Pacific patients and T2D: How can we do better?
Type 2 diabetes is at least twice as common among Pacific people1 and typically occurs 10 years earlier than in the overall New Zealand population.2 Pacific people have higher rates of mortality and complications; life expectancy is approximately 5 years shorter for Pacific people, mainly due to diabetes and its complications.3
This Medcase discusses rapid escalation of treatment for poorly controlled type 2 diabetes, highlighting ideas to improve outcomes for Pacific patients.
Mr M is a 44 year old Samoan man who arrives 20 minutes late to his Saturday morning appointment. Your nurse asks if you can fit him in, as she has been trying unsuccessfully to contact him about his HbA1c, which was 104 mmol/mol at the last check 6 months ago. Mr M was diagnosed with type 2 diabetes 5 years ago with an HbA1c of 72 mmol/mol. He has since been seen irregularly by multiple GPs. Despite advice about diet and exercise, his HbA1c continued to increase and two years ago he was prescribed metformin 500mg BD and cilazapril 0.5mg daily. However, repeat prescriptions have been irregular and the most recent one was 6 months ago. At that visit, his weight was 134kg (height 180cm, BMI 41), blood pressure was 154/94mmHg. What do you do next? |
The Pacific patient paradox: Poorer outcomes for those most in need
The case of Mr M is not unusual and there are multiple reasons for poor outcomes. Pacific patients are over-represented on various indices associated with poor health (low socioeconomic status, overcrowded housing, exposure to smoking and poor nutrition)2,4 but disparities persist even when these factors are removed.1 The health system can present substantial barriers to care. Patients report difficulties accessing clinics, clashes with other appointments or work, seeing too many doctors/clinics, language barriers and lack of interpreters.5,6 Cultural misunderstanding and unconscious bias can inhibit connections with Pacific patients, leading to racial discrimination and poor health outcomes.4
Patient voices: Comments from patients who did not attend diabetes satellite clinics in Auckland:5
I am taking too many tablets but I did not feel that my condition is changing.
My blood sugar was not very good but I could not afford to go to my GP to get the prescription…I had to go to work…I couldn’t take more leave. (Then) one day I got really unwell and had to go to ED. I was told that my kidney was failing and now I am on dialysis machine…My family is also suffering because I can no longer work full-time.
How can practitioners offer Pacific patients better care?
There is no one-size-fits-all approach to caring for Pacific patients. However, delivery of care in a culturally appropriate manner is important. Consider the following themes:4
- Rapport. Trusting, respectful relationships are important, allowing patients to better understand their condition and the aims of investigations and treatments.
- Continuity. Many patients like Mr M receive fragmented care for acute problems only. Ask the patient how to ensure regular follow-up; consider longer appointments with a trusted clinician, phone reviews, or funding to reduce GP or pharmacy costs.
- Holistic good health. For many Pacific patients, good health means being able to fully contribute to their family and community. Understand what is important to the patient and how treatments fit with their priorities. Offer self-management tools.
- Respect. Showing respect for those of higher social status is important. This can inhibit the sharing of personal or embarrassing information with the doctor. For example, patients may not reveal to the doctor that they are unable to afford the prescription cost.
- Dignity. A concern for dignity may outweigh concerns about health. Ask what is important to the patient and what treatments they wish to accept.
Back to Mr M: What do you do now?
Visit 1: Build rapport, re-establish treatment and arrange regular reviews Mr M apologises for arriving late. He tells you he works night shifts and finished late today. On examination, he weighs 140kg and blood pressure is 158/90mmHg. His cardiorespiratory and foot examinations are normal. You move on to discussing management, focusing on:
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Escalating treatment quickly is important and helps keep patients motivated. Consider combination therapies where possible to reduce the pill burden; it usually requires more than one antihyperglycaemic or antihypertensive agent to achieve targets.
Visit 2: Titrate medications, start blood glucose monitoring, CVD risk assessment and blood pressure control Mr M brings his wife to this appointment and you spend a few minutes getting to know her. She does the family food shopping and cooking and you discuss healthy eating for the family. Next, you review the blood test results with the following actions:
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Your nurse follows up with Mr M between visits and he is comfortable using the testing machine. He returns to see you one month later.
Visit 3: Start insulin and titrate antihypertensive medication Mr M’s renal function is satisfactory on the escalated antihypertensive treatment and he is tolerating the metformin/vildagliptin well. You review his blood glucose readings from the previous 3 days:
You start Mr M on a regimen of 10 units isophane (Humulin NPH) at bedtime and plan for him to continue the metformin/vildagliptin. You ask him to continue testing fasting blood glucose levels every morning initially, and plan for a patient-led titration whereby he will increase the insulin dose by 2 units every 3 days until fasting levels are within the target range of 6.1-7.9 mmol/L range. Once at target, he can reduce blood glucose testing to twice weekly. You arrange weekly nurse follow-up by phone and ask him to return to see you in four weeks days for review. You ask him to measure pre-breakfast and pre-dinner blood glucose levels on the 3 days before your visit to allow dose titration. Mr M and his wife then go to see your nurse to learn how to inject, store and handle insulin. They also discuss symptoms of hypoglycaemia and meal timings. |
Practical tips for starting insulin treatment
- Starting evening insulin is a useful first step to control overnight blood glucose levels and achieve target pre-breakfast blood glucose of 5-7 mmol/L, which may enable control of daytime levels. It also reduces daytime hypoglycaemia risk and makes monitoring easier, as only fasting glucose levels are required to inform dose adjustments of evening isophane insulin.
- Simplify blood glucose testing regimes by asking patients to record pre-breakfast and pre-dinner levels on the 3 days before their next review. This can improve compliance and allow better treatment titration.
- Consider patient-led insulin dose titration; for guidance see Examples for insulin initiation and titration, p 162 of General practice management of type 2 diabetes.
- Patients with significant insulin resistance may need twice daily premixed (biphasic) insulin or additional bolus therapy; review blood glucose readings early and titrate the dose as required.
Ongoing management: Titrate insulin and antihypertensive medications to targets, continue weight management Over time, you monitor blood glucose levels to ensure the evening isophane dose is optimised to achieve fasting (pre-breakfast) levels. However, you notice that despite adequate fasting levels the daytime readings are increasing, and pre-dinner readings are consistently above 10 mmol/L. At this stage you have the option to add morning isophane or switch to glargine at night; check BPAC8,9 or your local Health Pathway for information on how to do this. You continue to help Mr M manage his weight, blood pressure and cholesterol, with regular reviews and nurse phone-calls in between visits. |
In summary: Practice points |
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Useful patient self-management websites and apps
- Diabetes NZ’s Take Control website and App
- Diabetes Apps Health Navigator NZ
- Malakai Fekitoa on how he reduced his chance of getting type 2 diabetes
- Mediterranean and DASH (Dietary Approach to Stop Hypertension) diets
- Diabetes Health Navigator NZ
References:
- ʹAla Moʹui Progress Report: Health care utilisation Ministry of Health (2018)
- Health and Pacific peoples in New Zealand Statistics New Zealand and Ministry of Pacific Island Affairs.
- Tagata Pasifica in New Zealand Ministry of Health (2019)
- Best outcomes for Pacific peoples: Practice implications MCNZ
- ADHB Diabetes Service Community Engagement Project (2018)
- Taylor T, Wang Y, Rogerson W et al. Attrition after acceptance onto a publicly funded bariatric surgery programme. Obesity Surgery 2018;28:2500-2507
- A rising tide of type 2 diabetes in younger people: what can primary care do? BPAC (2018)
- HbA1c targets in people with type 2 diabetes – do they matter? BPAC (2010)
- Correspondence BPAC
- Initiating insulin for people with type 2 diabetes BPAC (2012)
This MedCase was created in 2019 by Dr Vicki Mount, MBChB DipPaeds, and reviewed by Dr Rinki Murphy, diabetologist and physician, senior lecturer in medicine at the University of Auckland, medical advisor for Diabetes Auckland.
MedCase supported by:
