of the obstacles was that the nurses do not have enough time to educate the patients about their disease. Data recently published in Diabetes, Metabolic Syndrome and Obesity: Target and Therapy 2019: 12; 717-27, title “The obstacles to diabetes self-management education and support from healthcare professionals’ perspectives: a nationwide survey”. That’s the reason why we focus on our program for the healthcare professional. We are trying to create a model to help them to practice, coaching skills for behavior changes and also a kind of education materials with all the tools to be efficient in the training. We have been elaborating different projects to work all together in the same way in the education program.
The Diabetes Association of Thailand has been working in the country since 1965. Dr. Wannee, what would you highlight as the main achievement of the association?
WN: At the beginning, the association mainly focused on patients with diabetes. We provided knowledge and explained what diabetes is, as well as how and why they have to take care of themselves. After focusing on the patients, we started to focus on providing up-to-date scientific knowledge for professionals. We published a guideline for the physicians and healthcare professions involved in diabetes care. The guideline has been approved at the national level, and we review it every 3 years. The Association, by specialists from several medical schools and representatives of National Health Security Office (NHSO) worked to improve diabetes service and care in our country. But some hospitals are still not complying with the guidelines. A large number of patients do not reach the optimal control, so we still have a lot to do. The majority of physicians focus on type 2 diabetes, but type 1 diabetes is also a problem. In 2014, we established a pilot project and research on implementation of standard care for patients with type 1 diabetes in collaboration with the NHSO and Medical Department of Ministry of Public Health. Now NHSO provides all the support to the Type 1 patient who attends diabetes self-management programs, for example, they are supplying the medication, self-monitoring of blood glucose and supporting education for the patient.
How else does the association partner with the industry and what are your expectations from pharmaceutical companies?
WN: While we were establishing our program, we had some collaboration with Sanofi Aventis, Roche Diagnostic, and with many University’s hospitals. We all worked and built up the team and program through 25 hospitals at the start. Now we have 32 different teams around the country that are now confident taking care of Type 1 patients. We had really good collaboration with the multi-stakeholders. Thanks to collaboration we can also collect information about the patients and have a better picture of Type 1 and Type 2 diabetes in Thailand.
SL: Actually, The Diabetes association of Thailand works closely with almost all university hospitals, diabetes center including our center. We are also part of the International Diabetes Federation, as a recognition center of excellence in Diabetes Education and Care since December 2017. This collaboration helps us with the standard in development of teaching modules and of course network. Ms. Anne Belton, one of the IDF committee on Diabetes Education Program (2003-2015) has visited our center twice during 28 Nov – 14 Dec 2016 and 18 Jan – 2 Feb 2018 as a consultant in our CDE program. Each year, we have to produce educational materials and also a report in our language and share with the national-international community in our experience, culture and progress on the research. We really need to have more support and collaboration. In Thailand, the population is not concentrated in the cities, the majority of Thai people are living outside of the urban areas. It is a challenge to reach them and try to treat them. If we are able to build long term partnerships, we will be able to improve access to treatment, diagnosis, and treat more patients.
One of the key challenges in Thailand is the rapidly ageing population – By 2025, the proportion of people over 60 years will exceed 20 percent. 1 out of 5 people aged over 60 years will have diabetes. And the International Diabetes Federation projects that the number of Thai people with diabetes in 2040 will increase to 5.3 million. What initiatives are in place to prepare for this major change?
WN: We are trying to stop the rise of diabetes. At the moment, even a reduction of new cases is not achieved at all. One of the main challenges is to stop obesity, but we are still seeing increasing number of patients in those fields. We concentrate our effort on those diseases, but the Thai people have also to understand that they should improve their lifestyle to maintain themselves in good health. We have a lot to do, especially regarding our food.
SL: I totally agree to stop obesity in all ages, especially in children and adolescents whose numbers are increasing more in urban areas according to data from our recent Thai national health survey 2014. However, for the last two or three years, we can see some changes that a lot of Thai people love to have outdoor exercise such as running, walking, biking events and the number is increasing. The lifestyle is changing but we have to make deeper changes to stop the increasing number of diseases.
When it comes to diabetes, we often hear of the rule of the 50/50 only 50 percent of diabetes patients are rightly diagnosed, only 50 percent are under treatment. Do you think this rule applies to Thailand? How do you rate the level of access to innovative diabetes products when looking at the Thai model of healthcare which is seen as a success?
WN: In 2014, the rate of un-diagnosed cases was about 44 percent. It is close to the rule of 50/50. In Thailand, people reaching treatment is higher than 50 per cent. But only 36 percent of people who come to the hospital or center achieved the treatment goal. That is why education is important, people need to have better control of their own diseases to prevent complications, come to regular checkup, and of course, have a good quality of life. Regarding innovative diabetes products, we would like to have more in the market. But due to budget and the income of the country and patients, access to innovation is limited. New technologies, especially insulin pumps, monitoring devices, and information technology can help Type 1 diabetic patients to achieve good control. However, they are very expensive and difficult to reach.
Dr. Wannee, you have a well-established background and knowledge in the area of diabetes. What would you like to be your greatest achievement in the field? Dr. Supawadee, as a final question – when we come back to Thailand to produce another edition of our HCLS Review, where will we see the Siriraj Center of Excellence for Diabetes?
WN: As I am kept on saying that I will stop working if I can put in place fully effective diabetes prevention. At the moment I am still looking for it, and how I can at least achieve the minimum. I am truly convinced that Thailand can do better and better in diabetes care. And the community is ready to actually change in order to reduce the diabetes burden.
SL: Since we opened the Centre of Excellence in education, we could already see that we improved our standard of care, especially in launching an approach in diabetes self-management education and support (DSMES) by CDE. By the next five years, we wish to have a full model of care and of education for medical students, healthcare professionals and patients. That we are able to see more results of the improvement of care outside of the Centre and outside the cities. We have to find a better way to reach the patient and let them know that even if they have a different disease, they need to have well-being and a well balanced life. They need to take care of themselves, and we are here to make their lives easier and show them that they can have a real life even if they have diabetes. Another issue is about more new technology and devices successfully and cost-effectively being used by our Thai diabetes patients.
Lastly, we would like to thank Dr Prasit Wattanapa, Dean of Faculty of Medicine Siriraj Hospital, Mahidol university, Dr Visit Vamvanij, Director of Siriraj Hospital and their team for their policy, vision and supports which move our center forward in all aspects of Diabetes.