Diabetes in Fiji

Diminishing Diabetes in Fiji 

Introduction

Diabetes mellitus (DM), commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period of time resulting in a variety of medical complications. Diabetes Mellitus, specifically DM 2, is a disease that is rapidly increasing all over the globe (What is Diabetes 2016). In Fiji, DM 2 and associated complications are the highest in the world: about 4 out of every 10 people have a diagnosis of diabetes. In Fiji, a diabetes-related amputation is carried out every 12 hours and children are developing this disease as early as 12 years old (International Diabetes Foundation 2015). The main cause of DM 2 is excessive body weight and not enough exercise. Seeing as how these things are both preventable, it is a serious epidemic that needs to be controlled and reversed. Due to a combination of a sedentary lifestyle, adoption of a Westernized diet, isolated geographic location, and a lack of funds/resources for proper medical care, the people of Fiji are suffering and need our help. With proper education, increased medical staff, utilization of local fruits and vegetables, and increasing activity levels, Fijians can be on their way to controlling, preventing, and maybe even eradicating Diabetes for good.

What is Diabetes?

Diabetes mellitus (DM), commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period of time. Symptoms include frequent urination, increased thirst, and increased hunger. If left untreated, diabetes can cause many complications like diabetic ketoacidosis, cardiovascular disease, stroke, chronic kidney failure, foot ulcers, lower limb amputations, and damage to the eyes. There are three main types of diabetes mellitus: Type 1 DM occurs when the pancreas is unable to create enough insulin. Type 2 DM begins with insulin resistance. Insulin resistance is a condition where your pancreas can produce enough insulin, but your cells fail to respond to the insulin properly. As the disease progresses, a lack of insulin may also develop in type 2 diabetes. This type is also known as “adult-onset diabetes” and the primary cause is excessive body weight and not enough exercise. Gestational diabetes is the third main form and occurs when a pregnant woman develops diabetes solely from being pregnant with no history of blood sugar issues previously (International Diabetes Federation 2015).

Diabetes Prevention in General

There are many ways to prevent diabetes that can be done right at home! Research shows that a healthy diet and increased aerobic exercise are both great ways of lowering your risk of developing type 2 diabetes. Increasing your fiber intake works to reduce your risk of diabetes by improving your blood sugar, lowers your risk of heart disease, and promotes weight loss by helping you feel full! Examples of good fiber sources include fruits, vegetables, beans, whole grains, nuts and seeds. A third way that is proven to prevent diabetes is through weight loss. “The Diabetes Prevention Program (DPP), a major federally funded study of 3,234 people at high risk for diabetes, showed that people can delay and possibly prevent the disease by losing a small amount of weight through 30 minutes of physical activity 5 days a week and healthier eating” (CDC Preventing Diabetes 2015). When overweight, your body is put under a significant amount of stress and must work much harder to go about its daily functions. Weight loss takes that stress off of the organs like the pancreas and can regulate blood pressure, blood glucose, and let you live a healthier lifestyle.

Food in Fiji

It’s no secret that the diet of the people of Fiji is one of the major causes behind their obesity epidemic. Many Pacific Islanders have transitioned to a more Western style diet consisting of fast foods and processed foods. Pacific Islanders often rely on imported foods that are highly processed. These foods are much cheaper for them and include white flour, white sugar, canned meat and fish, carbonated beverages, cookies, and candies (James 2016). Many locals sell their fruits and vegetables and then purchase imported foods with the money they made. This type of diet is seen as “glamorous” and in turn becomes very dangerous in terms of healthy living. On many islands, especially Fiji, 80 to 90% of the foods are imported. The ability to purchase imported foods is seen a status symbol and that you are rich enough to afford such luxurious treats. Unfortunately, as the population of Fiji grows, its agricultural production is also starting to diminish. Dolores James states that “local fruits and vegetables are becoming increasingly unavailable due to population growth, urbanization, exporting of produce, and selling produce to hotels for the tourism industry.”

Other Challenges Contributing to Diabetes

The behavioral side of education in Fijian schools poses a major challenge. Nutrition education is present in the children’s curriculum, but then junk food is sold for school lunches because it is a guaranteed way for the school to make an income. The schools opt for the cheaper imported junk food in order to save money and make a profit, which goes against what they are teaching in the classroom and probably causing the kids to not take the issue seriously. Life expectancy data in Fiji is extremely concerning and because a lot of these deaths are diabetes related, urgent action needs to be taken. The average age at which people develop diabetes and cardiovascular disease is getting younger and younger each year. “In Fiji, only 16% of the population is aged more than 55 years due to premature deaths primarily caused by non-communicable diseases such as diabetes and cardiovascular diseases” (Pacific Islanders Pay The Price 2010). The theory of the “thrifty genotype” proves to be a strong force behind the diabetes epidemic in Fiji as well.  According to this theory, the Fijians who made the original journey to the island were probably genetically programmed to withstand a scanty diet in order to survive the journey with little food. These same genes that cling to any calories they can get do not do well with junk food based diets.

Diabetes in Fiji in Numbers

According to statistics from the World Health Organization, surgeons in Fiji carry out a diabetes-related amputation every 12 hours and it is estimated that 33% of patients on the surgical wards in Fiji are people with diabetes (International Diabetes Foundation 2015). In Fiji, the costs of diabetes are increased substantially by the need for “offshore expenditure” due to its geographic location. This is when facilities needed for treatment are not available on the island itself. Fiji is a 2-day plane ride from the United States and extremely difficult to access for offshore doctors and health care professionals. 4 out of every 10 people in Fiji have diabetes and lower limb amputation for diabetic gangrene is now the commonest surgical operation in Fiji (Fiji 2016). According to a study done by researcher Ilaitia Delasau, 50% of diabetes-related amputees were not happy with the lead-up to their amputations. This unhappiness resulted from a combination of being uneducated about the purpose of the amputation, the follow up care, and events leading up to the amputation itself. Many felt confused as to why they lost their limb without much preparation for the disability this was going to cause them.

Income Issues

Most Fijians have an average annual income of less than $10,000. This low number makes it very difficult to afford treatment, surgeries, and let alone prosthetics if it comes to that. Amputees have to buy their own prosthesis, crutches or wheelchair with nothing provided by the government. “The cheapest below knee prosthesis cost around $775 and if the materials are imported from overseas, it can cost up to $970. An above knee one cost more than $1,000” (Delasau). That is a lot of money for someone who has no source of income with a family to support.

Migration Mayhem

Many Fijians have migrated from the village areas to the urban parts of Fiji for jobs. In the villages, they would eat lots of fish, fruit, and fresh vegetables. The majority of processed food is found in these newer urban areas and the move exposes people to a variety of different foods. The government in Fiji is very poor and does not help the cause at all, nor do anything to assist with costs for things like prevention, prosthesis, medications, etc. (Delasau).

As you can see in the figure above, Fiji is substantially above the rest of the world when it comes to prevalence of diabetes. The age at which diabetes begins to increase significantly is younger in Fiji than anywhere else is the world. The only reason the prevalence of diabetes decreases down to the rest of the world in the 75+ range is because the life expectancy in Fiji isn’t that high.

Problem Statement

Fiji is the country with the highest rate of diabetes and diabetes related conditions worldwide. I propose a diet and exercise regimen with proper education for prevention combined with medication for treatment could significantly decrease the number of deaths and amputations Fijians go through each year as a result of Diabetes.

Proposal

 I propose a three step global initiative to treat and eventually eradicate diabetes in Fiji. The first portion is education. Outlined further below, basically the education section would involve starting at the source of learning and lifestyle development: children. By putting nurses and/or nutrition counselors in every school, we can ensure children are getting the education they need and deserve on moderation, portion control, and healthy eating. Making sure there are adequate places for children to run and play to get activity into their day is important for a child’s metabolism. This education initiative would force schools to offer healthy options in the cafeterias for lunches and snacks. Right now, a majority of Fijian schools teach nutrition but don’t back it up and have processed junk to offer their students. In order to ensure the schools provided healthy food choices, I would start a greenhouse initiative in each school. It can be very simple to set up a cheap greenhouse to allow fresh fruits and vegetables to grow. Not only would this ensure the school had an abundant supply of healthy food, but it would be a lesson in agriculture for the students. They would learn how to grow and harvest their own healthy fruits and vegetables and potentially bring that knowledge home to their families. Instilling this kind of knowledge in a child could benefit themselves and their families they create for years to come.

The second part of my initiative is going to be a “teach a man to fish” model but with medical professionals. There are not enough medical professionals in Fiji to begin with, but it is important that the ones who are practicing there are well versed in all things diabetes. My initiative will combine a training/certification program of medical professionals to be hyperaware of signs/symptoms and risk factors for Diabetes when working with patients. This program will be working with the health care professionals at the Fiji School of Medicine. If the doctors, nurses, and PAs can prevent and/or diagnose diabetes properly, this will drastically reduce the incidences and complications from the disease. In addition, I would implement more education in the field of amputations and prosthetics. Many people who have had amputations in Fiji feel they were not explained to fully about what was going on, why they needed this, and how to cope afterwards. They basically performed the procedure and sent them home confused and dysfunctional. My medical teaching initiative will be sustainable and allow local Fijian healthcare workers to properly and effectively work with Diabetic patients.

The last part of my initiative is what I would like to call a “Grow Local!” campaign. There are many healthy fruits, vegetables, and whole grains in Fiji. If people understood how beneficial, lower price, and delicious these foods were, I believe they would be more inclined to cultivate and consume them. Right now, the glamour of Westernized processed food outshines their natural resources, but my Grow Local campaign would reintroduce the wonders Fiji has to offer and teach people about farming and supporting local businesses who are selling their foods. I believe these three factors together can create the kind of change we need to see in Fiji for the years to come.

1. Education

• Implement education programs that are hands on and interactive with students that teach them not only about healthy diet and exercise, but the adverse effects of illnesses like Diabetes
• Put a nutrition counselor and/or nurse in each school – nurses aren’t required in every school currently
• Teach things that are sustainable and realistic – the Westernized imported foods are not going to go away completely and it is unrealistic to tell people to avoid them all together. Educating people on moderation of these processed foods and portion control, while also substituting fresh fruits, vegetables, and whole grains could drastically improve people’s diet
• Exercise does not have to mean going to the gym and telling people to think of it as “exercise” won’t improve their level of activity. Focus on educating the public on ways to get in activity like walking along the beach, playing with their kids (or just playing outside if we’re speaking to children), and other simple ways to just add in activity to their day.
• Provide schools with the healthy options they need to serve to the children in the form of easy to create greenhouses in each school. These greenhouses will be made with PVC piping, plastic sheets, zip ties, and a few other cheap materials. For under $50, a decent sized greenhouse can be created and managed by the children at each school. Allowing tending to the plants and harvesting them to be a part of their curriculum and using these fruits and vegetables in their lunches is a cheap and functional way to increase healthy living.

2. Government/Policy

• Fiji’s weak government and lack of involvement in the field of Diabetes is contributing to their overall failure of treatment and prevention
• Ideally, policy would be implemented to train more health care professionals in Fiji to be hyperaware of diabetes risk factors and symptoms so that it can be prevented, caught early, and/or treated properly
• I plan to work with the Fiji School of Medicine to ensure that all medical students have a specific part of their residency dedicated to diabetes risks and prevention. If the people who are becoming doctors are experts on diabetes, it will greatly increase the awareness of the disease. Also, hold sessions to train home health care workers and identify at risk populations within the community.
• I also believe the Fijian government needs to place more money/funds into programs that will encourage healthy eating and exercising. Government involvement in the greenhouse initiative would be subsidized when in the public school system. There is too much processed food and junk that kids have access to every day, part of the reason that the earliest age of DM 2 instance in Fiji is 12! If governmental spending went more into education and prevention at the school level, it could start a new generation of healthy individuals for the years to come.

3. Funding

• National Institute of Diabetes and Digestive and Kidney Diseases
• NIDDK supports a wide range of medical research through grants to universities and other medical research institutions across the country.
• The Institute supports government scientists who conduct basic, translational, and clinical research across a broad spectrum of research topics and serious, chronic diseases and conditions related to the Institute’s mission.
• NIDDK also provides scientific resources to scientists for use in their research, and holds meetings where scientists can collaborate with other leaders in their field.
• American Association of Diabetes Educators
• The aim of AADE research is to critically examine the value that diabetes educators and diabetes education add to improved clinical measures, enhanced patient outcomes, and reduced medical costs. The association pursues research opportunities to contribute to the evidence base; expand opportunities for diabetes educators; and improve member awareness, comprehension, and analysis of relevant scientific information.
• The AADE Education and Research Foundation funds projects that advance the AADE Research Agenda. The focus of these activities is to gather evidence and translate the best scientific findings to support behavior change to achieve optimal patient health outcomes.

Sustainability

• By training/teaching healthcare providers how to recognize signs and symptoms of Diabetes and also how to treat it, we will be creating a long-lasting and sustainable source of treatment. We are not just giving a medication or doing a surgery, which can require continued visits, money, and supplies. Training these providers is a one-time commitment that has long lasting results. They can also train other interns/staff to help them recognize these things too.
• By encouraging Fijians to utilize their local fruits/veggies, it is creating sustainable means of attaining food. Instead of having to import the food from other places, this allows them to use food in their own country which is very sustainable

Limitations/Challenges 

• Fiji is an extremely isolated island. It takes a significant amount of time for people to get to the island and is expensive. The United States is where a lot of these funding organizations are from, and it is a two-day plane ride just to get to the island. Being in such a remote location, getting people and supplies there continuously to fund our efforts is going to be time consuming and expensive.
• Fijians sedentary lifestyle and the food they enjoy eating is a part of their culture, and eliminating or changing someone’s culture is not ethical or even possible most of the time.
• Medication for diabetes is for the rest of your life. Also, surgeries and prosthetics after amputations are necessary a lot of the time. All of this can get very expensive and many people in Fiji barely make enough money to live their day-to-day lives, let alone spend thousands on this stuff.
• By the time visible symptoms are occurring for a diagnosis, severe damage has already happened. This makes it very difficult to treat unless you can identify people that are genetically pre-dispositioned for diabetes, or live a lifestyle that would cause the risk of diabetes to increase.

Conclusion

The highest instances of diabetes are all from Western Pacific countries. Fiji in particular is the top country suffering from this deadly epidemic. Diabetes Mellitus 2 is preventable, treatable, and curable with the right diet, exercise, and lifestyle changes. With a country as geographically isolated as Fiji is, its no wonder they often receive little attention when it comes to medical resources and money donated to help. When you think about people who get DM 2 from an unhealthy lifestyle, you often think of adults. This isn’t just the case anymore in Fiji – children as young as 12 years old are so unhealthy that they are setting themselves on a path of destruction, disease, and lifelong pain. Pooling funds to support education initiatives, utilization of local fruits and vegetables, training of medical professionals, and an overall healthy lifestyle overhaul can change the lives of these people immensely. With this project, we can not only reverse diabetes and its effects on those currently afflicted, but we can prevent it from occurring in the subsequent generations with the hopes of eradicating it entirely.

Works Cited

Delasau, Ilaitia. “The Impact of Amputation On Diabetic Patient In Fiji.” Otago Southland Diabetes Research Trust, n.d. Web. 20 June 2016.

“Fiji.” International Diabetes Federation. N.p., n.d. Web. 20 June 2016. http://www.diabetesresearch.org/what-is-diabetes – June 2016

James, Delores. “Diet of Pacific Islanders.” Nutrition and Well-Being A to Z. N.p., n.d. Web. 20 June 2016.

Morgan, Jules. “Country in Focus: Turning the Tide of Diabetes in Fiji.” The Lancet Diabetes & Endocrinology 3.1 (2015): 15-16. Web.

“Pacific Islanders Pay Heavy Price for Abandoning Traditional Diet.” Bulletin of the World Health Organization 88.7 (2010): n. pag. Web. 20 June 2016.

Tuomilehto, J. Ram, P. “Cardiovascular Diseases and Diabetes Mellitus in Fiji: analysis of mortality, morbidity, and risk factors.” Bulletin of the World Health Organization 62 (1984): 133-143. Web.