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Contents lists available at ScienceDirect

Primary Care Diabetes

journal homepage: http://www.elsevier.com/locate/pcd

1 Do current standards of primary care of diabetes meet with

2 guideline recommendations in Trinidad, West Indies?

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1 Lexley M. Pinto Pereira a,∗ , Avery Hinds b , Issa Ali a , Ravita Gooding a , Michelle Ragbir a ,
2 Kavita Samaroo b , Shivananda B. Nayak a
3 Q1 a Faculty of Medical Sciences, The University of the West Indies, St Augustine, West Indies, Trinidad and Tobago

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4
b The North West Regional Health Authority, Trinidad, West Indies, Trinidad and Tobago
5

6 a r t i c l e i n f o a b s t r a c t
7

8 Article history: Aims: Primary care management of diabetes was examined using the Caribbean Health
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9 Received 4 December 2008 Research Council (CHRC) guidelines.
10 Received in revised form Methods: We retrospectively examined a cross-section of 646 type 2 people with diabetics
11 13 February 2009 over 12 months with 1st visit between 1997 and 2005.
12 Accepted 22 March 2009 Results: There were more women (65.8%) than men (34.2%) with age range between 29 and
89 years. Blood pressure and weight were evaluated in >95% of patients at each centre.
13 Waist circumference and BMI were not measured at any time and HbA1 c was infrequently
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14 Keywords: measured (1.6–7%) over the 12 months. Information on family history (87.5%), smoking and
15 Type 2 diabetes alcohol (78.1%), exercise (21.4%), socioeconomic status (19.4%) and education (0.3%), and
16 Caribbean fasting blood sugar (97.2%), lipid profile (51.8%) and serum creatinine (37.9%) were assessed
17 Primary health care at the 1st visit. At follow-up patients were advised on treatment compliance (47.2%), diet
18 Guidelines (34.2%), exercise (18.5%) and rarely on home monitoring of blood glucose (0.3%). Peripheral
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sensations, pedal pulses (6%), visual acuity (3.3%), fundoscopy (12.1%) and ECG (3.9%) were
scarcely examined at the annual visit.
Conclusions: Current management of diabetes in primary care in Trinidad falls short of
Caribbean guideline recommendations. The CHRC and Ministry of Health should jointly
educate caregivers of diabetes to implement the guidelines, with annual audits to identify
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shortfalls in management.
© 2009 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.

1. Introduction in the 2030 global projection [2]. In the region of the Americas 7
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diabetes prevalence of 35 million in 2000 is expected to rise to 8

0 Diabetes, a chronic progressive illness from deficient insulin 64 million in 2025 [3]. Without any urgent action deaths due 9

1 production or utilisation to its full potential, is characterised to diabetes are likely to increase by approximately more than 10

2 by high circulating glucose. The total number of people with 50% in the next 10 years and are projected to increase by over 11

3 diabetes is projected to rise from 171 million in 2000 to 366 80% in upper-middle income countries between 2006 and 2015 12

4 million in 2030, and most of this increase will occur as 150% [2]. 13
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5 in developing countries [1]. Among the 15 leading causes of Chronic non-communicable diseases inflict a heavy bur- 14

6 death, diabetes will move up 4 ranks from 11th in 2002 to 7th den of illness in the middle income Caribbean nations where

∗
Corresponding author at: The University of the West Indies, Faculty of Medical Sciences, EWMSC, Trinidad and Tobago.
Tel.: +1 868 663 8613; fax: +1 868 663 8613.
E-mail address: lexleyp@gmail.com (L.M.P. Pereira).
1751-9918/$ – see front matter © 2009 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
doi:10.1016/j.pcd.2009.03.003

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations
in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003 PCD 109 1–6
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15 diabetes appears to have reached epidemic proportions [4]. diagnosis was established, irrespective of the time elapsed, 71

16 After China and India, the highest increase in prevalence from which varied from 2 weeks to 3 months. For all patients data 72

17 1995 to 2025 is expected to occur by 41% in Latin America and for visit 2, and the 3rd and 6th monthly visits were collec- 73

18 the Caribbean [3]. Migration studies suggest the interaction of tively expressed as ‘every visit’ if at each of these visits every 74

19 lifestyle factors with genetic susceptibility causes non-insulin recommended assessment had been documented. 75

20 dependent diabetes mellitus (NIDDM) to be more common Case records of eligible patients were studied for his- 76

21 particularly in the African and the Indian diasporas. Preva- tory taking, physical examination; laboratory investigation 77

22 lence rates of NIDDM in African diaspora populations were and referrals as recommended in the Caribbean guidelines. 78

23 9%, 11% and 2% for blacks from the Caribbean, the UK and the For the initial visit records were examined for age, gender, 79

24 USA, and from Nigeria respectively [5]. In Trinidad, patients of education, socioeconomic level (based on Ministry of Health 80

25 Indian ancestry are at higher risk of developing NIDDM than criteria of utility items), history of medical conditions, family 81

26 other ethnicities [6]. history, regular exercise smoking and alcohol habits. Phys- 82

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27 Diabetes inflicts a heavy burden of illness and is the 3rd ical examination was studied for weight, Body Mass Index 83

28 leading cause of death in Trinidad and Tobago [7]. In a survey (BMI), waist circumference, blood pressure, examination of 84

29 in North Trinidad 12% of adults above 25 years had diabetes skin, eyes, mouth, feet, cardiovascular and central nervous 85

30 [8]. In a 1993 report people with diabetics comprised 13.6% systems. Home monitoring of blood glucose (HMBG), fasting 86

31 of admissions to general medical, surgical and ophthalmol- plasma glucose, HbA1c, serum creatinine, haemoglobin, fast- 87

32 ogy wards at a major hospital in North Trinidad, incurring an ing lipid profile, liver and thyroid function, microalbuminuria, 88

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33 annual financial cost of TT $10.7 million (US $1.8 million) [9]. ketones/proteinuria, an ECG and referrals were documented 89

34 In Trinidad, the larger of the two islands of the twin from the case notes. At each of the 2nd, 3rd and 6th monthly 90

35 island republic primary health care is delivered through visits, patient records were examined to note documentation 91

36 104 government-run health centres spread through the geo- of smoking and alcohol habits, weight/BMI, waist circumfer- 92

37 graphic boundaries of five regional health authorities (RHAs). ence, blood pressure, HMBG, dietary and exercise advice, foot 93
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38 A County Medical Officer of Health (CMOH) has administra- inspection, advice on compliance with treatment and inspec- 94

39 tive responsibility for the health centres in a county, and at tion of insulin injection sites (if relevant). HbA1 c evaluation, 95

40 each centre physicians, community nurses and pharmacists recommended at all visits was noted. For the annual visit, 96

41 deliver health care. The country is divided into eight counties, the records were assessed for advice on smoking and/or alco- 97

42 of which St. George is the largest and most densely populated. hol, weight/BMI, waist circumference, blood pressure, HMBG, 98

43 It has three subdivisions, St. George West (SGW), St. George HbA1 c, foot pulses and sensations, visual acuity, urea, BUN, 99

44 Central (SGC) and St. George East (SGE); St. George West is the lipids, fundoscopy, oral and mental health. 100
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45 most thickly populated.

46 In 1995 the Caribbean Health Research Council (CHRC) pro- 2.1. Statistical analysis 101
47 duced guidelines entitled “Managing Diabetes in Primary Care
48 in the Caribbean” and updated them in 2006 [8]. An early base- Data was analysed on SPSS version 16.0. Mean and median 102
line survey in 2005 reported a large proportion of people with
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49
values and ranges were calculated for all numerical data. Fre- 103
50 diabetics were uncontrolled [9]. The current study examined quencies were calculated for descriptive statistics. 104
51 the management of type 2 diabetes in public sector primary
52 health care in the county of St. George West, referencing rec-
53 ommendations made in the guidelines. 3. Results
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3.1. Study population 105

2. Methods
Records of 740 patients were available for analysis, but those of 106

54 This was a retrospective observational study in type 2 diabetes 646 patients were studied (87.3% response rate) due to incom- 107

55 in the county of SGW. There are eight health centres in this plete or illegible documentation. Patients were between 29 108
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56 county of which five, Maraval, Woodbrook, St. James, Care- and 89 years with a mean age of 57.90 (±10.76) years. There 109

57 nage, and George Street were selected based on highest patient were twice as many women (65.8%) as men (34.2%) who were 110

58 attendance. The study was approved by the Ethics Committee being treated for diabetes at the health centres (Table 1). Pro- 111

59 of The University of the West Indies, the North West Regional portional patient representation was 7.0% from Maraval, 9.2% 112

60 Health Authority (NWRHA) and the County Medical Officer of from Carenage, 16.7% from St. James, 29.9% from Woodbrook 113

61 Health of SGW. and 37.2% from George Street. 114

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62 At each centre the Chronic Disease Book provided a cen- At the 1st visit family history (87.5%), smoking and alco- 115

63 sus of patients who had received a doctor diagnosis of type 2 hol consumption (78.1%) and other medical conditions (96.1%) 116

64 diabetes. Patients attending the clinic for at least 1 year with were noted but education status was rarely sought (0.3%) 117

65 a 1st visit anytime from 1997 to 2005 were studied. Pregnant (Table 2). Less than a quarter of patients were asked about 118

66 patients, people with type 1 diabetics, those with compli- regular exercise (21.4%). 119

67 cations and under specialist care were excluded. Data was Blood pressure (99.2%) and weight (97.1%) were nearly 120

68 collected from the clinic records of each patient for the 1st, always recorded for patients. Waist circumference and BMI 121

69 2nd, 3rd-monthly and 6th-monthly visits and the annual visit. were never measured. Cardiovascular and central nervous 122

70 The 2nd visit was the next follow-up visit at the clinic after system examination was done in 24% and 22.5% of patients 123

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations
in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003 PCD 109 1–6
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Table 1 – Age and gender distribution of diabetic patients at the health centres.
Centre (n) Mean age (SD) Range (years) Females (%) Males (%)

Carenage (60) 55.47 (10.64) 29–79 42 (70.0) 18 (30.0)

St. George (240) 58.46 (10.72) 31–79 151 (62.9) 89 (37.1)
Maraval (45) 55.33 (10.44) 32–80 32 (71.1) 13 (8.9)
St. James (108) 58.87 (11.58) 32–89 61 (56.5) 47 (43.5)
Woodbrook (193) 58.02 (10.33) 30–83 139 (72.0) 54 (28.0)

Total (646) 57.90 (10.76) 29–89 425 (65.8) 221 (34.2)

124 respectively. Fasting blood sugar was examined in the major-

Table 3 – Guideline conformance for patients (%) at every
125 ity of patients (97.2%), lipid profile was estimated in just half visit.

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126 of the patient population (51.8%) and serum creatinine (37.9%)
Assessment Patients (%) managed
127 and haemoglobin (20.8%) were estimated in few patients. The
conforming with
128 HbA1 c was evaluated in just 1.6% of patients all of whom were guideline
129 from the Woodbrook centre with the exception of one patient recommendations
130 from Carenage. Urine protein and ketones were tested in
Smoking 1.0 (0.1)
131 approximately 80% of patients (Table 2). Only 2.2% of patients

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Alcohol 1.0 (0.1)
132 had an ECG at the initial visit. Thyroid function tests were done Weight 600 (92.9)
BMI 0(0)
Waist circumference 0(0)
Blood pressure 612 (94.7)
Table 2 – Guideline conformance for patients (%) at the Inspection of feet 55 (8.5)
1st visit. Home monitoring of blood glucose 20 (0.3)
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Assessment Patients (%) managed in Fasting plasma glucose 0 (0)
conformance with HbA1ca 21 (3.3)
guidelines Advice on diet 220 (34.2)
Advice on exercise 119 (18.5)
History Counsel on compliance with treatment 305 (47.2)
History of medical conditions 620 (96.1)
Family history 535 (87.5) Assessed for the 2nd, 3rd and 6th monthly visits.
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Exercise patterns 138 (21.4) a

20 patients were from the Woodbrook health centre.
Smoking 504 (78.0)
Alcohol 505 (78.2)
Education 2 (0.3) at three centres in 5.3% (34) of patients, of which 26 were from 133
Socio economic level 125 (19.4)
the Woodbrook centre. 134
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Examination At follow-up visits approximately half of the patients 135

Waist circumference 0 (0) (47.2%) were counselled on compliance with treatment and 136
Weight 627 (97.1)
one third (34.2%) were advised about diet. Advice on HMBG 137
BMI (0)
(0.3%), smoking and alcohol (0.1%) was nearly never given 138
Blood pressure 641 (99.2)
Skin 230 (35.9) (Table 3). Few patients were advised about regular exercise 139
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Eyes 176 (27.5) (18.5%). The HbA1 c was evaluated in 3.3% of patients who were 140

Mouth 5 (0.8) all, with the exception of one, from the Woodbrook centre. 141
Feet 221 (34.2) At the annual visit, no patient was referred for oral or men- 142
Central nervous system 144 (22.5) tal health evaluation. Blood pressure was measured in 95% of 143
Cardiovascular system 156 (24.3)
patients. Waist circumference and BMI were never recorded, 144

Laboratory investigation but weight was measured in 94.9% of patients (Table 4). 145
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Haemoglobin 133 (20.8) Peripheral sensations, pedal pulses and visual acuity were 146
HbA1ca 10 (1.6)
measured in ≤6% of patients. Fundoscopy was done in 12.1% 147
Fasting plasma glucose 628 (97.2)
of patients. Laboratory investigations were requested for lipid 148
Lipid profile 330 (51.8)
Serum creatinine 242 (37.9) profile (50.2%), urea and creatinine (37.9%), and urine pro- 149

Liver function tests 144 (22.6) tein (43%). In 3.9% of patients an ECG was recorded at this 150

Thyroid function testsb 34 (5.3) visit and the HbA1 c was evaluated in 7% of patients who
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151
Urine ketones 518 (81.2) all, with the exception of two came from the Woodbrook 152

Urine protein centre. 153

Other 504 (79.1)

ECG 14 (2.2)
Referral to dietician 220 (34.1) 4. Discussion
Referral to ophthalmologist 4 (0.6)
This retrospective assessment of the management of type 154
a
All except one patient were from the Woodbrook health centre. 2 diabetes in a cross-section of primary care patients in 155
b
26 of 34 patients were from the Woodbrook health centre.
Trinidad, found that several recommendations in the CHRC 156

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations
in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003 PCD 109 1–6
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BMI > 28.5 [19]. Overall and abdominal adiposity are strongly 192
Table 4 – Guideline conformance for patients (%) at the
annual visit. related to the development of type 2 DM. The additive effect 193

of these two factors on risk prediction makes waist circum- 194

Assessment Patients (%) managed in
ference an important measurement in managing the diabetic 195
conformance with
guideline patient [20]. Examination of skin, eyes, feet, peripheral pulses 196

recommendations and sensations were recorded for about a quarter to a third 197

of patients for the 1st visit and rarely thereafter, providing 198
Advice on smoking and alcohol 1 (0.2)
speculation that neuropathies and fundal changes and sub- 199
Weight 613 (94.9)
BMI 0 (0)
sequent complications may have been missed in patients. 200

Waist circumference 0 (0) The poor compliance of physician measured estimations com- 201

Blood pressure 614 (95.0) pared with those done as nursing procedures could reflect the 202

Foot pulses 39 (6.0) poor doctor–patient ratio at the centres. Health centres are 203
Foot sensation 39 (6.0)

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over-crowded with at least 50 patients presenting to be seen 204
Visual Acuity 21 (3.3)
by two doctors on the morning assigned to chronic diseases. 205
Fundoscopy 78 (12.1)
The high proportion of patients in whom family history was 206
Oral and mental health 0 (0)
elicited is most likely an awareness that the disease runs in 207
Investigations families and afflicts several members at the same time. Educa- 208
HbA1 ca 45 (7.0)
tional and socioeconomic status of patients was infrequently 209

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Lipid profile 324 (50.2)
Blood urea 245 (37.9)
enquired about. Patients of lower socioeconomic status are 210

Serum creatinine 245 (37.9) more likely to access government facilities [21] and have 211

Urine protein 245 (43.3) higher morbidity from diabetes with increased cardiovascu- 212

ECG 25 (3.9) lar risk factors. In India a cross-sectional survey stratified by 213

a
the level of urbanisation demonstrated an inverse relationship 214
43 patients were from the Woodbrook health centre.
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for higher education with low prevalence of hypertension and 215

diabetes, suggesting that lower socioeconomic groups with 216

157 guidelines for managing diabetes in primary health care are lower educational status are vulnerable to these diseases [22]. 217

158 not met. Patients with low education and socioeconomic status should 218

159 The observed higher gender prevalence of women with dia- be targeted for continuous education for disease prevention 219

160 betics has been previously reported for diabetic admissions to and effective self-care. 220

161 a public sector hospital in North Trinidad [10]. Women with Though fasting blood glucose was nearly always deter- 221
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162 diabetics have a higher risk of developing coronary artery dis- mined at the 1st visit, less than 1% of patients were advised 222

163 ease than their male counterparts regardless of menopausal on HMBG at any visit. Blood glucose self-monitoring critical to 223

164 status [11] and should be keenly followed up for optimal care. achieving euglycaemia is endorsed by the American Diabetes 224

165 Prevalence of the disease in young patients of 29 years is a con- Association [23]. The lipid profile estimated in approximately 225

cern which signifies that the disease affects young individuals 50% of patients is encouraging considering that the preva-
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166 226

167 in this Caribbean island just as in the USA [12] and elsewhere lence of hypercholesterolaemia progressively increases when 227

168 [13,14]. Managing type 2 diabetes in youth presents a daunting assessed with age, hypertension, type 2 diabetes and BMI 228

169 challenge because of the difficulty in reversing obesity coupled [24]. Serum creatinine was investigated in less than half of 229

170 with a typical non-adherence in this age-group. Childhood the patients. Diabetic kidney disease inflicts a heavy social 230

171 and adolescent obesity is a major public health concern [15] and economic burden prompting Trinidad’s Ministry of Health 231
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172 in Caribbean populations which have shown a steep increase to institute in 2007 a cost-free dialysis facility. Compromised 232

173 in weight in young adults over 19 years between 1995 and renal function is a contraindication for metformin, on which 233

174 1999 [16]. Blood pressure and weight which were nearly always most patients are managed at the health centres, and failure to 234

175 recorded at all visits in all centres are estimated by a clinical monitor renal function presents a serious concern. Even more 235

176 assistant but, BMI which is calculated by the physician was worrying was the measurement of HbA1 c in not more than 7% 236
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177 never measured. The high frequency of blood pressure mea- of patients at the annual visit. It is not surprising that people 237

178 surement is significant as hypertension co-exists in 57.2% of with type 2 diabetes attending primary care clinics in Trinidad 238

179 diabetic patients attending primary health centres in Trinidad have poor glycaemic control [8,25]. This biological marker rec- 239

180 [17]. ommended by the ADA [23] screens undiagnosed diabetes and 240

181 Waist circumference a surrogate marker for patients at monitors disease progression. Lack of dedicated laboratory 241

182 increased risk for cardio-metabolic diseases, such as coronary facilities at health centres could account for poor compliance 242
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183 heart disease and diabetes [18] was never measured at any with measurement of HbA1 c. Blood is sent to a central labo- 243

184 visit, though like blood pressure it is simple enough to be ratory facility for HbA1 c estimation which is simple enough 244

185 assessed by trained nursing staff. Clinical assistants satisfac- to be done immediately at the centres. It is not known if sam- 245

186 torily perform their assigned procedures on clinical measures ples and/or reports were lost in transit or follow-up in the long 246

187 and dipstick assessment of urine. They should be trained to wait before the patient’s next visit. Physicians at the centres 247

188 record BMI and waist circumference, so that physicians would express frustration about the poor doctor patient ratio and the 248

189 have more time for clinical evaluation. In a national survey of lack of support for basic clinical chemistry investigations. 249

190 127,420 US households, type 2 DM was more likely to be diag- Carter and Adams evaluated guidelines for hypertension 250

191 nosed in individuals with hypertension, dyslipidaemia and and diabetes in Barbados, another Caribbean nation and 251

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations
in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003 PCD 109 1–6
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299
252 observed glycaemic control and BMI assessment and coun- references
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254 guidelines [26]. These authors observed the guidelines had not
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Acknowledgements
Association for Weight Management and Obesity Prevention; 360

NAASO; Obesity Society; American Society for Nutrition; 361

296 The authors thank Dr. Randolph Phillip, County Medical Offi- American Diabetes Association. Waist circumference and 362

297 cer, St. George West for facilitating the study at the various cardiometabolic risk: a consensus statement from shaping 363

298 health facilities. Dr. Donald Simeon, Director CHRC made valu- America’s health: association for Weight Management and 364

able comments on the manuscript. Obesity Prevention; NAASO, the Obesity Society; the 365

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations
in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003 PCD 109 1–6
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366 American Society for Nutrition; and the American Diabetes [24] A. Lara, M. Rosas, G. Pastelin, C. Aguilar, et al., 387
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Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations
in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003 PCD 109 1–6