Christine Marie D. Rosal, Country Manager of Novo Nordisk Pharmaceuticals (Philippines) gives a startling image of the current state of diabetes in the Philippines, the major reasons behind the soaring rates of diabetes and what the government along with companies such as Novo Nordisk can do to prevent a worsening of the current situation.

It is a well-known fact that there is a high rate of diabetes in the Philippines. What is the biggest factor in the high rate of diabetes?

The International Diabetes Federation estimated that in 2012, 4.3 million people or 8.2 percent of the adult population in the Philippines have diabetes, and another 6.6 million people have pre-diabetes. The number of people suffering from diabetes is increasing rapidly these years, and more than half of diabetics in the Philippines are unaware that they have the disease.

The main problem is that most people with diabetes do not control their blood sugar very well. 85 percent of people with diabetes in the Philippines have blood sugar levels above the levels recommended by organizations like the American Diabetes Association. These people have a greatly increased risk of developing complications. Poorly controlled diabetes is the leading cause of kidney failure and blindness, the second leading cause of amputations after traffic accidents, and poorly controlled diabetes is associated with increased risk of heart attacks, strokes, dementia, and impotence in men. The longer your blood sugar is out of control the higher the risk of developing complications.

Poorly controlled diabetes not only reduces the quality of life but also reduces life expectancy. More than 10,000 people each year in the Philippines get end-stage renal disease and each year more than 60,000 people die because of diabetes.

How can the risk of developing complications due to diabetes be reduced or avoided?

The risk of developing complications can be greatly reduced when the blood sugar is well controlled. Insulin is the most potent medicine to control blood sugar and it is important that more diabetics start using insulin earlier.

Many predisposing factors for diabetes are present in our country. Aside from genetics, the increase in diabetes prevalence in the Philippines is caused by a change in lifestyle of the population. There is an increase in consumption of fast food and younger generations are taking on more sedentary lifestyles.

Though diabetes awareness is low in the Philippines, it is improving thanks to various initiatives from different diabetes organizations. In fact, we are one of the few countries where there are so many diabetes societies: Diabetes Philippines, the Philippine Society of Endocrinology and Metabolism, AACE, IDF, etc. Several organizations are thus catering to the same thing: awareness, management, and alleviation of diabetes.

In the insulin market in the Philippines, there are three major multinational players: Novo Nordisk, Eli Lilly and Sanofi-Aventis. Among the three of us, we roughly hold 90 percent of the market in value. We are all working towards increasing insulinization rates in the country and increasing awareness on diabetes.

Out of convenience many people with diabetes use oral medication too long and postpone the use of insulin even though their blood sugar cannot be controlled with oral medications alone. Some patients may be concerned about injections and some associate the use of insulin with ‘end-stage’ disease and try to avoid insulin, even though this may be the only medicine that can bring their blood sugar under control.

Another reason for the low rate of insulinization comes from the fact that the many different associations around the world do not tend to put insulin at the top treatment list. They try to exhaust all the oral therapies first. Nonetheless, we see improvements on this side.

Most people do not understand why they would need to go for injections if oral tablets are an alternative. The truth is, and what we need to make them understand, that there are many benefits to insulin therapy versus oral therapy. Insulin therapy could actually extend the patients’ lives. Moreover, our modern-day devices are so convenient and needles are so thin that it should not hamper the everyday activities of a normal person. 

A large part of treating diabetes will have to do with changing lifestyles. Do you think that the epidemic can really be stopped?

The first thing that anyone from any culture can do is to watch their diet and eat healthy. One also needs to be physically active at least 30 minutes per day five days per week. Whether people will do so or not remains a personal choice. All too easily, people take their cars or taxis for short distances. How to change the mindset of an entire population? It is very difficult. It requires a joint effort of various organizations from outside the pharmaceutical industry too.

What role should Novo Nordisk play in this?

Novo Nordisk is a focused healthcare company and the mission of Novo Nordisk is to change diabetes and improve the lives of people with diabetes. The company’s strategy is to make a difference for people with diabetes by developing and bringing innovative products to the market. We focus on protein-based therapies like insulin and GLP-1 analogues and also have in-house research and production of delivery devices and needles. We partner with the major groups in the country, help in diabetes awareness projects, educate healthcare providers and patients, and also offer more affordable alternatives for patients that cannot afford the more innovative medicine. We are the only company with a full range of modern as well as human insulin for different types of patients.

The Philippines is an out of pocket market. The type of insulin people buy does not only depend on the state of their disease but also on their ability to pay. For the poorest in the country affordability is a big problem, especially because diabetes is a lifelong disease. Without the help of the government, some patients cannot sustain treatment. Primary prevention of diabetes is critical and more should be done at all levels in society.

Our initiatives to partner with the different diabetes societies are a good start to fight this epidemic. Ultimately, however, I do believe that there needs to be a public-private partnership to address the problem.

How much of a priority is diabetes for the Philippine government today?

The government is aware that diabetes is becoming a major public health issue and the Department of Health has initiated an insulin access program for the DOH hospitals. However, this may not be enough as diabetes management is more than procuring medicines. It also involves awareness, education, close monitoring by qualified healthcare professionals, and ensuring that the treatments are readily accessible. The government also has other more immediate concerns such as dengue prevention, providing potable drinking water, curing communicable diseases, respiratory infections, and immunization, reproductive health, to name a few.

Novo Nordisk is globally regarded and respected as a highly innovative company. Can you elaborate on the level of innovation you wish to bring, or have brought, to the Philippines?

Novo Nordisk is the world’s leading diabetes care company with 27 percent value market share of the total diabetes market. Within the insulin segment the position is even stronger; half of all patients worldwide that use insulin, use insulin from Novo Nordisk.

Novo Nordisk brings innovative products to make therapies more effective, safer and more convenient for patients. Our future pipeline is very rich and includes a full portfolio of next generation insulin that will provide better control and more benefits to patients. Novo Nordisk is the leading company within GLP-1 analogues and the pipeline also includes an innovative once-weekly GLP-1 analogue. There are exciting combination products in the pipeline too, and we are even developing oral insulin and oral GLP-1.

For patients who cannot afford the latest therapies, we still offer vials or our so-called ‘human insulin range’. Within our range of devices, we have introduced the FLEXPEN and NovoFine needles. The fact that our needles have become finer and shorter also helps to address the injection-stigma we face in the Philippines.

Let’s take the FLEXPEN as a case study of product launch in the Philippines. What process do you go through as a company and how do you prepare the market to absorb your products? Can you also tell us more on how the response of the market has been so far?

When developing and launching new products we always have the patient in mind. Feedback from patients and healthcare personnel is critical to define the unmet needs that have to be addressed. FLEXPEN is a disposable insulin device that provides a very accurate and reliable dose. It is easy to dial the dose and inject, and the device can be carried in the pocket like a normal pen. The dosing scale is clear and readable, and blind people can dial the dose through audible clicks when using the device. The different types of insulin are marked differently so blind people can distinguish between different types of insulin.

Before launching any product we do comprehensive clinical studies and compare with other products in the market. We also do market research and engage in concept testing. After the market research and surveys, we get local feedback from a small advisory board or key opinion leaders group. This is followed by a big launch event and more traditional post-launch marketing activities. Even all of our staff will try to self-inject using a test medium. 

As for the market response, we see the introduction of new and better products as significant drivers to overall market growth. The acceptance is definitely a lot better than for the vials. The Philippines has welcomed the new products, which is also reflected in our sales.

What are your expectations for future sales and growth, once you manage to bring in the other products in the next three years?

When I first took over a year ago, our growth had declined and the affiliate was at the verge of a turnaround. My first task consisted of strengthening the management team and we completed this in January 2013.

Now, all our efforts are focused on ramping up our organization for growth.  We expect to be aligned with the rest of Novo Nordisk worldwide. The company has delivered double digit growth in 45 consecutive quarters.

We strongly believe our efforts will help in changing diabetes. Too many people are dying prematurely or suffering from complications that could have been prevented, and this has to be changed. Our local team is headstrong, committed and passionate in changing diabetes and we will make sure we take a central part in the progress of diabetes management in our country, the Philippines.