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More than meets the eye in diabetes

Diabetes mellitus is a rapidly growing ‘epidemic’. The number of adults with diabetes has doubled since 1980 to an astronomical figure of 347 million globally.

This rise is attributed to an ageing population, increased obesity and lack of exercise. The prevalence of diabetes mellitus in Malta is about 10 per cent of the whole population, with 90 per cent being the mature, late onset type. This condition has serious public health implications because of its associated morbidity and mortality.

About four million deaths each year are attributed to diabetes-related complications worldwide, half of which are linked to cardiovascular disease, including heart attacks and strokes. However, their quality of life is also affected.

Two per cent of diabetics are blinded with the condition and a much higher percentage are left partially sighted. Poor peripheral circulation and neuropathy lead to difficulties in walking and foot ulcers that may require an amputation of a lower limb. Kidney failure may require long-term dialysis.

Therefore, diabetes mellitus is a very costly disease which, apart from being lethal or crippling, is a huge burden on health economics and social security. The costs of diabetic care are not only the myriad of surgical or medical treatments required but also the implications on the social welfare, be it sick leave, reduced work abilities, early pension or disability benefits, just to mention a few.

Diabetic eye problems are relatively preventable. Laser treatment has been around since early 1970s and it is a well known fact that it is a very effective treatment if applied early enough. However, the timing of laser treatment is essential because benefit falls sharply if treatment is applied late. Therefore, in order to optimise the timing of laser treatment in diabetic eye disease a proper screening programme has to be in place. The disease has to be detected before any symptoms are experienced and, therefore, a good screening programme means that all diabetics over the age of 11 years need to be examined on a regular basis.

That such regular check-ups of diabetic patients’ eyes are beneficial has been proven by the Icelandic group, which, on the institution of the screening programme, managed to cut the diabetic blindness rate from 2.4 per cent in 1980 to below 0.5 per cent by 2000.

Due to technical advantages in telescreening, leading to increased screening efficiency, from a public health standpoint, diabetic eye disease is one of the most cost-effective health procedures known. The cost of screening is far lower than the cost of diabetic blindness.

Therefore, what are we waiting for in Malta? Our relatively small contained population renders itself more feasible to screening. Presently, some diabetics are screened by their ophthalmologist or diabetologist at Mater Dei Hospital or privately. Others have their retinae/fundi photographed at the diabetic clinic at Mater Dei, some are examined by their GP and there are those who do not bother at all until they experience a probem with their eyesight. The end result is a hotchpotch of widly differing levels of screening from the best possible to none at all.

The common factor is that, at present, regular check-ups are the responsibility of the patients when, in fact, the onus has to be on the health authorities.

Whether it would mean using the health centres again or using a mobile unit, manned by a medical photographer, that visits different villages on the island on a regular basis is something one can discuss. One thing, though, I’m sure about is that active screening has to be instituted because passive screening has proved to be very ineffective and costly for the patient and the Government. We have to make the extra effort to screen patients. Patients absconding from screening would be very costly.

It is unbelievable to know that the Diabetic Clinic at Mater Dei still lacks the full-time service of a dietician and a psychologist. Tailor-made dietary plans for diabetics are crucial and, in my experience, the biggest threat in cases of diabetes mellitus is the state of denial of some patients.

The services of a psychologist would be very useful not only in this scenario but also in dealing with the emotional distress the diagnosis and the disease itself may cause, encourage family participation, deal with adolescent concerns and advise how to cope with schooling or employment.

In Malta, diabetic care and control of its sequelae has to be a prime objective.

Active tight retinal screening of the whole diabetic population is essential to prevent or limit a devastating and costly eye disease. Doing nothing is not an option, especially when faced with the spiralling costs of diabetic eye care.

Franco Mercieca is a Labour Party candidate.

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