Features

International: Building diabetes care around the patient

A 'one stop' programme providing personalised care could help Mexico turn the tide of its diabetes epidemic.
diabetes

A 'one stop' programme providing personalised care could help Mexico turn the tide of its diabetes epidemic

Standing in a consultation room at the National Institute of Medical Science and Nutrition in Mexico City, Martin Ortega is feeling proud of himself. He recounts the story of how, for two years, he ignored signs of diabetes. The company director, now 53, admits he was too scared to seek medical help.

It was only when his vision became blurred that he visited an ophthalmologist who referred him to a new one-stop programme that aims to stop diabetes in its tracks.

Today hes with the head of service, nurse Maria Luisa Perez, who tells Mr Ortega he is a model patient. Hes lost a total of 12kg and his blood sugar

...

 

A 'one stop' programme providing personalised care could help Mexico turn the tide of its diabetes epidemic

Standing in a consultation room at the National Institute of Medical Science and Nutrition in Mexico City, Martin Ortega is feeling proud of himself. He recounts the story of how, for two years, he ignored signs of diabetes. The company director, now 53,  admits he was too scared to seek medical help.

It was only when his vision became blurred that he visited an ophthalmologist who referred him to a new one-stop programme that aims to stop diabetes in its tracks.

Maria_Luisa Perez_&_Martin Ortega
Nurse Maria Luisa Perez with diabetes patient Martin Ortega. Picture: NCD Alliance

Today he’s with the head of service, nurse Maria Luisa Perez, who tells Mr Ortega he is a ‘model patient’. He’s lost a total of 12kg and his blood sugar levels have reduced from 11.7 to 4.9.

He is one of 1,500 patients that Ms Perez has worked with to prevent debilitating complications. With her encouragement, he’s ditched his car and walks 23,000 steps a day. He has also stopped drinking his usual litre of orange juice for breakfast and litre of fizzy drinks during the day.

Mr Ortega beams as he says: ‘I’m going to have to live with this disease for the rest of my life – but I am going to live with it.

‘The complications of the disease are horrible. With our plan, we have a high success rate in reducing them’

Maria Luisa Perez

‘My best friend, the car, has now been set aside. I walk or take public transport. I exercise more and I eat more vegetables. I learned all this in the institute here.’

Ms Perez is delighted with his and others’ progress. In the four years since the programme started only one patient has suffered a serious complication – a foot amputation due to ulceration. ‘I get a great deal of satisfaction from my job,’ she says. ‘The complications of the disease are horrible. With our plan, we have a high success rate in reducing them.’

Diabetes places a heavy burden on Mexico. Around 15% of the population, or 11.5 million people, have the disease, compared with the UK’s 9%, according to the International Diabetes Foundation. Since 2000, it has been the leading cause of death in women and the second-highest in men. Almost 100,000 people died from it in 2016.

Model for chronic care

Treatment is problematic. There are 101 diabetes clinics in the country but they are over-subscribed and lack staff and laboratory capacity.

A National Strategy for the Prevention and Control of Overweight, Obesity and Diabetes was produced in 2013. The institute responded with the new programme at its Centre of Healthcare for Diabetes Patients.

Up until then, its director Sergio Hernandez says, diabetes was treated as an acute problem – his aim was to introduce a chronic care model.

It works like this: around ten patients arrive at 7am and can expect to stay all morning. At this point they have all the necessary blood and other tests done, with a nurse colleague working closely with the laboratory.

All in one place

While the results are being processed, the patients have individual appointments and group sessions with a range of nine different health professionals, including a podiatrist, an endocrinologist, a nutritionist, an ophthalmologist, a psychologist, a dentist and a diabetes educator, who is a trained nurse.

The test results are analysed and the patients have a formal consultation with the doctor. An afternoon session repeats the process with another set of patients. The patients return a month later, then a month after that, then at two-month and three-month intervals. Finally, the patients are referred back to primary care and are reviewed at the institute every 12 months.

What makes this service special is having all the different health professionals in one place at the same time, so all the necessary interventions are done together.

Team advantage

National data show that 40% of patients in the public health system do not attend appointments once they are diagnosed, particularly men. Dr Hernandez says: ‘We concentrate it all in one morning or one afternoon so they just need to take this time off work once a month – not nine separate appointments.’

The second advantage is that the different health professionals can feed back to each other in real time to tailor treatment. ‘The psychologist may say to me or the nurse, “you have to talk to them in this way, or be gentle as they are angry”. There are many advantages to having the whole team together in one moment.’

To qualify for the programme, patients must have been diagnosed in the past five years, with no complications. They must not smoke, and they have to be supported by a family member or carer.

More educators

There are no specialist diabetes nurses in Mexico – although there are specialist cardiac, intensive care, surgical, geriatric and paediatric nurses. Ms Perez is probably the closest to what might be considered a diabetes specialist nurse.

After doing a four-year degree in nursing and a year of social service training, as is the norm in Mexico, she chose to work in intensive care, but later began diabetes nursing for inpatients as well as outpatients. She then trained to be a diabetes educator, of which there are around 100 in Mexico, though less than 10% of them are nurses.

‘We need more nurse diabetes educators and we need them not only at a tertiary level like this but at primary and secondary level,’ says Ms Perez. Currently, she spreads her knowledge by training general nurses in diabetes and gives talks in schools, but she would like to extend her work by educating families at home.

‘Nurses are really important but they can’t do this by themselves’

Gabriela Allard

The institute plans to publish data on its first results in the coming months. It is expected to report around a 70% success rate, and it is hoped other centres will follow its lead.

Gabriela Allard, president of the Mexican Diabetes Association and herself a diabetes educator, says nurses are crucial to making inroads into the epidemic. ‘The nurse is the first contact the patient has when they come into the clinic. Every doubt the patient has, they ask the nurse.

‘Nurses are really important but they can’t do this by themselves – they must receive support from nutritionists, psychologists, doctors, endocrinologists and more.’

Ms Perez believes that if the programme was scaled up it could start to put a dent in the epidemic. ‘It’s going to be a lot of work, but if we concentrate on education then perhaps we can do it.’

Supporting children to overcome obesity

More than 30% of children in Mexico are overweight or obese. At the Children’s Hospital of Mexico Federico Gómez, located in the centre of Mexico City, paediatricians, nurses and psychologists are working together at its Childhood Obesity Clinic to help 400 patients a year aged 6-16 lose weight to reduce their risk of type 2 diabetes.

The children attend once a week in an intensive seven-week course and are followed up monthly for six months.

Leticia, 15, began putting on weight when she was seven, after her parents split up. ‘I was very affected. I ate because I felt bad.’ But since she was referred to the clinic in January, when she was morbidly obese, she has lost 11kg and exercises every day with either belly dancing, Zumba or swimming.

Alma Almiray Soto-child obesity clinic
Nurse Alma Almiray Soto at work in the child obesity clinic. Picture: NCD Alliance 

Alma Almiray Soto is one of the two children's nurses who work at the clinic on food and exercise interventions. She says the environment for young people is challenging, with so much processed food, as well as technology replacing physical games.

Success means moving from obese to the overweight category, eating more healthily, incorporating exercise into daily routines and being emotionally stable. The low success rate – 30% at six months – does not faze her. She says: ‘I’m proud of the kids who lose weight. There’s a lot of touching moments, and some sad.

‘The ones who succeed have taught me how to be motivated. They have problems, but they come through them and they are so strong.’


 Jacqui Thornton is a freelance journalist. Her trip to Mexico was made possible by NCD Alliance, a civil society network

 

 

Want to read more?

Subscribe for unlimited access

Enjoy 1 month's access for £1 and get:

  • Full access to nursing standard.com and the Nursing Standard app
  • Monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal

This article is not available as part of an institutional subscription. Why is this?

Jobs