Dr João Filipe Raposo outlines the importance of a collaborative, multidisciplinary approach to diabetes care management, an approach embodied by the APDP - Diabetes Portugal. He also touches on the APDP's unique patient-centric model and the digital future of diabetes care.


Could you introduce how you came to enter the diabetes field and give an overview of the APDP?

I am an endocrinologist by profession and trained at the Portuguese Cancer Institute, working on oncological diseases with links to endocrinology. Before that and during my time as a medical student, I studied in a research lab that worked in diabetes and looked at diabetes complications and why they occur, mainly within animal models. After finishing my residency in Endocrinology, I began working part-time at the APDP – Portuguese Diabetes Association, which is the oldest diabetes association in the world, being founded shortly after the discovery of insulin in 1926.

Later on, I became the medical director at the APDP and one of the board members, as well as an associate professor at the NOVA medical school in Lisbon and currently, I’m the President of the Portuguese Society of Diabetes. This is a multi-faceted scientific society that looks at diabetology, meaning diabetes therapies, as well as treatment of diabetes complications., More than a society of medical doctors of different specialities, we also have nurses, pharmacists, and researchers among other professionals, all involved in this therapeutic area, so it is quite a large society.

The APDP is a patient society with a unique model as it also provides clinical services for patients and is the nation’s largest outpatient diabetes clinic. It is a multi-faceted approach that has integrated care for non-communicable diseases (NCDs) like diabetes and has been the standard of care for years in Portugal’s diabetes treatment.


What model does the APDP utilise to be able to fund so many operations?

It is a non-profit organisation, similar to an NGO, but the outpatient centre is funded by the Portuguese national healthcare system and all the services are covered for the patients. Furthermore, the APDP provides research from the clinical perspective and provides Portuguese data. It is important to have a strong patient organisation and to be as strong as our members, therefore allowing us to demonstrate the added value we provide to the nation, especially as national healthcare systems around the globe are currently in a stage of transit and suffering.

The old model of healthcare was to fit the patients within the system, rather than adapt the system to the patient’s needs. This talk of patient-centricity is a big topic, but it is not happening as it should be, and NCDs are the biggest burden on the system. More needs to be done.


Is the APDP’s unique model of also being an outclinic centre well known in and outside Portugal?

This model was unique until the early 90s, and as we have connected more to the international scene, it is getting better known on the global stage. Nevertheless, this model is not easily replicable in other systems and it all depends on how the national healthcare system works. As aforementioned, the national systems of healthcare are suffering and being stretched financially, therefore, it is important to find alternative solutions to providing patients with the care they need, taking into consideration different approaches.

For sure our approach is different and other nations are looking at this model. In our country, it has started the conversation around the coordination of functional units of diabetes care to link diabetes in hospitals with primary healthcare. In the past, both these bodies did not communicate, so this advancement is a positive start. At the European level, the engagement between primary healthcare and hospitals is a key discussion point all across the continent.

I will also say that diabetes is a good area to focus on how patients interact with the healthcare system. For example, people living with type 1 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.


What is the overall burden of diabetes in Portugal?

We publish each year a report looking at diabetes data from the national healthcare system. Diabetes in Portugal has one of the highest prevalences in Europe and around 40 percent of type 2 diabetics are undiagnosed, with a big chunk of the budget being allocated to hospitalisation and acute care and treatment of the condition. Around 10 percent of the Portuguese healthcare budget is allocated towards treating diagnosed diabetes, and this is only direct costs and does not take into consideration indirect impacts such as loss of income.

There are a few reasons for the high prevalence such as an older population and a high rate of childhood obesity. I would say we need to take the burden from the families and homes and focus on the social issues to have a more complete treatment plan.


Are there any national campaigns focused on diabetes?

Diabetes is a societal health concern that 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 misconnection between knowledge and behaviour. Possibly we are missing a more strategic approach to the more high-risk population, and this could be something to undertake in the future.

We also must take into account that the lack of resources required to combat a particular area of disease will become a greater burden in the future, 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.


There is a push to introduce wearables and apps to ensure the population is more active. How important are these in diabetes?

As aforementioned, we need to facilitate people to make the correct decision. Digitalization and providing tools can be important and we must educate the people on how to use the information gathered using these tools to better their lives. They must know tracking their data is not for the government’s benefit, but theirs, and the decisions they make will impact their current and future health outlooks. For people living with diabetes, just tracking the glycaemic level is basic, and we must look at overall physical improvement and well-being for a long-term better life for patients.

At the scientific society, we are working to prove healthcare literacy and communication. Many medical professionals believe all patients understand all the jargon, but this is not the case, and we must be clear in our message so that all people understand.


What role do you see the commercial industry playing in pushing the needle in a positive direction for diabetes care and treatment?

They are definitely changing how they approach care, but it is still quite superficial and they are engaging the patient less than they should. Many look at the patient’s needs at the end of the process and not throughout. Saying that, areas such as quality of life are being taken into more consideration,

Not only companies, but regulators must use the patient’s voice more. For example, the regulator is 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 must have 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.

In terms of technology, we are moving more towards systems such as digital health and online consultations. At times, these apps and processes complicate the process, and we must develop a clear treatment map and see how the new innovative systems can be blended with the older traditional model along with reimbursement Overcomplicating the process can be a detriment also.


What is your outlook on diabetes care in the next five years in Portugal?

I am optimistic that diabetes care will improve. The inequality of care in Europe and Portugal exists, and it is really important to plan how we get the most innovative treatments to the most patients. New drugs are always coming to market, but it is about making the correct decisions and allocating the budget correctly. All in all, we must work together in a collaborative effort towards advancing patient outcomes in diabetes.