Prof. Dr. Temel Yilmaz, president of the Turkish Diabetes Foundation, discussed how the disease has made a massive impact in country and what can be done to tackle the issue before it develops further. He also shares how the organization is working to improve the lives of diabetes patients in Turkey.
How has the prevalence of diabetes in Turkey been evolving over the last few years?
Based on the results of two studies conducted over a single decade, Turkey has seen the rate of diabetes in its population double. The first survey of the Turkish Diabetes Epidemiology Study (TURDEP) was conducted in 1997. This study revealed the percentage of the population with diabetes was 7.2 percent. By the second survey in 2010, the rate of diabetes in Turkey had skyrocketed to 13.6 percent. Research conducted by the World Health Organization (WHO) in 1996 estimated the rate of diabetes to be 5.6 percent in the region and projected the rate to reach 7.4 percent in 2021. However, in 2000 the diabetes rate reached 7.4 then doubled after 10 years. These results were shocking in comparison to what had been forecasted by the WHO. Turkey is one of the countries with the highest increase in diabetes prevalence in the world. An increase in diabetes is normal, but this explosion is a question being discussed within the foundation in partnership with the Ministry of Health (MoH).
What has been the cause behind this massive spike of the disease in the country?
After many discussions about the causes behind this dramatic increase in the disease, two main factors have been identified – lack of activity and poor nutrition. The Turkish people do not like sports, but we do like technology. We are adopting new technologies at one of the fastest rates in the world. The MoH conducted a survey on teenagers and found out that every five years, the amount of time they spend with smart devices increases exponentially. Lack of movement is a prevalent issue worldwide.
The TDF and the MoH have also agreed that the consumption of fast-food is increasing in the country. There are two types of fast-food – American fast-food such as burgers and fries, and local or national fast-food. National fast-food are the traditional foods which are popular but also very greasy and fatty. Looking at the food market, American fast-food only accounts for 15 percent of the industry, whereas the majority comes from the national food. Traditional food often defines the diabetes situation in a country. I also serve on the International Diabetes Federation (IDF) member board. Of IDF member countries, the highest rates of diabetes come from the middle eastern region. Countries that have traditional foods high in carbohydrates, white flour, and red meats have higher rates of diabetes – for example, Mexico and India. The countries that have healthier national foods, such as Japan, consequently have lower rates of diabetes.
How government stakeholders address the critical situation of diabetes to avoid the disease from becoming a national epidemic?
In an IDF survey, it was forecasted that Turkey would be in the top ten countries with the highest number of diabetes patients over the next ten years. The MoH is aware of this issue because diabetes and related conditions are responsible for one-fourth of the country’s entire healthcare expenditure. However, patients still have access problems to certain drugs. The healthcare stakeholders in Turkey are in a complicated position of working to meet patient needs but also trying to decrease the cost related to diabetes.
Talking about the issues of both these groups, the realities can be very mixed. The MoH does not include some new drugs in the reimbursement list because of their high cost. Only drugs which have been registered for over 15 years are part of the reimbursement program. New treatment drugs are very expensive, and diabetes is such a widespread issue. To enter the area and subsidize treatment for all patients would exhaust the budget completely. From a patient perspective, the innovative treatment is unreachable. On the other hand, the healthcare system does not have the capacity to support these costs. It is a complex situation with no white or black solution. The suggestion of the TDF is for the MoH to establish indications to identify the most eligible patients who need these innovative treatments. The predicted expenditure is around 3 million for new diabetes drugs, but if the government identifies the patients most in need, this expenditure can be reduced.
What are your expectations for the industry regarding the treatment of diabetes?
The industry is in a very difficult position right now. Turkey is one of the countries with one of the lowest drug prices and many patients from neighboring countries come to Turkey to buy drug supplies. After the recent economic crisis, the pharma industry has been severely impacted. Due to the condition of the dollar, insulin companies in Turkey are making losses on each unit sold. If a drug costs EUR 100 in Germany, in Turkey it costs EUR 20. As a Turkish citizen, I support that action that we keep the health care costs in the country affordable. However, we are currently in the bottom line and facing two challenges when it comes to drugs. Big pharmaceutical companies do not bring new molecules to Turkey and they postpone the launches of drugs. This year in the diabetes sector, there have been three or four molecules postponed from the Turkish market. It is understandable that once pharma companies accept the government prices in Turkey, other markets like India and Russia will also reduce their prices. The pharma industry is anxious because if these unsustainable prices in the country are picked up by other markets, their business will suffer. The industry is also threatened by the current exchange rate crisis. Pharma companies are in a loss right now and if it continues, the problem will only become larger. This is the biggest threat that is commonly shared among diabetes patients, physicians, and the government. We all hope to avoid a drug crisis.
What would you like to be seen as your personal contribution to the diabetes issue in Turkey?
For the last 30 years, I have been dedicated to patient rights. During this time, I have been directly involved with patients and in the foundation activities to bring several programs to the public. For example, together we achieved free insulin and testing strips for patients under 18 years old. The TDF has also established a diabetes camp to help educate diabetes patients about the disease. This center has the capacity to reach 5000 patients yearly. . It is the biggest in the world and has been deemed a center of excellence by the IDF.
Another project I am very proud of is the formation of the Diabetes Parliament. For the last eight years, on World Diabetes Day, 14th of November, patients have the opportunity to reach the top level stakeholders of the government. There is a representative from the president’s office, members from the national parliament, Ministry of Health, Ministry of Labour and Social Security, and Ministry of Education. We have over 300 patients in attendance and speakers are given five minutes to discuss their issues and needs. The government members do not speak until after patients state their cases. Last year, the national parliament gave one mother the opportunity to give a speech about the challenges faces by her child who uses continuous glucose monitoring (CGM) at one of their agenda meetings. Through this initiative, solutions are found and the tension between the government and diabetes patients can be resolved.