Getting to the heart of diabetes at IJN

At present, around 3.6 million Malaysians are living with diabetes – the highest rate of incidence in Asia. This figure is expected to more than double to seven million by 2025.

In view of this, Institut Jantung Negara’s (IJN) senior consultant cardiologist Datuk Seri Dr Azhari Rosman says that healthcare providers need to pay attention to how they can help patients with diabetes manage their condition. “There is this misconception that once you develop diabetes it’s the end of the road, but this is really not the case at all. As long as you receive the right treatment – in time – and make the necessary lifestyle changes, you can live a healthy and productive life. It’s all about managing risk,” he adds.

This focus on managing risk is the cornerstone of IJN’s Diabetes Lifestyle Clinic. The heart centre has stayed ahead of the curve in offering specialised support for diabetic patients, having started its diabetes educator services in 2007. Dr Azhari explains the centre recognised the need for diabetes care after assessing the profile of its own cardiovascular patients.

“We found that around two-thirds of patients with diabetes were likely to have a serious cardiac event before developing any other diabetes-related problems such as kidney failure, blindness, loss of limbs, or stroke,” he says. “Just looking at patients who have undergone angioplasty at IJN, around 60% have diabetes. So our focus here is not about just controlling blood sugar levels, but it’s about controlling cardiovascular risk factors.”

IJN’s diabetes services are even more relevant now, as more young Malaysians are developing the condition. For these patients in particular, the disease has a higher chance of being more aggressive, causing serious health complications. Compounding this is that many diabetics are unaware that they even have the condition, as they may not experience any symptoms initially.

“It can take about five to six years before diabetes manifests as obvious symptoms, or be detected in the blood. By this time, the patient’s blood vessels would already be damaged. I’ve seen some cases where the we can’t even perform a surgery or angioplasty, because the blood vessels have already narrowed so much (due to long-standing diabetes),” adds Dr Azhari.

As such, IJN’s diabetes services are cardiology-driven, with reducing the risk of cardiovascular disease being its primary focus. Patients are first treated for their cardiac conditions, and receive medication to lower both their cardiovascular risk and blood sugar levels. Then they are referred to a diabetes educator and a dietitian to get tailored advice on how to administer their medication or injections and manage lifestyle adjustments to control their diabetes.

“Additionally, if the patients have developed or are at the risk of developing any complications, we will also coordinate with doctors from the relevant disciplines such as endocrinology, ophthalmology, or nephrology, so that patients receive the support they need,” adds Dr Azhari. “Diabetes is a whole body disease, so we function as a one-stop centre by integrating all the different disciplines involved to effectively cater to the patient’s needs.”

Empowering patients

Arguably, one of IJN’s key strengths in diabetes care is the expertise of its diabetes educators. These health professionals are specifically trained to help patients through the process of understanding and controlling the condition. IJN principal diabetes educator Siah Guan Jian explains that the patient themselves will play the most important role in keeping their diabetes in check.

“Patients are the ones who have to manage what they eat, be diligent about taking their medication, and have to learn how to manage their sugar levels. With the latter especially, they need to understand how to monitor sugar levels, and how to evaluate them accurately. So education is a big part of what we do – we aim to empower patients with information so they can have better control over the disease,” she says.

Siah, who is currently serving as president of the Malaysian Diabetes Educators Society, adds that IJN’s diabetes educators also take the time to work through patients’ fears of administering injections. “We understand that many people have a real fear of injections,” she says. “But it’s something that can be overcome with proper guidance and patience; we take the time to help patients work through these fears, and get them more comfortable with administering such treatments.”

“Many mistakenly think that having to receive insulin injections means that they’re at the last leg of the disease – it’s not true!” adds Dr Azhari. “Sometimes you may have to start insulin treatment early to control the condition better; ultimately, any treatment the doctor is advising you on is for the sake of better long-term outcomes.”

Between trying to interpret blood sugar readings and switching up lifestyle habits, patients can feel overwhelmed by everything that they need to do. “Research has shown that over 60% of diabetics experience depression after being diagnosed because of this,” says Siah. “That’s why we take the time to offer emotional support to help patients cope with adjusting to living with the condition.

New and more effective treatment

While most are familiar with insulin-based treatments for diabetes, there are actually now a wider range of medications and treatment options available to patients. For example, sodium-glucose co transporter-2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists are two of the latest and proven classes of drugs that can help patients with Type 2 diabetes control their blood glucose levels while considerably reducing the risk of cardiovascular death. Both of these are tablet medications.

SGLT2 inhibitors work by preventing the kidneys from reabsorbing glucose back into the blood. Meanwhile, GLP-1 receptor agonists mimic naturally occurring hormones called incretin, which help the body lower post-meal blood sugar levels and reduce appetite.

What has been a game changer for patients in particular, are continuous glucose monitoring (CGM) systems. These devices enable both doctors and patients to accurately monitor patients’ glucose levels over a period of time, giving them a more comprehensive overview of the patient’s blood glucose control. “This enables the patients to directly see their how their dietary and lifestyle habits have been affecting their glucose levels,” says Siah.

She adds that while CGM is not new, the system used by IJN is a more stable and less invasive. “In the near future, we will be introducing an even more advanced version that is connected to a smartphone app, so patients will be able to view their glucose levels in real-time,” she says.

With many more types of drugs and treatments currently in the pipeline, IJN also aims to provide patients with resources of the latest in treatment. “We are focused on educating healthcare providers as well, because not everyone is familiar with the various combinations of treatments that are currently available,” says Dr Azhari. “In our conversations with general practitioners especially, we’ve found that many of them simply do not have the time or resources to educate patients all the finer points of living with diabetes . This is why our diabetes educators accept referrals from doctors outside of IJN as well.”

He adds that the centre also plans to introduce even more diabetes services in the near future, including a weight-loss clinic. “I feel that our model is a benchmark for diabetes services, as we’ve had a 13-year head-start in this area; in order to effectively help patients, we need to look at the condition holistically, and help patients manage all aspects of it easily,” he says.