Diabetes’ Burden on MexicoBy Miriam Bello | Mon, 11/23/2020 - 09:13
Since 2006, World Diabetes Day (WDD) has been celebrated every Nov. 14. In 1991, WHO’s concerns regarding the increasingly growing numbers of diabetes patients spurred a response to this potential threat. WDD was officialized and the date was market after the birthday of Frederick Banting, who co-discovered insulin with Charles Best in 1922.
The primary goal of this day is to raise awareness of the importance of taking coordinated and concerted action to confront diabetes as a critical global health issue. Each year, WDD changes its theme to promote different key pillars to confront diabetes. For 2020, the theme is The Nurse and Diabetes, as the former play a fundamental role in supporting people with diabetes. Nurses are the first point of contact regarding education for diabetic patients and are essential for diagnosis and treatment of people with this disease.
Diabetes in Mexico
The Mexican Federation of Diabetes describes this disease as a condition that affects the body's ability to transform food into energy. Insulin helps to get energy from food. Without enough insulin, glucose stays in the blood and over time, this excess can lead to serious complications. People with this condition have high levels of glucose in the blood as their body does not produce enough insulin or cannot use the body’s insulin. One out of 10 people in the world live with diabetes, with Type 2 being the most common condition (90 percent), which is when the body does not produce enough insulin. Type 1 diabetes is when the body produces no insulin.
In Mexico, diabetes, specially Type 2, became a healthcare burden in 2000, when it started to be the primary cause of death among women and the secondary cause of death among men. Diabetes has many health complications: it increases the risk of heart disease and strokes, can lead to blindness, kidney failure, sexual impotence and amputations.
Obesity, sedentarism, bad eating habits, genetics, family background and age are among the factors that lead to developing diabetes. In 2016, Mexico registered the highest mortality rates among men and women and from that year on, the numbers continue to be concerningly high.
WHO estimates that Mexico has around 8.7 million people suffering from diabetes, but there might even be 12 million people living with it without a diagnosis. These figures put the country among the Top 10 with the highest rates of this disease. According to the Ministry of Health, in 2019, Mexico registered 33,516 new cases of diabetes Type 2, with Tabasco (3,596 cases, 10.7 percent) and Jalisco (3,110 cases, 9.3 percent) reporting the majority of cases. Guanajuato, with 132 cases, was the state with the lowest rate of diabetes cases.
In 2019, 50.4 percent of the diabetes patients were women and 49.6 percent were men. On average, most cases are registered between the ages of 55-64, with 26.1 percent of the cases, followed by the age group of 45-54 with 22 percent.
The mortality rates from diabetes are one of the highest for the country. In 2018, the Ministry of Health registered 101,257 deaths from diabetes. State of Mexico (14.83 percent), Mexico City (9.05 percent) and Veracruz (8.70 percent) reported most of these deaths. People over 65 years of age represented 60.97 percent of the deaths from diabetes in 2018. These figures make diabetes responsible for 14 percent of the total deaths in Mexico, placing it as the second cause of death in the country.
Costs of Diabetes
María Jesús Salido, CEO of SocialDiabetes, spoke with MBN to put diabetes in context. “Living with diabetes requires daily medication and adequate devices for the continuous control of the disease, as well as a certain level of knowledge and awareness to make critical decisions for the patient’s health.” Salido explained that due to the highly segmented health system in Mexico, care is deficient and patients receive neither the necessary clinical supplies nor the multidisciplinary care that the disease requires. “For all these reasons, the treatment depends almost entirely on the resources and means of each patient, as well as the level of individual awareness regarding the disease.”
The economic burden of diabetes was estimated to be around US$3.872 billion, says ENSANUT. In total, Mexico spends around 2.5 to 5.6 percent of its GDP on treating diabetes directly or indirectly, through attention to overweight and obesity. According to Yannis Mallis, Director General of Novo Nordisk, from every MX$100 (US$4.92) destined to treat diabetes, MX$93 (US$4.57) are used to treat diabetes complications. According to the insurance company Monterrey New York Life, the cost of a medical treatment for diabetes is of MX$131,000 (US$6,500).
Out of pocket expenditure to treat diabetes can push families into poverty. A patient with no social security can spend between MX$2,000 (US$98.36) and MX$6,000 (US$295.08) per month, according to Milenio. A study by IMCO describes three different expenditure scenarios to picture the magnitude of the disease;
- If an average family had to pay 20 percent of the treatment, its annual disposable income would fall to MX$101,000 (US$4,900).
- If an average family had to pay 60 percent of the treatment, its annual disposable income would fall to MX$48,000 (US$2,360.64)
- If an average family had to pay for the treatment in full, they would have to incur in debt and/or sell their assets.
Fernando de Obeso, CEO of Salud Facil, told MBN that diabetes goes beyond being a healthcare priority. For Mexico, this has become an economic priority. “The economic component of diabetes is key to access treatment. It is essential to avoid any other complication, such as kidney failure, which would worsen costs.” According to de Obeso, years ago, Seguro Popular made a study to determine how much it would cost to treat a patient with kidney failure, which circled around MX$250,000-300,000 (US$12,300-14,800) per year. Over time, diabetes complications become unpayable for individuals and public healthcare systems. Diabetes requires a lifestyle change to not let the disease become worse and efforts to promote this among the population have to go beyond communication initiatives. “From my perspective, economic incentives for people to improve their health would change this concerning panorama in Mexico and, with time, the expenses of those initiatives would be reduced by the positive health outcomes of patients.”
De Obeso’s comments can be easily reflected in the figures from the Mexican Federation of Diabetes. A patient with no control over their disease and presenting medical complications (which are likely to occur) can cost up to MX$1,163,028 (US$57,200). Diabetes on a patient with their condition treated and under control costs MX$88,024 (US$4,300).
Diabetes costs productivity, too. According to the US Chamber of Commerce, the loss in productivity caused by employees with chronic diseases represents almost 5 percent of Mexico’s GDP. An OCDE study made in 2016 reports high levels of overweight and obesity reduce the available global workforce by 2.4 million full-time workers a year, as they tend to be hired less and, if they do get the job, they turn out to be less productive. On a more recent note, the Director General of IMSS confirmed this statement and added that “Mexico is losing more than 400 million working hours due to diabetes, which is equivalent to 184,000 full-time jobs.”
How to Combat Diabetes
To achieve an overall successful transformation for the healthcare sector, tackling the healthcare and economic burden of diabetes is essential. In 2018, Mexico Health Review spoke with Gabriela Allard, Director of the Mexican Association of Diabetes (AMD), who mentioned that to reduce costs and improve patients’ health, the focus must be on prediabetics. Controlling conditions like metabolic syndrome, which includes symptoms such as high blood pressure, high levels of blood sugar, excess body fat around the waist and high cholesterol levels, is the window of opportunity to stop the disease, as these are all key conditions that increase the risk of Type 2 diabetes. According to Allard, each diabetic patient will cost the system MX$1.8 million (US$89,699.40) in 30 years. “By the time patients become diabetic, we have lost many opportunities. But if we work on prevention, the health system will save a lot of money.” Education is the first step, followed by diet and then special attention to vulnerable groups such as pregnant teens. Most teenage mothers visit a doctor when the pregnancy is advanced, meaning that during the unattended period, their glucose levels have not been under control, which can derive on gestational diabetes, says Allard.
Mexico has a very negative trend related to its diabetes attention habits. MBN spoke with Camilo Garay, Country Manager of 1DOC3, and he explained that Mexican patients learn about the disease only after presenting symptoms, leading to severe healthcare complications. This conclusion was reached after a study made alongside IMCO for its yearly diabetes report on understanding how patients behaved and how this compares to other countries with a lower diabetes incidence.
Prevention Efforts From the Public Sector
SSA, IMSS and ISSSTE are reinforcing their prevention campaigns for diabetes. As a result of COVID-19 limitations, digital approaches were implemented by IMSS, for instance, through its online platform called CHKT. IMSS offers a survey to determine a patient’s healthcare risks, including red flags regarding diabetes. The institute also created a strategy called Diabetes: Protege a tu Familia (Diabetes: Protect Your Family) as it noticed that many Type 2 diabetes cases can be avoided through the adoption of healthier family lifestyles. Furthermore, through IMSS’ family medicine units, the institute manages the NutrIMSS and Yo Puedo (I Can) programs. The first works with people with overweight or at risk of diabetes, hypertension or another chronic disease, who receive a dynamic workshop to change their lifestyle. Yo Puedo is an educational strategy targeting the same group of people as NutrIMSS.
ISSSTE, meanwhile, implemented the Program for the Prevention and Regression of Overweight and Obesity at 148 of its clinics and medical units to treat and contain obesity as a way to reduce the economic burden of treating complications derived from metabolic and cardio vascular diseases. The institute also has a strategy called Transformando tu Estilo de Vida (Transforming Your Lifestyle) that targets patients with cardiovascular problems, diabetes mellitus, high blood pressure and some types of cancer, which can cause disability and loss of up to 10 years of life.
SSA created Grupo GISAMA, which works toward a transformative eating environment to facilitate the adoption of healthier lifestyles. Moreover, the ministry has exhorted the whole healthcare system to transform to ensure treatment continuity through integrated healthcare networks. SSA works through 12,392 first attention clinics for chronic diseases (UNEMEC EC) distributed through the country, which are meant to strengthen first care attention to achieve a successful diabetes control for patients. These clinics also work with 1,976 groups for chronic disease support, including diabetic patients. These efforts have led to more than 700,000 educative sessions on nutrition and physical activity. According to SSA, the outstanding results of these groups have encouraged the Ministry of Health to have at least one group per first attention care unit.
These preventive programs are complemented by direct public policy. Mexico has increased taxes on sugary drinks to promote water consumption. Moreover, the country has recently approved a new labeling norm for packed food and beverages to include a warning to easily identify products that contain high levels of calories, sugars, saturated fat and sodium. The country has also regulated the sale of junk food at schools, for example in the state of Oaxaca, and has implemented other measures including educational campaigns, the regulation of the advertising of foods and beverages with high caloric content aimed at children, as well as the promotion of breastfeeding. Physical activity has also been addressed through promotional campaigns, the adaptation of public spaces for exercise, bicycle lanes and "open street" programs in which car traffic is temporarily suspended allowing access to pedestrians, runners and cyclists.
Prevention Efforts From the Private Sector
According to the General Council of Official Pharmacists Associations, a study among Spanish community pharmacies showed pharmacists have an important role in the detection of patients with diabetes and are also essential in treatment adherence and follow-up. In Mexico the panorama is similar, according to Santiago González, Operations Director of Farmacias YZA. “Pharmacies have a great capacity that we can detonate. The penetration of ANADIM’s affiliated members is close to 95 percent of the population and at pharmacy-adjacent offices we have the opportunity to raise awareness of the disease and be an option for detection and follow-up,” González told MBN.
Pharmacies have been considered the most feasible and logical tool to achieve a greater healthcare coverage in Mexico. However, there are other tools that can contribute and promote care options for patients with chronic diseases. “Technology can be an ally to increase patients’ self-management capabilities and to support professionals’ decision-making, connecting the two environments and favoring doctor-patient communication,” said Salido.
The pharmaceutical industry has in fact integrated technology tools to improve its offering. Through the “Beyond the Pills” initiative, companies complement their drug treatment with digital platforms to favor follow-up and to ensure treatment continuity. This trend also favors personalized medicine, which leads to better treatment development and specialized treatment focus for patients.
Roche is one of the companies using the Beyond the Pills approach to treat diabetes. The pharmaceutical company has a digital platform to manage diabetes called mySugr. Through it, Roche is able to offer seamlessly accessible patient solutions within an open platform to better respond to unmet needs. Their aim is to support people with diabetes to spend more time in their ideal glucose target range and improve their quality of life. With mySugr, users have the ability to automatically upload blood glucose data from their preferred device into the mySugr logbook app, and to share data with healthcare professionals and caregivers.
Importance of Prevention
Preventing diabetes means living a longer, healthier life, avoiding large costs that can further contribute to damaging individual well-being. Diabetes has become an epidemic in Mexico and a sanitary crisis as well. According to IMCO, for a single person, it is 21 times cheaper to change their health habits than to develop diabetes and any of its complications. For a prediabetic patient, changing their habits on time can lead to a cost of the disease of MX$92,860 (US$4,600), whereas a prediabetic that does not pay attention to their habits can spend around MX$1,976,052 (US$97,200). Both figures represent costs 30 years after diagnosis. Fundacion Federada says that healthy lifestyles are the cornerstone of any diabetes treatment. Type 2 diabetes, the largest burden for Mexico, starts developing long before symptoms appear, meaning that constant healthcare attention and checkups are key for its timely treatment or to prevent it.
Experts also recommend public policy strengthening to tackle prevention. IMCO highlights the creation of a National Obesity System to evaluate the functionality of the current public policies and to measure relevant actions to reducing obesity. The country needs to unify the criteria and reference values for these policies by creating an instrument that can guide all actions against obesity. Strengthening preventive actions at school remains a priority, along with promotion of physical activity. IMCO says incentives are needed to grow infrastructure that facilitates physical activity, as well as new rules for obtaining resources from federal funds and housing subsidies, while quantifying the necessary budget in public works for sidewalks, bike paths and urban infrastructure projects that promote physical activation.