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Education and Motivation are the Best Medicines for Type 2 Diabetes

Lessons from Albania’s transformation into a Western Diabetes culture

We hear from Sulejman Budo, MD a recently retired endocrinologist who practiced in Albania during the communist era and through the country’s transformation into a democracy.

Education is the best medicine

‘During my medical practice, I learned that the best management of diabetes and the best medicine for diabetes is called  “education”. 

‘Most of my time during the initial consultation with a person newly diagnosed with diabetes is spent educating them. We would discuss healthy nutrition, physical activity, treatment of hypertension, especially how to eat without salt.  I would also cover how to care for their feet, pre-breakfast hyperglycemia caused by the dawn phenomenon, and night hypos, etc. 

“Education of Educators” is important and begins with primary care practitioners (family doctors in Albania) and nurses who are the front line in educating people with diabetes to control their diabetes properly.  Even doctors who specialize in the treatment of diabetes, have to be educated continuously through scientific meetings, to be able to transmit their updated knowledge to general doctors, nurses, etc.  

Each person is their own nurse and dietician

‘Self-management of diabetes is critical.  Each person with diabetes should be nurse, dietician, etc. of their own disease.  

‘It’s a common medical opinion that people with high school and college educations are better at self-management.

In my practice, however, I noticed that people such as workers or farmers with low educational levels often took better care of their diabetes, than higher educated people. 

Motivation is critical to success

‘To illustrate this phenomenon within a family, I treated a couple (the husband a lawyer and his wife a notary) who were equally overweight and both diagnosed with diabetes at about the same time. After short term education, they were advised to make a lifestyle change to lower their body weight by eating healthy foods, starting metformin, and treating their hypertension. 

‘After 3 months there was almost no progress.  Their diabetes remained uncontrolled, Their hypertension continued and I changed their treatment to Janumet, a combination of sitagliptin and metformin. I emphasized again that they should consider lifestyle changes, but nothing had improved when I saw them again 3 months later. At this point, I was obliged to add Insulin Lantus to their Janumet. 

‘During this period, the brother of the lawyer was also diagnosed with type 2 diabetes.  He is fishermen with only primary school education and was unfamiliar about health in general. He promised me that will follow every advice correctly because he didn’t want to be like his father who died from diabetic complication and he would not follow the example of his brother and his sister-in-law. I prescribed hypocaloric diet, aerobic and anaerobic physical therapy and advised him to consult with me again after 3 months. 

‘In the beginning, he was unhappy because I was not treating him with anti-diabetic drugs, like his brother but I explain that my strategy for him was different. His motivation was strong, and the results after 3 months were impressive — his HbA1c dropped from 11% to 8.3%, he lost 5 kg in body weight, and his blood pressure improved. 

‘Even 5 years after diagnosis, his diabetes, as well as his lipid profile and hypertension, are well controlled with just lifestyle changes, Metformin, Atenolol, and hydrochlorothiazide.

‘I try to explain to each newly diagnosed person the importance of motivation, and that it’s not dependent on the level of academic education.

Early screening to prevent/postpone type 2 diabetes

‘Nearly half of people with type 2 diabetes don’t know that they are suffering from diabetes. This means that either they have no signs, or the symptoms are insignificant, so they do not complain. 

‘It is important to measure the fasting blood sugar of anyone above 40 years old, or at any age for people who are highly predisposed for diabetes.  Early diagnosis and treatment extends lives and avoids many of the complications of diabetes. 

‘In a study, we found that 36% of newly diagnosed people with type 2 diabetes, had eye complications (diabetic retinopathy at different stages). This meant that all these people had already lived 10-15 years with diabetes without knowing of it. This tells us that even slightly elevated blood glucose over the long term will damage nerves, big vessels (atherosclerosis), reproduction (male impotence), the gastrointestinal tract or kidney system. 

Screening indirectly improves the quality of life and decreases the economic burden, which is around 5 times more to diabetics in contrast to healthy people. 

‘In my country, as everywhere, we encounter a new occurrence; increased type 2 diabetes in children. When I was a medical student, if I said that type 2 diabetes existed in children, I would fail the class. Nowadays, however, their number is increasing every passing day.  So it’s very important to screen for diabetes even at a young age, especially if a child is overweight, has parents, or first degree relatives with diabetes. 

‘In the context of screening, it is important to discover gestational diabetes, even later after delivery. When found, the woman should be kept under close observation thereafter.

Western diet and a sedentary life culture are diabetes drivers

‘During 1985 when the Communists still ruled Albania, I helped screen everyone in my country for diabetes, which resulted in only 1% of the population having diabetes.  

‘Today, that number is around 5%. Why is that so?

‘During the dictatorship in our country, people worked very hard, and there was a lack of food. In the years after 1991, our democracy increasingly brought Albania into a Western-style of life but this resulted in less physical activity and a more sedentary life (more TV programs, computers, electronic devices) with more cars, fewer bicycles, and no walking.  At the same time, a lot of unhealthy food options became available, in particular, many carbonated drinks and snack foods.

Prevention of diabetes still relies on the concept of “eat less and walk more”.   With less actual walking done, however, and more food options readily available, our national diabetes problem has increased.

‘In this modern context, education and motivation are even more important to preventing and delaying diabetes.  Effective education means using magazines, websites, Radio-TV programs, and social media to emphasize physical activity and healthy eating.  

Sulejman Budo, MD worked as endocrinologist at the university hospital in Tirana, Albania from 1971 until he retired recently. He co-founded the Albanian Diabetes Association in 1989 and was its president for several years and still volunteers.

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