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December, 2017 >>

The Berlin Declaration: Inspiration for primary care

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )

Ashok Kumar Das  ( Department of Endocrinology, Pondicherry Institute of Medical Sciences, Pondicherry, India )

Cecilia JImeno  ( Department of Medicine, University of the Philippines College of Medicine, Manila, Philippines )

Wannee Nitiyanant  ( Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand )

Goh Su-Yen  ( Singapore General Hospital, Singapore )

Truong Le  ( Van, Vietnam )

Abstract

This paper describes the seminal Berlin Declaration, released in December 2016, and draws inspiration from it to ensure early prevention, early detection, and early control of diabetes, and provide early access to the right interventions for diabetes care. Discussion focuses on actions which primary care physicians can take in their individual practices to help achieve the goals laid down in Berlin Declaration.  Collective efforts, involving simple, achievable and measurable interventions, will facilitate fulfillment of the Berlin Declaration's aims and objectives.
Keywords: Diabetes management, Prevention of diabetes, Primary care diabetes, Type 2 diabetes.


Introduction


The primary care physician is the backbone of the health care system, and provides medical care to the vast majority of people living with diabetes. 1 Evidence shows that training of primary care physicians can have significant effects on cardiovascular outcomes. 2 Therefore, the primary care physician has to be included in all efforts to ensure optimal diabetes management. One such initiative is the Berlin Declaration, which was released on 13 and 14 December 2016. 3

The Berlin Declaration


The Berlin Declaration is part of a global movement promoting early action to contain the type 2 diabetes epidemic. This declaration is a milestone in the Early Action in Type 2 Diabetes initiative, which was launched in 2015. This initiative encourages implementation of policies related to diabetes control. These policies focus on four pillars of early action: early prevention, early detection, early control and early access to the right interventions.
The Berlin Declaration is a consolidated document written by four international working groups which reviewed current evidence and practices, related to these four pillars of action. This document identifies key issues, and achievable, measurable means of resolving them. The Declaration, though a global document, is appropriate for all countries, as it can easily be customized to local needs. Though targeted towards national policy formulation, the Berlin Declaration is based upon ground reality. It highlights best practices from around the world, and provides inspiration for proactive control of diabetes.
At an individual level, too, Berlin's message are equally relevant. The primary care physician can easily utilize the suggestions contained in the Berlin Declaration to assess, improve and monitor his or her practice.

Early Prevention


1) Offer lifestyle advice to persons with pre-diabetes or impaired glucose tolerance.

2) Restrict advertising and availability of foods rich in sugar, refined carbohydrates and saturated fats in hospital canteens.

3) Encourage consumption of fresh fruits and vegetables.

4) Ensure provision of facilities for exercise within health care facility premises. 

Early detection

1) Administer validated screening risk assessment tools to all relatives/care givers of patients attending your clinic, and to all non-diabetic patients.

2) Screen all high risk individuals, such as those with HIV, hepatitis, psoriasis, tuberculosis and metabolic syndrome, for diabetes.

Early control

1) Provide self-management education to persons with diabetes and their family
members.

2) Follow national or international guidelines on management of type 2 diabetes.

3) Encourage monitoring of glycaemic control with HbA1C and other parameters.
 

Early Access to Right Interventions

1) Ensure easy availability and affordability of good quality drugs in the pharmacy.

2) Encourage utilization of medical insurance schemes

3) Encourage local non-governmental organizations to invest in diabetes programmes.

The efficacy of these interventions can be measured by simple ways. The average HbA1C of all patients with diabetes attending the clinic is one such method. Another way is to monitor the percentage of patients receiving routine examinations and being offered basic investigations. However, few developing countries address this aspect of quality control. 4 The Berlin Declaration encourages health care professionals, and systems, to measure and audit the quality of their work by simple, standardized indices. The support of local authority is essential i.e., providing information on situation of diabetes in their setting, up-date diabetes knowledge, and management algorithm/guideline (risk assessment, screening, and treatment). Current public health systems can be utilized effectively to improve diabetes care delivery at the primary care level. 5

Summary


The Berlin Declaration provides an opportunity for primary care physicians to modify their practices. By promoting concordance between national diabetes programmes, management guidelines and individual practices, this will ensure that we all speak the same language, i.e., the language of early prevention, detection, control and early access to right interventions.
This in turn, will ensure that we are able to contain the diabetes epidemic, and improve the health of not only individuals living with diabetes, but society as a whole.

References


1. Goyder EC, McNally PG, Drucquer M, Spiers N, Botha JL. Shifting of care for diabetes from secondary to primary care, 1990-5: review of general practices. Br. Med J. 1998; 316: 1505-7.
2. Simmons RK, Bruun NH, Witte DR, Borch-Johnsen K, Jørgensen ME, Sandbæk A, Lauritzen T. Does training of general practitioners for intensive treatment of people with screen-detected diabetes have a spillover effect on mortality and cardiovascular morbidity in 'at risk' individuals with normoglycaemia? Results from the ADDITION-Denmark cluster-randomised controlled trial. Diabetologia. 2017 Mar 9. Doi: 10.1007/s00125-017-4230-6. [Epub ahead of print]
3. The Berlin Declaration - driving early action in type 2 diabetes. Cited on 24 December 2016. Available from URL: http://www.idf.org/berlin-declaration-driving-early-action-type-2-diabetes.
4. Shivashankar R, Kirk K, Kim WC, Rouse C, Tandon N, Narayan KV, Ali MK. Quality of diabetes care in low-and middle-income Asian and Middle Eastern countries (1993-2012)-20-Year systematic review. Diabetes Res Clin Prac. 2015; 107: 203-23.
5. Kalra S, Julka S, Joshi R, Shah A, Jindal S, Agrawal N, Das AK. Strengthening diabetes management at primary health level. Indian J Endocr Metab  2015; 19: 443.

 


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