1 time in Indiaijcpgroup.com/idej/IDJ_June_G02W02.pdf · 2019. 6. 3. · 1 Introduction COVER STORY: Swimming may Strike Off Diabetes! Continuous physical exercise could enhance body's

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Indian Diabetes Educator Journal (IDEJ), first of its kind in India and has successfully completed 4 years. IDEJ

is developed with the aim of keeping the members of diabetes care team abreast with concepts of Diabetes Self-Management Education/Support (DSME/S). IDEJ has set a new benchmark in educating the diabetes

educator about the evolving concept of DSME/S, reaching to more than 8,000 doctors with hard copies and more than 25,000 doctors and diabetes educators digitally.

Poor medication adherence is one of the major contributing factors towards inadequate blood glucose control in patients with diabetes. Poor medication adherence in type 2 diabetes is well-known to occur commonly and is associated with inadequate glycemic control; increased morbidity and mortality and increased costs of

outpatient care, emergency room visits, hospitalizations and managing complications of diabetes. Our cover story talks about the benefits of swimming in diabetes. This issue provides a cross-sectional view of adherence problem in diabetes, determinants and risk factors of adherence, how poor adherence affects glycemic

control, how can adherence be improved/encouraged in patients and the clinical outcomes with improved medical adherence. In lifestyle section, this issue also covers the benefits of bitter gourd in diabetes and prescribes an exercise regimen for diabetes patients.

We sincerely thank our contributors for making this issue delightful reading for our readers. We dedicate this

journal to all the health care professionals who are working relentlessly towards making “India a Diabetes Care Capital of the World”.

Sincere Regards,

Expert Contributors of the MonthExpert Contributors of the Month

Dr Shrinath Shetty

MBBS, MD, DM (Endocrinology)

Consultant Endocrinologist and Diabetologist KMC Hospital, Mangaluru, Karnataka

Dr Jamal Ahmad

MBBS, MD (Gen Medicine), DM (Endocrinology), FCCP, FRCP (UK), PhD (Medicine), Dsc (Endocrinology)

Centre for Diabetes and Endocrinology, Faculty of Medicine, JN Medical College and Hospital AMU, Aligarh, Uttar Pradesh

Dr Vinod Mittal

MD, FRSSDI, FICP, FCAM, FCCP, FGSI

Senior Consultant Diabetologist and HeadCentre for Diabetes and Metabolic Diseases - Delhi Heart and Lung InstituteDirector, Delhi Diabetes Care Centre, New Delhi

Dr Mallik Arjun

MD (General Medicine), DM (Endocrinology)

Consultant Endocrinologist, Meka's Hospital Davangere, Karnataka

Dr KR Puttaraj

Consultant PhysicianProfessor of Medicine, Spandana Health Care Centre, Tumkur, Karnataka

Dr Prachi Bansal


KEM Hospital, Mumbai, Maharashtra

Dr Neeraj Sinha

MBBS, MD (General Medicine), DM (Endocrinology), Gold Medalist (WBUHS)

Diabetes, Thyroid and Hormone Care ClinicPatna, Bihar

Dr N MD Attaullah

MD (Medicine)

Physician and Diabetologist, Harmain Hospital Falaknuma, Hyderabad, Telangana

Dr Subodh Jain

MD (Medicine)

Physician and Diabetologist, Diabetes Care Centre, Allahabad, Uttar Pradesh

Dr Abhishek Shrivastava

MD, DMSC-Endocrinology (England)Diploma in Diabetes (Boston)

Consultant Endocrinologist, National Hospital Jabalpur, Madhya Pradesh

Table of Content

01

05

08

11

14

20

17

Cover Story: Swimming may Strike Off Diabetes!

Dr Shrinath Shetty

Medication Adherence in Diabetes: How Big a Problem?

Dr Vinod Mittal

Factors Contributing to Poor Medical Adherence

Dr Subodh Jain

Determinants of Adherence to Diabetes Medications

Dr Neeraj Sinha

Risk Factors for Medication Adherence in Diabetes Patients

Dr Jamal Ahmad

Medication Adherence and Glycemic Control

Dr Mallik Arjun

Medication Adherence in Diabetes: Challenges Faced

Dr KR Puttaraj

26Medication Adherence and Improved Outcomes in Patients with Diabetes


23Promoting Medication Adherence in Patients with Diabetes

Dr Prachi Bansal

36Conference Highlights

37Diabetes Quiz

38Predictors of Poor Medication Adherence

30Lifestyle Modification: Exercise

31Lifestyle Modification: Diet

34NDEP Best Practices

Dr N MD Attaullah

39Questions to Ask your Patients to Assess Medication Adherence

1

Introduction

COVER STORY:Swimming may Strike Off Diabetes!

Continuous physical exercise could enhance body's propensity to use and absorb glucose by interfering with

certain molecular signalling pathways. Exercise improves metabolic system by reducing insulin resistance prevalent in skeletal muscles.

ExpertOpinion

Dr Shrinath Shetty


Consultant Endocrinologist and Diabetologist, KMC Hospital Mangaluru, Karnataka

Swimming as a health sport

Swimming is classified as an aerobic exercise, where use is made of the entire body including length of the leg, width of the

palm, foot width and leg muscle strength.

Swimming is an excellent exercise for fitness and health because the horizontal body position allows for the blood to flow

evenly throughout the body with almost the same pressure; besides almost all parts of the body can move in balance.

What do the doctors say?

Swimming is one of the sports recommended by many doctors and government agencies working in the health field. Swimming

has gained a lot of importance because of its health benefits.

ROLE OF SWIMMING

Growth Physical development Health (Hypertension, asthma, pinched nerve)

Cardiovascular health, heart

2

Researchers have suggested that exercise can cause changes in the heart, blood vessels, lungs and muscles depending on the

type, duration and intensity of the exercise. Regular exercise improves lung elasticity and increases the number of active alveoli, which in turn leads to an increase in the storage capacity and distribution of oxygen to the bloodstream. Regular exercise also brings

about an increase in the size of the muscle fibers and energy supply system in the muscles.

Swimming and diabetes

Activities such as walking, cycling, jogging and swimming rely primarily on aerobic energy-producing systems. It has been estimated that energy expenditure on breaststroke swimming is 10 METS (metabolic equivalents), which is equivalent to 7.0 kcal/min. Thus, swimming can reduce the risk of diabetes owing to the massive burning of carbohydrates in the body.

Only 30 minutes of swimming for

3 times/week can burn 900 calories

bringing down the risk of type 2 diabetes by more than 10%.

Research showed that a 200-meter breaststroke swimming activity is very

good for diabetes patients.

Swimming improves insulin sensitivity.

An interesting research finding suggested that swimming exercises have an effect on decreasing depression among men with type 2 diabetes. In addition, physical activity and exercise in water may have some beneficial effects on mood. Another research has

showed that low-volume high-intensity intermittent swimming is

an effective and time-efficient training strategy for improving insulin sensitivity, glucose control and biomarkers of vascular function in inactive, middle-aged mildly hypertensive women.

The results of a study showed a 22% improvement in insulin sensitivity after high-intensity swimming training, but no change

for those who swim at a low pace.

Swimming makes simultaneous use of upper and lower body muscles, which could also benefit people with diabetic

neuropathy, who suffer from numbness.

3

Recommendations from American Diabetes Association

American Diabetes Association (ADA) has recommended that it is important to understand your body's typical blood glucose response to exercise in order to maintain blood glucose within optimum levels. The blood glucose varies depending on the:

¢ Blood glucose level before you start swimming

¢ The intensity of swimming

¢ Duration of active swimming

¢ Changes made to the insulin doses.

ADA Recommendation: Prolonged, rhythmic aerobic activities using large muscle groups such as swimming may be done continuously or as high-intensity interval training (HIIT).

Swimming Tips

Swimming casually Once or twice a week does not need extensive management.

In case of low blood sugar, consume glucose tablets or several sips of a glucose drink before a swimming session.

Starting to swim regularly Consult your doctor beforehand to assess the current health state and outline initial goals.

Beginners should not swim alone.

Swimming regularly Frequent monitoring of blood glucose is recommended.

If undergoing professional training, training days may require reductions of quick-acting insulin and long-acting insulin.

When training, glucose should be consumed every 30 minutes.

Swimming tips for diabetes patients

4

The role of a diabetes educator

¢ Explain the health benefits of swimming in diabetes to your patients.

¢ Talk to the patients before they start swimming about their current state of health and initial goals.

¢ Teach patients to identify symptoms of hypoglycemia and what to do to prevent such episodes.

¢ Make patients aware about the importance of protective footwear, especially to those who are already experiencing diabetic neuropathy.

References

1. Yang Q, Wang W, Ma P, et al. Swimming training alleviated insulin resistance through Wnt3a/-catenin signaling in type 2 diabetic

rats. Iran J Basic Med Sci. 2017;20(11):1220-6.

2. Syahrastani S, Badri H, Argantos A, et al. The impact of 200 meter breast stroke swimming activity on blood glucose level of the

student. IOP Conf Ser Mater Sci Eng. 2018;335(1).

3. Colberg SR, Sigal RJ, Yardley JE, et al. Physical activity/exercise and diabetes: A position statement of the American Diabetes

Association. Diabetes Care. 2016;39(11):2065-79.

4. Saiiari A, Moslehi M, Sajadiyan M. Effects of crawl swimming on depression in type 2 diabetic patients. Procedia - Soc Behav Sci.

2011;30:2156-60.

5. Connolly LJ, Nordsborg NB, Nyberg M, et al. Low-volume high-intensity swim training is superior to high-volume low-intensity

training in relation to insulin sensitivity and glucose control in inactive middle-aged women. Eur J Appl Physiol.

2016;116(10):1889-97.

6. Swimming and Diabetes. Available at: https://www.diabetes.co.uk/sport/swimming.html. Accessed April 4, 2019.

5

Medication Adherence in Diabetes: How Big a Problem?

Introduction

Medication regimens encompass both disease prevention and treatment making adherence an important consideration

in patient care. Adherence is generally lower in cases where medications were not tolerated or were taken more than twice-daily, with concomitant depression and with

scepticism about the importance of medication.

Studies have shown that rate of medication adherence vary

from 36% to 93%, depending on the type of medication studied, the population examined and the methods used for

assessing adherence.

ExpertOpinion

Dr Vinod Mittal

MD, FRSSDI, FICP, FCAM, FCCP, FGSI

Senior Consultant Diabetologist and HeadCentre for Diabetes and Metabolic Diseases - Delhi Heart and Lung InstituteDirector, Delhi Diabetes Care CentreNew Delhi

Poor medication adherence has a negative impact on health care costs!

India accounting for 90% of diabetes cases in South East Asia, is estimated to spend ID 426 per person with diabetes. A study has shown that poor adherence to prescribed therapy leads to 30-50%

treatment failures leading to worse treatment outcomes. There is inadequate data from India on the

cost of diabetes care and adherence to treatment. Out of the few studies conducted in India, one has reported that each 10% increase in medication adherence translates

in a decrease of 6.6% in all-cause hospitalizations.

Research has suggested that there are strong associations between decreased antidiabetic medication adherence and increased health

care service utilization in older adults with type 2 diabetes mellitus in a managed care setting.

Adherence to antidiabetic medications was found to be a greater driver of cost reduction than other concurrent medications such as statins being used in a diabetes patient.

Clinical outcomes are affected in nonadherent patients

Medical adherence is the key to solving the problem of suboptimal

achievement of therapeutic targets. A study conducted in Michigan in 2004 showed that nonadherent patients had both statistically

and clinically worse outcomes than adherent patients. Non-adherence is significantly associated with glycated hemoglobin (HbA1c) and low-density lipoprotein (LDL) cholesterol levels.

Increase of 0.14% in HbA1c and an increase

of 4.9 mg/dL in LDL cholesterol levels.

A 10% increase in nonadherence to

metformin and statins.

6

Medication adherence is also related with self-care behaviors, which may have a direct or indirect

effect on outcome. Studies have suggested that medication adherence and outcomes may be mediated directly through achievement of intermediate targets important to patients with diabetes mellitus and indirectly through its correlation with other adherence behaviors affecting

outcomes.

MEDICATION NONADHERENCE

¢ Found to be present in more than 1 of every 5 patients.

¢ Was associated with higher HbA1c, blood pressure and

LDL cholesterol levels.

¢ Is the reason for enhanced risk of all-cause hospitalization.

¢ Is the reason for the rise in all-cause mortality.

Increased mortality due to poor medication adherence

Many randomized controlled trials have exhibited the link between poor medication adherence and increased mortality.

Nonadherent patients had higher mortality compared with adherent patients. This also supports the clinical importance of

nonadherence as a risk marker for adverse outcomes.

Medication persistence - No gap in prescription drug

supply for at least 30 days.

Medication Possession Ratio (MPR) - The percentage

of time a patient has access to medication.

METRICS OF ASSESING MEDICATON ADHERENCE

7


¢ Assess risk factors for nonadherence in diabetes patients.

¢ Develop strategies to facilitate taking medication persistently on time.

¢ Provide ongoing support and assessment of adherence at each visit.

References

1. Swain SP, Samai S, Sahu KS, et al. Out-of-pocket expenditure and drug adherence of patients with diabetes in Odisha. J Fam Med

Primary Care. 2008;7(6):1229-35.

2 IDF Diabetes Atlas. Eighth Edition; 2017.

3. Capoccia K, Odegard PS, Letassy N. Medication adherence with diabetes medication: a systematic review of the literature. Diabetes

Educ. 2016;42(1):34-71.

4. Ho PM, Rumsfeld JS, Masoudi FA, et al. Effect of medication nonadherence on hospitalization and mortality among patients with

diabetes mellitus. Arch Intern Med. 2006;166(17):1836-41.

5. Martin LR, DiMatteo MR (Eds.). The Oxford Handbook of Health Communication, Behavior Change, and Treatment Adherence.

Oxford University Press; 2013.

6. Balkrishnan R, Rajagopalan R, Camacho FT, et al. Predictors of medication adherence and associated health care costs in an older

population with type 2 diabetes mellitus: a longitudinal cohort study. Clin Ther. 2003;25(11):2958-71.

7. Pladevall M, Williams LK, Potts LA, et al. Clinical outcomes and adherence to medications measured by claims data in patients with

diabetes. Diabetes Care. 2004;27(12):2800-5.

8. Polonsky WH, Henry RR. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key

contributors. Patient Prefer Adherence. 2016;10:1299-307.

8

Medication Adherence in Diabetes: Challenges Faced

Introduction

Poor medication adherence in type 2 diabetes is well-documented, very common and is associated with

inadequate glycemic control. The challenges in medication adherence in diabetes are linked to key patient-centric factors, physician-centric factors and health care or

perceived financial burden focussed factors.

ExpertOpinion

Dr KR Puttaraj

Consultant PhysicianProfessor of Medicine Spandana Health Care Centre Tumkur, Karnataka

Patient-centric

¢ Forgetfulness

¢ Poor family support

Health care

¢ Cost

Forgetfulness

Many patients forget to take medications with them while traveling. Older/occupationally retired age groups have been found to be

especially prone to forgetfulness owing to frequent dosing and multiple drugs in the prescription. Many patients deliberately take

drug holidays without informing the physician.

Many patients feel that their diabetes is under control and hence, they stopped taking medications.

9

Lack of awareness

Poor family support

Many patients are not aware of the consequences of missing the drugs. It has been seen that adherence is better in educated patients. It was also noted that low-income patients were less adherent to the prescribed therapy than high-income patients.

Poor family support was a significant factor associated with low medication adherence. Family

member's nonsupportive behavior is associated with poor adherence to diabetes medication

regimen. Participants of a study have emphasized the importance of family support for diabetes

self-care behaviors and also said that the nonsupportive family behaviors sabotaged their efforts to

perform these behaviors.

An interesting finding is that family functioning is also significantly associated with household family

structure. Clinicians should explore the functionality in the family unit to achieve optimum blood

glucose control.

Glycemic control

Adherence is lower in patients with uncontrolled glycemic levels. With a decline to medication adherence, there is a decline in the efficacy and glycemic control as well.

Complex treatment plan

Many patients feel that it is difficult to stick to a prescribed treatment plan and so stopped medication. When the treatment regimen is simple, the patient adherence is effective.

Difficulty in reading prescriptions labels, taking more than two doses of type 2 diabetes medications per day are correlated with higher HbA1c levels and poor compliance with the prescription.

10

Cost

Studies have shown that every 10% rise in medication adherence results in a mean decrease of 6.6% in all-cause hospitalizations. The direct cost on diabetes health care is usually very high for people in developing countries. Higher out-of-pocket costs for antidiabetic medications are

particularly linked to poor medication adherence.


¢ Make the family members aware and encourage them to actively participate in the care of diabetes patient especially in a resource poor environment.

¢ Discuss the cost of medication with the patient and offer assistane when available or possible.

References

1. Khotkar K, Chaudhari S, Jadhav PR, et al. Assessment of medication adherence in type II diabetic patients: a cross-sectional study.

MGM J Med Sci. 2017;4(2):65-9.

2. Mayberry LS, Osborn CY. Family support, medication adherence, and glycemic control among adults with type 2 diabetes. Diabetes

Care. 2012;35(6):1239-45.

3. Iloh GP, Collins PI, Amadi AN. Family functionality, medication adherence, and blood glucose control among ambulatory type 2

diabetic patients in a primary care clinic in Nigeria. Int J Heal Allied Sci. 2018;7(1):23-30.



5. Swain S, Samal S, Sahu KS, et al. Out-of-pocket expenditure and drug adherence of patients with diabetes in Odisha. J Fam Med

Prim Care. 2018;7(6):1229-35.



11

Factors Contributing to Poor Medical Adherence

Introduction

A large number of demographic factors such as younger age, lower education level and lower income contribute to poor

medication adherence in patients with diabetes. Some of the critical factors which are potentially modifiable are discussed here.

ExpertOpinion

Dr Subodh Jain

MD (Medicine)

Physician and Diabetologist, Diabetes Care Centre, Allahabad, Uttar Pradesh

Six key factors

contributing to

poor medication

adherence

Perceived treatment efficacy

Hypoglycemia

Treatment complexity and convenience

Cost of treatment

Medication beliefs

Physician trust

Perceived treatment efficacy

When the patients do not get any tangible sense that the prescribed medication is contributing to positive and relatively immediate outcomes, it is difficult for them to adhere to the medication. In a study among 477 patients of type 2 diabetes, it was seen that medication adherence was associated with perceived need. The results showed that self-reported medication adherence over 6 months was associated with greater weight loss and hence improving HbA1c levels.

12

Hypoglycemia

A cross-sectional study of patients with type 2 diabetes treated with metformin and sulfonylurea agents reported that patients having moderate or worse symptoms of hypoglycemia had poorer medication adherence.

Even a single hypoglycemic event may result in poorer medication adherence as the patient

chooses to keep his/her blood glucose levels in a higher range where further hypoglycemic events will be less likely.

Cost of treatment

Out-of-pocket costs for medications is a major factor linked with problematic adherence across

various treatment conditions. Higher out-of-pocket expenditures are likely to lead to poor

medication adherence. Results of a study indicated that the out-of-pocket cost of insulin may also

be associated with nonadherence to prescribed regimens and hence poorly managed diabetes.

Treatment complexity and convenience

If the patient finds the treatment more difficult or cumbersome, adhering to medication becomes

challenging. Research has shown that the prescribed number of medicine doses per day was

inversely associated with medication adherence.

Frequent dosing and multiple drugs in the prescription especially attributed to the poor nonadherence in patients. In a study where majority of patients were on three-drug combination

regimen, results showed poor compliance to drug therapy and hence poor glycemic control.

Medication beliefs

Many patients harbor negative notions or skeptical views about medications prescribed to them. They are often apprehensive that the long-term risks will outweigh any likely benefits. Sometimes, people feel that it is difficult to stick to a prescribed treatment plan and so stop taking their

medications.

13

Physician trust

Adherence to hypoglycemic medications has been linked to patient's trust in their physicians. In a study, it has been reported that when patients feel that their needs during medical visits have been heard and addressed to, they are more likely to adhere to the medications prescribed. The quality of

communication between a doctor and his/her diabetes patient is also directly linked to the degree of medication adherence in the patients. In those cases where there is a high trust in the doctor, even out-of-pocket expenditure does not act as a barrier in ensuring adherence to medication regimen.

Even, social and family support is definitely a factor in increasing adherence.


¢ Talk to the patient about the adverse effects that nonadherence to medication may cause.

¢ Assess patient behavior/attitude towards medications and implement strategies to ensure medication adherence.

References



2. Herkert D, Vijayakumar P, Luo J, et al. Cost-related insulin underuse among patients with diabetes. JAMA Intern Med.

2019;179(1):112-4.


MGM J Med Sci. 2017;4(2):65-9.

14

Determinants of Adherence to Diabetes Medications

ExpertOpinion

Dr Neeraj Sinha

MBBS, MD (General Medicine)DM (Endocrinology), Gold Medalist (WBUHS)

Diabetes, Thyroid and Hormone Care Clinic, Patna, Bihar

The extent to which a person's

behavior such as taking medication, following diet and/or executing

lifestyle changes, corresponds with agreed recommendations from a

health care provider.

Medication adherence defined by WHO

Medical adherence is an important determinant of clinical outcomes in patients with diabetes: It is associated with better control of

immediate risk factors, lower risks of hospitalization, lower health care costs and lower mortality. The potential determinants of medical adherence are patient factors, prescriber factors and factors related to the prescribed medication or the prescription

system.

Patient factors Prescriber factors Prescribed medication

Patient factors

Research has shown that previous exposure to diabetes

therapy has a significant impact on adherence. An age effect is also observed; old age being a predictor of adherence. A research study has shown that patients 25-44 years of age were seen to be 49% less likely to be adherent when

compared with patients 45-64 years of age. Patients between 65-74 years were 27% more likely to be adherent while those

above 75 years of age were found to be 41% more likely to be adherent.

¢ Men were significantly more likely to be adherent

than women.

¢ Education level and household income were both associated with adherence.

¢ Patient's beliefs about the severity of the disease affects adherence.

1615

Common cause for nonadherence among younger patients may be attributed to a recent diagnosis

of the disease, limited knowledge of the disease, fear of side effect and burden of drug regimens. Older patients with longer duration of disease receive proper support and are more aware of the

importance of glycemic control in preventing potential complications and so survive with better quality of life.

Ethnic differences have also been noticed in a research study, which suggests that Indian patients are more likely to be nonadherent to medications compared with patients from Chinese, Malay or Singapore.

Prescriber factors

A statistically significant association of adherence has been noted between age of prescriber and

adherence to medication. Research did not identify any difference in adherence between patients

with primary care prescriber versus those who had endocrinologist prescribers. However, patients with nonendocrinologist specialist prescribers showed slightly but significantly lower adherence

than those with primary care prescribers.

Physicians can play a major role in improving medication adherence by improving interaction with patients. The physician-patient relationship plays a major role in keeping the patient well-informed

about the medications they consume.

Prescription factors

Total daily pill burden has been found to be positively associated with antidiabetic medication adherence. Patient out-of-pocket

costs were negatively associated with adherence. Majority of the diabetic patients are on three-drug combinations and show poor

glycemic control owing to poor compliance to drug therapy.

Unreported side effects and a lack of confidence in immediate or future benefits were signifcant predictors of suboptimal adherence. Physicians should not feel deterred from prescribing multiple agents in order to achieve adeqaute control of

hyperglycemic, hypertension and hyperlipidemia.

It can be said unarguably that there are drugs and insulin for management of diabetes, but it is only adherence, which makes them work.

16


¢ Inculcate behavioral change such as self-management and self-monitoring of blood glucose.

¢ Talk to patients about diabetes, oral hypoglycemic agents and insulin.

References

1. Elsous A, Radwan M, Al-Sharif H, et al. Medications adherence and associated factors among patients with type 2 diabetes mellitus

in the Gaza Strip, Palestine. Front Endocrinol (Lausanne). 2017;8:100.

2. Kirkman MS, Rowan-Martin MT, Levin R, et al. Determinants of adherence to diabetes medications: findings from a large pharmacy

claims database. Diabetes Care. 2015;38(4):604-9.


MGM J Med Sci. 2017;4(2):65-9.

4. Grant RW, Devita NG, Singer DE, et al. Polypharmacy and medication adherence in patients with type 2 diabetes. Diabetes Care.

2003;26(5):1408-12.

5. Lin LK, Sun Y, Heng BH, et al. Medication adherence and glycemic control among newly diagnosed diabetes patients. BMJ Open

Diabetes Res Care. 2017;5(1):e000429.

17

Risk Factors for Medication Adherence in Diabetes Patients

Introduction

Decreased adherence to antidiabetic medication is correlated with increased health care service utilization in adults with

type 2 diabetes. It is important to understand the risk factors, which increasse the chances of poor medication adherence in diabetes patients. Some important risk factors which may

lead to low adherence for medications are poor satisfaction with health facility, perceived poor satisfaction with doctor-patient relationship, perceived lack of knowledge about

ExpertOpinion

Dr Jamal Ahmad

MBBS, MD (Gen Medicine), DM (Endocrinology), FCCP, FRCP (UK), PhD (Medicine), Dsc (Endocrinology)

Centre for Diabetes and Endocrinology, Faculty of Medicine, JN Medical College and Hospital, AMU, Aligarh, Uttar Pradesh

diabetes, perceived lack of knowledge about effect of missing doses and initial years of having diabetes.

In the past, some Indian studies have also shown

that lack of family support, distance from the hospital, cost of the treatment and socioeconomic

status are also causative factors for poor

medication adherence.

Age, gender, educational achievements, socioeconomic status and employment affect adherence.

Number of drugs and doses to be taken, treatment duration, cost of medication, compatibility of dose

regimen with daily activities.

Disease-related presence or absence of symptoms, intermittent or variable conditions, chronic or acute illness.

DEMOGRAPHIC RISK FACTORS

18

Understanding of the disease and its

consequences, perception of threat

posed by the disease.

Comprehension of the cost

benefit of the treatment.

Motivation of the patient family,

involvement of the patient in decisions

regarding treatment, decreased

physical abilities.

PATIENT-RELATED RISK FACTORS

PATIENT-HEALTH CARE RELATIONSHIP-RELATED RISK FACTORS

Easy access to physician/health care.

Quality and effectiveness of the patient-health care professional interaction, time spent by the health care provider.

Attitude of the physician towards the patient and treatments, quality and adequacy of the communication given by information provider.

19


¢ Address the myths of the patients about the disease and its management.

¢ Educate the patients about the need for adhering to treatment and side effects of the treatment.

References

1. Venkatesan M, Dongre AR, Ganapathy K. A community-based study on diabetes medication nonadherence and its risk factors in

rural Tamil Nadu. Indian J Community Med. 2018;43(2):72-6.

2. Balkrishnan R, Rajagopalan R, Camacho FT, et al. Predictors of medication adherence and associated health care costs in an older

population with type 2 diabetes mellitus: a longitudinal cohort study. Clin Ther. 2003;25(11):2958-71.

3. Inamdar SZ, Kulkarni RV, Karajgi SR, et al. Medication adherence in diabetes mellitus: an overview on pharmacist role. Am J Adv

Drug Delivery. 2013;1(3):238-50.

Some perceive diabetes as

social stigma, while others

fear that they will become

dependent on treatment.

PSYCHOLOGICAL AND HEALTH-BELIEF-RELATED RISK FACTORS

Knowledge and attitude

of the patient.

Patients also feel that the

consequences of the disease

could have a serious impact

on their well-being.

Unsupportive family or

friends.

20

Medication Adherence and Glycemic Control

Introduction

Optimal glycemic management is essential to avoid the negative health and economic consequences of type 2

diabetes. The glucose-lowering efficacy of type 2 diabetes medications may only be realized through optimal patient adherence. Factors which have been identified by patients

with diabetes to negatively impact their adherence to medication include the incidence of treatment-related side effects, especially weight gain and hypoglycemia.

ExpertOpinion

Dr Mallik Arjun

MD (General Medicine), DM (Endocrinology)

Consultant Endocrinologist Meka's Hospital, Davangere, Karnataka

MEDICATION ADHERENCE

Maintains blood sugar levels within normal ranges. Promotes self-management behavior.

HbA1c levels

A research was conducted to assess the impact of administering oral hypoglycemic agents

intermittently other than as recommended. The result has shown that diabetes patients with

decreasing levels of medication adherence were consistently associated with a smaller glycated hemoglobin (HbA1c) reductions compared with a nonadherent patient. In newly diagnosed patients,

it was seen that patients with the highest and lowest baseline HbA1c level were associated with poorer medication adherence.

Another research study has reported that increasing levels of medication adherence were typically marked with greater HbA1c

reductions across all lines of oral hypoglycemic therapy. Adherence in this case was assessed through Medication Possession Ratio (MPR) and it was seen that a 10% improvement in MPR was

associated with a - 0.09% change in HbA1c for oral hypoglycemic agents monotherapy and dual

drug therapy; however, the change in HbA1c was - 0.21% for triple therapy. Research clearly supports the suggestion that even a modest rise in medication adherence can bring about

meaningful improvements in HbA1c control with the rising need to escalate therapy.

21

Hypoglycemia and medication adherence

It has been seen that hypoglycemia was more frequent among adherent patients compared with nonadherent patients, and this was more predominantly seen in patients on triple drug therapy.

Across the oral hypoglycemic treatment continuum, it is seen that regimens associated with weight loss and lower incidence of hypoglycemia are generally associated with better medication

adherence and improved glycemic control.

Glucose self-monitoring and adherence

Research has also shown that patients who are adherent to their medications are also more likely to adhere with behavioral

modification, glucose self-monitoring, attendance with medical care and other aspects of diabetes self-management. Lower HbA1c

values acts as a tool for identifying patients with poor medication-taking behavior who can then be targeted for directed adherence counseling services. Patient's knowledge about diabetes is associated with better medication adherence and better glycemic

control, hence health care providers should pay attention to knowledge about diabetes that the patients carry towards medication adherence.

22


¢ Talk with patients about why they are on diabetes medications and why its important to take their medications as prescribed.

¢ Discuss medication adherence barriers at each visit.

¢ Ask patients open-ended questions about concerns related to health benefits, side effects and cost.

References

1. Gordon J, McEwan P, Idris I, et al. Treatment choice, medication adherence and glycemic efficacy in people with type 2 diabetes:

a UK clinical practice database study. BMJ Open Diabetes Res Care. 2018;6(1):e000512.



3. Waari G, Mutai J, Gikunju J. Medication adherence and factors associated with poor adherence among type 2 diabetes mellitus

patients on follow-up at Kenyatta National Hospital, Kenya. Pan Afr Med J. 2018;29:82.

4. Krapek K, King K, Warren SS, et al. Medication adherence and associated hemoglobin A1c in type 2 diabetes. Ann Pharmacother.

2004;38(9):1357-62.

5. Al-Lamki L, Lamki AN. Evaluation tools in postgraduate medical education: Do we need “Made in Oman” tools? Sultan Qaboos Univ

Med J. 2009;9(3):219-23.

6. Al-Qazaz KH, Sulaiman SA, Hassali MA, et al. Diabetes knowledge, medication adherence and glycemic control among patients with

type 2 diabetes. Int J Clin Pharm. 2011;33(6):1028-35.

23

Introduction

Half of all those suffering with diabetes do not take their medications as prescribed; however, the good news is that

opportunities exist for health care providers to improve patient adherence to medications and lifestyle changes.

ExpertOpinion

Dr Prachi Bansal


KEM Hospital, Mumbai, Maharashtra

Promoting Medication Adherence in Patients with Diabetes

Talk to the patient

The most effective interventions consider the relationship between medication-taking

behaviors and patient understanding, beliefs, feelings and everyday life. Providers should

ask structured and refined questions, so that they can identify barriers and collaboratively work with patients to improve adherence.

Improve recall

Strategies to improve recall include educational programs for the patient, disease management

programs and counseling, behavioral support, medication reminders and specialized packaging.

Motivate the patient to correlate drug intake with daily events/habits, maintain required modifications, use in case of chronic disease.

Patients may benefit from the use of reminder devices such as

calendars, strategically placed notes and reminder telephone calls.

Encourage patients to use pill boxes to organize their medication and

to set an alarm on their smartphones or clock to remind them to take their medications. They can also sign up for refill reminders at the pharmacy or the doctor's clinic.

24

Effective communication with the patient

Effective communication with the patients such as avoiding the use of medical jargon as well as encouraging patients to ask questions if they do not understand, will improve medication adherence. Make

use of a teaching method that allows patients to repeat in their own words the information discussed in the visit so that the health care provider knows that the patient has truly understood the

information given to him. Convey risks and benefits associated with treatment including addressing patient concerns and promote a

shared decision making environment to improve patient-physician communication.

Provide correct and complete instruction regarding medication to

the patient in both verbal and written form. Verbal counseling about diabetes, its treatment and lifestyle modification should be

provided.

Electronic monitoring

Electronic monitoring systems were useful in improving adherence for individual patients. Similar electronic monitoring systems for

insulin administration could help health care providers determine patients needing additional support.

25


¢ Encourage patients to use pill boxes to organize medications.

¢ Teach patients how to use electronic medication containers, home blood glucose and blood pressure measurement device.

References



2. Inamdar SZ, Kulkarni RV, Karajgi SR, et al. Medication adherence in diabetes mellitus: an overview on pharmacist role. Am J Adv

Drug Delivery. 2013;1(3):238-50.

3. Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care. 2004;27(5):1218-24.

26

Introduction

Continuity of care, a provider factor and medication adherence, a patient factor in chronic disease management

affect both the health outcome and the health care expenditure in chronic disease management. In diabetes patients, poorer medication adherence leads to the

worsening of health outcomes.

ExpertOpinion


MD, DMSC-Endocrinology (England)Diploma in Diabetes (Boston)

Consultant Endocrinologist, National Hospital, Jabalpur, Madhya Pradesh

Medication Adherence and Improved Outcomes in Patients with Diabetes

Improved glycemic control Fewer hospitalizations Fewer visits to emergency department

HIGHER MEDICATION ADHERENCE

Medication adherence and intermediate outcomes

Several studies have shown links between medication adherence and intermediate outcomes such as blood glucose, glycated hemoglobin (HbA1c) level and health care utilization among diabetes mellitus patients.

27

Medication adherence and all-cause mortality

Adherence and use of acute care resources

Study has shown that adherence to antidiabetic medication has an effect on the long-term

all-cause mortality and hospitalization for cerebrovascular disease and myocardial infarction

in newly diagnosed patients. In this cohort study, it was seen that poor medication adherence

within first 2 years following the diagnosis of diabetes mellitus had an increased risk for long-term all-cause mortality and cardiovascular disease. It was noted that poor medication

adherence increased the mortality rate by 45% and the incidence of cardiovascular disease by 41%.

A research study has shown that adherence to glucose-lowering agents is associated with a significant reduction in use of acute care resources without any increased total medical costs.

Research has shown that nonadherent patients are more likely to have emergency department visits and hospitalization compared to adherent patients.

The probability of hospitalization as well as visits to emergency department go down in

adherent patients. The probability of an acute complication also reduces as the adherence is

improved. It was seen that adherence was associated with a significant reduction in the probability of an acute complication being diagnosed over the 3-year period post the

study period.

28

It substantially reduces acute

care costs.

REDUCED USE OF EMERGENCY DEPARTMENT RESOURCES IS IMPORTANT

Lessens the economic

burden of diabetes for

society as a whole.

Avoids unexpected loss of

time, productivity and

workdays for patients and

caregivers.

Prevents intrinsic health

risks such as health

care-associated

infection.

Medication adherence and complications

With improved adherence, chances of developing micro- and macrovascular complications such as hyperglycemia, hypoglycemia,

or hypoglycemic coma is diminished. Hence, the reductions in acute complications is linked with reduction in the need of acute care

and taken together they indicate that the adherent patients have better managed type 2 diabetes relative to nonadherent patient.

Hence, adherence also contributes towards improving quality of life.

29


¢ Provide ongoing support and assessment of adherence at each visit.

¢ Explain to patients how adherence will improve their quality of life.

References



2. Kim YY, Lee JS, Kang HJ, et al. Effect of medication adherence on long-term all-cause-mortality and hospitalization for

cardiovascular disease in 65,067 newly diagnosed type 2 diabetes patients. Sci Rep. 2018;8(1):12190.

3. Curtis SE, Boye KS, Lage MJ, et al. Medication adherence and improved outcomes among patients with type 2 diabetes. Am J

Manag Care. 2017;23(7):e208-14.

30

Lifestyle Modifications: Exercise

Prescription for exercise in diabetes

Exercise prescription should be tailor made keeping in mind the person's physical status and capacity, interests, feasibility of the mode of exercise and above all the

motivation levels.

FITT PRESCRIPTION

F: Frequency I: Intensity T: Time/duration T: Type

AEROBIC EXERCISE PRESCRIPTION

¢ Frequency: 4-7 days/week; training of less than 2 days/week does not generally result in a meaningful increase in

exercise capacity.

¢ Intensity: Ideal intensity; 70-85% of heart rate maximum; lower intensity is better for older people and those starting a

problem.

¢ Time: 20-60 minutes of continuous exercise or accumulated in bouts of at least 10 minutes; target is to achieve a total of

at least 150 minutes/week of moderate physical activity.

¢ Type: Walking, running, cycling, elliptical cross trainer, rowing, swimming and climber.

Resource:

Module on Exercise and Diabetes Mellitus by Dr Ashish Contractor; Certificate Course in Diabetes Education.

Superfood of the month: Bitter gourd

Lifestyle Modifications: Diet

Momordica charantia (bitter melon or bitter gourd) is one of the most promising

plants for diabetes.

It holds the potential to significantly improve diabetic conditions and associated

late complications with no ill effects on body organs.

Flowering vine in the family

Cucurbitaceae.

Bitter gourd has

hypoglycemic effect.

It preserves islet

-cells and their

functions.

It stimulates glucose

utilization in peripheral and skeletal muscle.

It suppresses key gluconeogenic

enzymes.

Climbing perennial with elongated

fruits, a useful medicinal and vegetable plant for human health.

It has intensely bitter fruits commonly

used in cooking and as a natural remedy for treating diabetes.

NUTRITIONAL VALUE OF BITTER GOURD

High amounts of vitamin C, A, E, B1, B2 and B3

FolatePotassium, calcium, zinc,

magnesium, phosphorus and ironFlavonoid, isoflavones,

terpenes, glucosinolatesDietary fiber

It inhibits intestinal

glucose uptake.

31

This is a nicely flavored recipe which not only has the pungency of onions but also the aroma of roasted sesame seeds and the tanginess of mango powder. The ingredients together not only make 'karela' palatable but also an extremely healthy food.

Ingredients needed

¢ Sliced onions (2 cups)

¢ Thinly sliced and deseeded bitter gourd (2 cups)

¢ Turmeric powder (1/2 tsp)

¢ Chilli powder (2 tsp)

¢ Sugar (1 tbsp)

¢ Dried mango powder/amchur (1 tsp)

¢ Roasted sesame seeds (1 tbsp)

¢ Oil (2 tsp)

¢ Salt (to taste)

Method

Step 1: Combine the bitter gourd and a little salt in a deep bowl and mix very well. Keep aside for 20 minutes.

Step 2: Squeeze all the water from the bitter gourd and place them on a kitchen towel to dry them completely.

Step 3: Heat the oil in a deep non-stick kadhai, add the onions and sauté on a medium flame for 1-2 minutes.

Step 4: Add the bitter gourd, mix well and cover and cook on a slow flame for 15 minutes, while stirring occasionally.

Step 5: Add the turmeric powder, chilli powder, sugar, dried mango powder, sesame seeds, salt and 1 tbsp of water, mix well and

cook on a medium flame for 2 minutes, while stirring occasionally.

Step 6: Serve hot.

Recipe of the month: Onion and Karela Vegetable Delight

32

NUTRITION VALUE PER SERVING

Energy: 80 cal Protein: 1.6 g

Fat: 3.7 g

Carbohydrates: 10.1 g

Cholesterol: 0 mg

Fiber: 2.8 g

Sodium: 2.7 mg

Source: Dalal T. Onion and Karela Subzi, Diabetic recipe.

33

NDEP Best Practices

Dr N MD Attaullah from Harmain Hospital, Hyderabad has been following NDEP best practices. Some of the remarkable features from his practice are given below.

Education on the right usage of insulin as per the patient

Commonly used insulin vials are U40 and U100, with U40 being typically

used in India.

Diabetic foot issue

Educate on various lesions and the importance of each.

ExpertOpinion

Dr N MD Attaullah

MD (Medicine)

Physician and Diabetologist Harmain Hospital, Falaknuma Hyderabad, Telangana

34

Kidney diseases and diabetes

Awareness on drugs used and contraindications.

eGFR calculation

Calculation of eGFR is based on serum creatinine (using APP-National Kidney APP).

Podiatry service

What is the meaning of the service, how to use it in diabetic foot and how is it

performed?

35

Conference Highlights

4th World Congress on Advances in Diabetes Care and Metabolism

Event Date: November 06-07, 2019

Event Location: Chicago, USA

This meeting will include new research prospects that focus on subjects like nanotechnology in diabetes treatment, stem cell therapy in diabetes, challenges of diabetes health care, diabetes in young adults, cardiovascular risks in obese, clinical researches

in diabetes, physiotherapy in diabetes, bariatric surgery and endocrine glands and hormones apart from the broad areas of research in the field.

Benefits of Participation

Diabetes Congress 2019 is open for oral presentations; poster shows and scientific panel discussions across the highlighted

sessions within the web site and proposals on alternative topics that don't seem to be listed also are welcome. Provided they meet the objectives of the conference. We are focusing to inspire, discuss and work along to bring out an answer for numerous issues related to diabetes, obesity, endocrinology and metabolism.

Who can attend?

Diabetes Congress 2019 will provide a platform for the diabetologists, endocrinologists and experts both from Industry and

Academic working in various subdomains of diabetes, obesity, endocrinology and metabolism. This conference is open for all the

Diabetes Doctors, Specialists, Endocrinologists, Researchers, Physicians, Business Analysts, Academicians, Lab Technicians,

Nurses, Diabetes Educators, Nutritionists, Dietitians and students.

Opportunities for Conference Attendees

Specialists and educators

¢ Speaker Presentations

¢ Poster Display

¢ Symposium hosting

¢ Workshop organizing

https://diabetesconference.euroscicon.com/

36

Diabetes Quiz

Answers

Yes

No

Optimum glucose levels

Not taking medications as prescribed is a leading cause of hospitalizations.

¢ Yes

¢ No

Q-1

Exercise, stress relief and eating a balanced diet are more important to manage blood glucose than taking medications.

¢ Yes

¢ No

Q-2

Barriers to proper adherence to diabetes medication include all of the following except:

¢ Lack of awareness

¢ Optimum glucose levels

¢ Cost of medication

¢ Family support

Q-3

37

Predictors of Poor Medication Adherence

¢ Missed prescription refills

¢ Forgetfulness

¢ Poor eyesight

¢ Depression

¢ Language barrier

¢ Poor coping skills

¢ Missed appointments

¢ Multiple comorbidities

¢ Lack of trust in the provider

¢ Lack of prescription drug coverage

¢ Poor understanding of medical conditions

¢ Medical conditions without symptoms

Characteristics of patients at high-risk of nonadherence

¢ Low literacy indicators

¢ Believes that medications either won't improve their condition

or can make it worse

¢ Believes that they can manage their diabetes without the help

of medications

¢ Emphasizes side effects they have heard or read about

¢ Has concerns about the high cost of medications

Predictors of poor medication adherence

38

Questions to Ask your Patients to Assess Medication Adherence

Q. 1 Do you forget to take your medicine?

Q. 2 Do you decide to not take your medicine?

Q. 3 Do you miss taking your medicine because you feel better?

Q. 4 Do you ever decide to take less of your medicine?

Q. 5 Do you stop taking your medicine because you feel sick due to the effects of the medicine?

Q. 6 Do you forget to bring along your medicine when you travel away from home?

Q. 7 Do you not take your medicine because you run out of it at home?

39

40

NOTES

41

Disclaimer: Although great care has been taken in compiling and checking the information given herein to ensure that it is accurate, the publisher shall not be in no way directly or indirectly responsible for any error, omissions or inaccuracy in this publication whether arising from negligence or otherwise. IJCP Publications Ltd. does not guarantee, directly or indirectly, the quality or efficacy of the product or service described in the advertisements or other material which is commercial in nature in this publication.

Copyright 2019 IJCP Publications Ltd. All rights reserved.

The copyright for all the editorial material contained in this book Indian Diabetes Educator Journal, Issue No. 51, June 2019, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

This book is Published and Edited by IJCP Academy of CME at Regd. Office: E-219, Greater Kailash Part - 1, New Delhi - 110048. E-mail: [email protected], Website: www.ijcpgroup.com, HIP/IN/Mumbai/2447 as a part of its social commitment towards upgrading the knowledge of Indian doctors.

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