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DiabCare 2008: Survey on Glycaemic Control and the Status of Diabetes Care and
Complications Among Patients with Type 2 Diabetes Mellitus in the Philippines

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 Philippine Journal of Internal Medicine
DiabCare 2008: Survey on Glycaemic Control and the Status of
Diabetes Care and Complications Among Patients with Type 2
Diabetes Mellitus in the Philippines
Cecilia A. Jimeno, MD*, Leorino M. Sobrepeña, MD**, Roberto C. Mirasol, MD***
Abstract
Introduction: DiabCare 2008 study was conducted to
understand the current status of diabetes care in the
Philippines. It is the continuation of the similar studies
conducted in 1998 and 2003. It is expected to shed
some light on the changes in status of diabetes care
over the past decade in the Philippines.
Methodology: A total of 770 diabetic patients were
recruited from general hospitals, diabetes clinics and
referral clinics, out of which 724 were type 2 diabetic
patients. The following information were collected
during direct patient interview and review of medical
records: demographic data (date of birth/age, sex,
educational status, marital status, ethnicity, etc),
medical history (duration of diabetes and concomitant
diseases), risk factors, clinical examination reports, self-
monitoring data, diabetes education, complications,
eye and foot examinations, diabetes management
and HbA1C measurement. Quality of life, adjustment
to illness, and compliance to medications and health
maintaining behaviors were also evaluated using
structured questionnaires.
Results: The mean HbA1c was 8.03 ± 1.96 % and only
15.0% of the patients achieved ADA target of <7%.
Introduction
Type 2 Diabetes Mellitus (T2DM) is increasing at
an alarming rate globally1 and the Philippines is no
exception to this trend. Diabetes has affected around
4.6% (3.9 million) of Filipino population and the number
is presumed to double by 2030.2,3 In the Philippines
National Nutrition and Health Survey (NNHeS) 2008 data
set, the prevalence of diabetes was found to be 7.2%,
a prevalence estimate that closely approximates the
projections of the IDF for that year. On the other hand,
the prevalence of pre-diabetes in the 2008 Philippine
NNHeS was found to be 9.1% and 14% using the World
Health Organization (WHO) and the American Diabetes
Association (ADA) criteria respectively. 3 T2DM is found
to affect more Filipino females than males. 4 The WHO
mortality profiles reveal that diabetes mellitus is one
of the top 10 causes of mortality in the Philippines.5
*Associate Professor UP College of Medicine, Dept of Pharmacology;
Clinical Associate Professor, UP College of Medicine, Manila, Philippines
**Institute for Studies on Diabetes Foundation Inc., Marikina City,
Philippines 1810
***St. Luke’s Medical Center, E. Rodriguez Ave., Quezon City,
Philippines.
Original Article
42.5% of patients had LDL levels >2.6 mmol/L; 14.3% had
triglycerides >2.2 mmol/L; 19.2% had HDL<1 mmol/L and
53.9% of the patients were on lipid lowering agents.
68.4% patients were hypertensive and 64.4% were
receiving anti-hypertensive medication. Microvascular,
macrovascular and severe late complications were
reported in 68.1%, 14.8% and 9.4% patients respectively.
The rates of diabetic complications were cataract
32.7%, neuropathy symptoms 45.2%, microalbuminuria
15.8%, history of angina pectoris 10.7% and cerebral
stroke 4.7%. Two thirds of the non-insulin users were
worried about starting insulin therapy.
Conclusion: The results are suggestive of inadequate
control of blood glucose among Filipino patients with
type 2 diabetes mellitus, with a significant proportion
of the sample having associated complications and
co-morbidities. This warrants immediate attention as
diabetes control and complications status has not
improved over the past decade.
Keywords: DiabCare, Diabetic complications, Glycaemic
control, Hypertension, Dyslipidaemia
A study from the Western Pacific region also
suggests an association between inadequate glycemic
control and high risk of microvascular complications.6
High prevalence of metabolic syndrome further adds
to the disease and complications burden.7 Peripheral
Arterial Disease (PAD), a macrovascular complication
of diabetes, is widespread among Filipinos. 8
To gauge the effectiveness of the health care
system, it is imperative to constantly evaluate the status
of diabetes care. The results of DiabCare Philippines
2008, a part of the multi-national DiabCare-Asia project
in association with Novo Nordisk, is a reflection of
the existing practices followed for the management
of this disease, its complications and the change in
diabetes care over the years. DiabCare studies have
been conducted earlier in 1998 and 2003, and the
results from these previous studies when combined with
the current study can be used to examine trends in
the care of diabetics.
The primary objective of the study was to
describe the disease management, control status
and complication profile of the diabetic population.
Secondary objectives comprised of evaluating the
relationship between duration of diabetes to its
Volume 50 Number 1 Jan.-Mar., 2012 15
 Jimeno CA, et al
complications and quality of life, along with other
psychosocial aspects. The relationship between the
physicians’ perception and their current practices for
diabetes management was also evaluated.
M ethodology
DiabCare Philippines 2008 survey was conducted
between December 2008 and May 2009 across 40
centers in the Philippines. Consecutive patients were
enrolled by the individual physicians involved in the
study. About 40 doctors participated in this study
which were mainly primary physicians, diabetologists
and endocrinologists practicing across the Philippines.
Investigators from each center selected patients
from their clinical records or databases. Patients for
inclusion were required to have received treatment for
diabetes in a particular centre for the last 1 year,
and were also required to visit the clinic at least
once during last 3-6 months apart from the initial visit.
Patients were enrolled after evaluation of inclusion/
exclusion criteria.
The study details were explained to the eligible
patients who were then asked to sign the informed
consent form upon expressing their willingness to
participate in the study. The study did not necessitate
any specific visit and the data was collected during
the patient’s routine visit to clinic.
Data Collection and HbA1c Assessment:
The following information were collected during
direct patient interview and review of medical records:
demographic data (date of birth/age, sex, educational
status, marital status, ethnicity, etc), medical history
(duration of diabetes and concomitant diseases), risk
factors, clinical examination reports, self-monitoring
data, diabetes education, complications, eye and
foot examinations, diabetes management and HbA1C
measurement. Laboratory assessment was performed
only for HbA1c, whereas for all other investigations,
the most recent data from patient’s medical records
was captured. A standardized Case Report Form (CRF)
was used for recording data.
In addition, patients were interviewed to evaluate
quality of life using a questionnaire adapted from the
WHO-5 Well Being Index 11 and the DAWN (Diabetes
Aspirations Wishes and Needs) survey which consisted
of Ps y ch o s o c i a l q ue s t i onna i r e , a nd C om p l i a n c e
questionnaire. In WHO-5 well-being questionnaire,
responses (All or most of the time) are considered as
Positive and responses (Some of the time or not at all)
are considered negative and responses are measured
as positive responses (%) and negative responses (%).
Blood samples for HbA1c measurement were
collected from venous/capillary blood (as per National
Glycosylated Standardisation Programme (NGSP)
guidelines) by the participating clinics. The samples
were stored at 20C to 80C for testing purposes and
discarded immediately after analysis. Bio-Rad HPLC D
10 or Variant 2 method was used for the estimation
of HbA1c. Bio-Rad was also responsible for the lab
selection, supervision as well as the quality assurance
16 Volume 50 Number 1 Jan.-Mar., 2012
DiabCare 2008: Survey on Glycaemic Control and the Status of Diabetes Care
of the centralized measurements.
Statistical Plan:
A sample size of 1988 patients was calculated
based on the least prevalent complication i.e.
cardiovascular disease (CVD) among diabetes patients,
to provide adequate probability of capturing even
the lowest occurring complication. Windows based
software (PEPI, version 4) by PM Gahlinger and JH
Abhramson, 1993-2001, with 5% level of significance
and 20 to 30 % margin of error was utilized for the
above calculation. The data set for analysis of various
parameters had been confined to age (18- 85 years),
BMI (18-40 Kg/m2), HbA1c (4-16%), FPG - 54-306 mg/
dl (3-17 mmol/), PPG - 54-500 mg/dl (3-27.77mmol/l)
and the duration of diabetes up to 25 years.
Both the primary and secondary end points were
analyzed through descriptive statistics. The former
were presented as mean ± standard deviation (SD),
range or percentages while the latter as number
and percentage. ANCOVA and logistic regression
methods were applied to analyse the influence of
predictor variable on change in outcome variables
for continuous and discrete variables respectively. All
tests were two-sided and a p- value of less than 0.05
was considered significant.
Novo Nordisk was responsible for CRF collection,
transportation of blood samples to central laboratory
for HbA1c estimation, data management, quality control
and statistical analysis.
Outcome measures:
The primary outcome for this study was the
status of glycemic control of Type 2 diabetic patients
as measured by the mean and standard deviation
of the HbA1c, as well as the proportion of study
participants who are within the target goals for good
glycemic control. Generally, the glycemic target is
either a value less than or equal to 7.0% or in some
guidelines, a more stringent target of < 6.5%. The
mean HbA1c was compared against this benchmark;
as well, patients were classified as being in control
or uncontrolled, upon comparing their study HbA1c
with these targets and the proportion of patients who
had good glycemic control was calculated.
R esults
A total of 770 patients were initially enrolled in the
study, but only 724 ( 94% of the patients) were type 2
diabetic patients and included in the present analysis
(data of other diabetic patients are excluded from
the analysis). The response rate was more than 85% in
majority of the study variables. However, the response
rate was lower for HbA1c by records (76.8%), HbA1c
by survey (45.7%), triglyceride value (74.9%), cholesterol
value (78.2%), nephropathy evaluation (76.2%) and eye
complications (photocoagulation assessment – 64.9%,
cataract assessment- 66.9%, advanced eye disease
assessment- 63.9%, legal blindness assessment- 0%).
HbA1c by records are the results which have been
done in the course of their regular follow ups, while
DiabCare 2008: Survey on Glycaemic Control and the Status of Diabetes Care Jimeno CA, et al

HbA1c by survey means that for all patients, after

informed consent had been obtained, blood was
drawn and was processed in a single laboratory which
complies with the NGSP standards for doing the test.
Demographic Characteristics
The mean age of the participants in the study
was 61.56, s.d 11.3 years, with 67.4 % women.
Mean BMI was 25.72, s.d. 4.0 kg/m2, and with 74%
of the participants having a BMI greater than 23
kg/m2, concluding that majority of the respondents
were overweight or obese. The mean age of onset
of diabetes was 52.20, s.d. 11.27 years and the
mean duration of diabetes was 9.0, s.d. 6.0 years.
Demographic and metabolic characteristics of type 2
population are summarized in Table I.
M easures of Metabolic Control
Glycaemic Parameters
Over the last one year, the frequency of testing
for FPG and HbA1c was 6.84 ± 8.86 and 2.57 ± 1.43
times respectively. The mean values for glycaemic
control based on the HbA1c obtained by the survey
was 8.03 ± 1.96 % (n=332), while the clinic records
showed the following mean results: FPG 7.23 ±
2.27mmol/L (n= 547) and PPG 9.38 ± 3.07 mmol/L
(n=174). HbA1c by survey was available for only 45.7%
of participants and revealed that only 15.0% (109 /332)
had HbA1c < 7.0%. Table II illustrates the proportion
of patients achieving the glycaemic control targets
set by American Diabetes Association (ADA) and other
professional bodies.

Table I. Demographic and metabolic characteristics of Study Participants, Table II. Distribution of Participants according to Achievement of Glycaemic
N=724, 2008. targets According to Various Guidelines, N=724, 2008.
DEMOGRAPHIC AND METABOLIC DATA VARI- ADA GUIDE- EU GUIDELINES IDF/ AACE
CHARACTERISTICS ABLES LINES GUIDELINES
Age (years)* 61.56 ± 11.30 Target N (%) Target N (%) Target N (%)
Gender, male/female 222/ 488 (30.7/67.4%) HbA1c <7 109 ≤6.5 66 (9.1) <6.5 77
(%) (15.0) (10.6)
BMI (kg/m2)* 25.72 ± 4.0
≥7 223 > 6.5 266 (36.7) ≥ 6.5 255
BMI groups:
(30.8) (35.2)
≥23 / ≥25 kg/m2 74 / 52.1%
≤ 7.22 337 ≤6 185(25.5)
Duration of diabetes (years)* 9.0 ± 6.0
(46.5)
Waist circumference: (%)
>6-<7 134 (18.5) < 6.1 187
Male (≥90 cm) / Female (≥80 cm) 54.4 / 72.4 %
(25.8)
FPG
Duration of diabetes groups: (%)
(mmol/
≤1 / 1-5 / >5-10 / >10 years 4.28 / 27.9 / 28.7 / 34.0 %
dL)
> 7.22 210
Age at onset (years)* 52.20 ± 11.27
(29.0)
Educational status
≥7 228 (31.5) ≥ 6.1 360
LCTRW# 13 (1.8%) (49.7)
5 years 87 (12.0%) Main cohort, n=724. ADA, American Diabetes Association; EU, European Diabetes
Policy Group; IDF, International Diabetes Federation; AACE, American Association of
10 years 231 (32.0%) Clinical Endocrinologists

Graduate 359 (49.5%)

Lipid Parameters and BP control
Postgraduate 18 (2.5%)
Based on the clinic records, 94.8% (686/724)
Risk factors
of patients had dyslipidemia. The mean LDL, HDL
Family history 523 (72.0%) and triglycerides levels were 2.91± 1.19, 1.38 ±2.62
Smoking 83(11.5%) and 1.81±2.87 mmol/l respectively. The proportion of
Alcohol 63 (8.7%) patients exceeding the American Heart Association
Health expenses
(AHA)-recommended targets were 42.5% (308/724) for
LDL>2.6 mmol/l, 19.2% (139/724) for HDL<1 mmol/l and
Government/ Community 32(4.4%)
14.3% (104/724) for triglycerides >2.2 mmol/l. 53.9%
Self 627 (86.6%) (390/724) were receiving lipid lowering drugs - Statins
Insurance 46 (63.5%) 89% (347/390) and fibrates 18.2% (71/390).
Ethnic groups Hypertension was found in 68.4% of the study
Filipino 691 (95.4%) participants (495/724), and the mean SBP/DBP of
the survey population was 126.0±15.9 / 76.8±8.59
Chinese 24 (3.3%)
mm Hg respectively. Anti-hypertensive medications
Pacific Islander 2 (0.3%) were prescribed to 64.4% of the study population
Others 52 (7.2%) (466/724) with the following distribution: angiotensin
*Data expressed as mean ± SD. BMI, body mass index; OAD, oral antidiabetic drug; II receptor blockers (ARB) (265/466, 56.9%), calcium
SU, Sulphonylurea; BG, Biguanide; AGD, Alpha glucosidase inhibitors; TZD, Thiazoli-
dinediones; #Limited Capacity To Read and Write
channel blockers (CCB)(153/466, 32.8%), ACE inhibitors
Main cohort, type 2 diabetes mellitus, n=724 (ACEI) (93/466, 20%), diuretics (59/466, 12.7%) and beta
blockers (BB) (52/466, 11.1%).

Volume 50 Number 1 Jan.-Mar., 2012 17

 Jimeno CA, et al DiabCare 2008: Survey on Glycaemic Control and the Status of Diabetes Care

Complication Status (326/482) of participants. Symptoms of neuropathy were

The following are the proportions of patients who found in 45.2% (218/482) of patients. Ankle jerk was
were evaluated for various diabetic complications: absent in 69.1% (333/482) of patients.
61.7% (447/724) for diabetic eye complications, 81.1% Out of 593 patients who were evaluated for
(587/724) for diabetic nephropathy, 66.6 % (482/724) diabetic foot complications, 2.8% (17/593) had absence
for diabetic neuropathy, 81.9% (593/724) for foot of foot pulses, 1.3% (8/593) had undergone leg
complications and 99% (717/724) for cardiovascular amputation, 0.16% (1/593) have had vascular surgery/
disease. The prevalence of microvascular (retinopathy, angioplasty and 0.84% (5/593) reported active ulcer
nephropathy and neuropathy) and macrovascular gangrene.
(angina pectoris, MI, CABG/Angioplasty/Stents and Among the cardiovascular complications 10.5%
stroke) complications were 68.1% (493/724) and 14.8% (76/724) had history of angina pectoris, 2.76% (20/724)
(107/724) respectively. Severe late complications (legal had myocardial infarction, 1% (7/724) reported CABG/
blindness, MI, CABG/Angioplasty/ Stents, Cerebral stroke, Angioplasty and 4.7% (34/724) patients reported stroke.
ESRD and Leg amputation) were found in 9.4% (68/724) 22.1% (160/724) received anti-platelet treatment.
of participants. Most of the complications were found Infections were reported in 10.9% (79/724) of
to increase with an increase in the duration of diabetes patients comprising of skin infections, urinary tract
(Table III). and respiratory tract infections. 9% (65/724) patients
reported erectile dysfunction.
Table III. Prevalence of diabetic complications stratified by dura-
tion of diabetes Diabetes Management
DURATION OF DIABETES CATEGORIES
78.5% (568/724) patients were on OADs and 42%
DIABETIC COMPLI- (304/724) were on insulin. Mean duration of insulin
CATIONS ≤1 year >1 – 5 >5-10 >10 years
years years treatment was 4.77±5.1 years. The following is the
distribution of patients using different OAD’s: biguanides
Cataract (N=146) 1 (5.9) 12 (10.3) 48 (33.8) 70 (38.5)**
73.8% (419/568); sulphonylureas 56.5%(321/568),
Non-proliferative 3 (18.8) 15 (12.9) 27 (19.0) 42 (23.2)*
thiazolidinediones 20.6% (117/568), dipeptidyl-peptidase
diabetic retinopathy
(N=90) -4 (DPP-IV) inhibitors 9.9% (56/568), alpha glucosidase
inhibitors 6.0% (34/568), meglitinides 3.3% (19/568), and
Photocoagulation 1 (6.7) 4 (3.4) 11 (7.9) 14 (8.1)*
(N=33) traditional medicines were taken by 3.2% (18/568). 10.9%
Microalbuminuria1 3 (50) 19 (23.2) 25 (26.3) 41 (34.2)
patients were on fixed dose combination (FDC) of
(N=93) two drugs. The types of insulin that were used include
Angina pectoris ( 1(3.2) 11(5.5) 31(15) 32(13.2)** premixed 43.4% (132/304), basal 26.3% (80/304), basal-
N=76) bolus 4.3% (13/304) and bolus alone 16.8% (51/304).
Myocardial infarction 0 (0) 0 (0) 7 (3.4) 13 (5.3)*** The mean dose of insulin was 41.3±23.4U/day and the
(N=20) mean number of injections was 2.07±1.44 per day. The
Cerebral stroke (N=34) 0 (0) 5 (2.5) 12 (5.8) 16 (6.6)* proportions of patients receiving once, twice and more
than twice-daily injections were 25.6% (78/304), 54.9%
Angioplasty (N=7) 0 (0) 0 (0) 2 (1.0) 5 (2.1)*
(167/304) and 6.25% (19/304) respectively. Approximately
*30 – 300 mg/L; N=number of patients evaluated for each complication;
numbers in parentheses indicate % out of N, * NS, **Statistically signifi-
half of the patients (48.4%, 147/304) were on analogue
cant (p<0.05), *** p < 0.01 insulin. Insulin was administered by a pen device in
45.7% (139/304) and by a syringe in 43.8% (133/304).
Cataract was reported in 32.7% (146/447) and non- The mean numbers of sessions in various aspects of
proliferative retinopathy in 20.1% (90/447) of patients diabetes education over the last year were as follows:
respectively. Severe late eye complications reported Diet 1.17±1.63, exercise 0.96±1.56, SMBG 0.88±1.60,
were photocoagulation (33/447, 7.4%), and proliferative foot care 0.89±1.52 and general diabetes education
diabetic retinopathy (37/447, 8.3%). No data was 1.40±2.39. 46.2% (335/724) did SMBG and mean number
available for legal blindness. of tests conducted per month was 13.43±15.94.
In the preceding year, 94.7% (556/587) of the
volunteers had undergone serum creatinine testing, Quality of Life and treatment adherence
with 7.3% (43/587) having values above 2 mg/dl. The responses to WHO-5 well-being index, DAWN
Proteinuria testing was done in 54.5% (320/587) with QoL and treatment adherence questionnaires are shown
15.8% (93/587) testing positive for microalbuminuria (30- in Table IV. In the questions related to psychological
300 mg/L) and 2.04% (12/587) having macroalbuminuria well-being, approximately 50% of patients responded
(>300mg/L). 1.5% (9/587) patients had end-stage renal positively in various aspects (cheerfulness, calmness
failure requiring dialysis or transplant . The method of and being relaxed, being active and vigorous, waking
microalbuminuria detection was either a spot urine test up fresh and rested and finding interest in daily life),
or an analysis of urine collected over 24-hour period. and around 1/3 responded negatively.
Diabetic neuropathy was evaluated among 482
patients with monofilament testing being done in 67.6%

18 Volume 50 Number 1 Jan.-Mar., 2012

 DiabCare 2008: Survey on Glycaemic Control and the Status of Diabetes Care Jimeno CA, et al

Table IV. Psychological well-being, quality of life and treatment D iscussion

adherence – the DiabCare Philippines 2008 study
% Positive* % NegativeΨ DiabCare Philippines 2008 study was conducted to
get an overview of the prevailing situation of diabetes
Psychological well-beinga
management, control and complications in the
P1. I have felt cheerful and in 50.0 27.8 country. Comparison with the similar data collected
good spirits over the past decade was done to understand the
P2. I have felt calm and relaxed 47.9 28.9 changes with regards to demographic features, clinical
characteristics and management strategies. In addition
P3. I have felt active and vigorous 45.6 30.9
to the previous two DiabCare studies (1998 and 2003),
P4. I woke up fresh and rested 48.7 30.2 the PAD- SEARCH study published in 2007 is considered
P5. My daily life has been filled 50.3 31.4 here as it also provides valuable insights into the status
with things that interest me of diabetes care in the Philippines. Since the PAD-
Quality of lifeb SEARCH study involved only type 2 diabetic patients
above 50 years with a history of one or more of the
Q1. I feel my diabetes is well 78.6 18.5 risk factors like smoking, hypertension or dyslipidemia,
regulated
it has been considered only in few relevant sections.8
Q2. I am constantly afraid of my 45.2 52.8 Also, the number of patients participated in 1998 and
disease getting worse 2003 DiabCare Philippines study were more than 2700
Q3. I am tired of complying with 65.1 31.7 as compared to the present DiabCare 2008 study
my medications where only 724 patients were included.
Q4. I feel that my diabetes is 56.9 49.9 Majority of the patients (94%) recruited in the
preventing me from doing what I present study have been diagnosed with Type 2
want to do diabetes. The investigators participated in this study
were ~60% endocrinologists and diabetologists, 25%
Q5. I am worried about the risk of 41.5 54.3
internist physicians and ~15% primary care physicians.
hypoglycaemic events
In the 2008 cohort, both the mean age of the
Q6. Coping with diabetes is more 54.6 41.2 patients and mean age at onset of diabetes (61.56
difficult at present than it used to years, 52.2 years) are slightly higher as compared
be
to DiabCare 2003 (60.0 yrs, 50.0 yrs) and DiabCare
Q7. I feel burned out from having 63.8 31.4 1998 (59.3 years, 50.3 years).9,10 The mean duration
to cope with diabetes of diabetes is comparable among the various surveys
Subjects not using insulin with 9.4 ± 7.0 years in DiabCare 1998 and 9.0 years
in both DiabCare 2003 and DiabCare 2008. 9,10 More
S1. I am very worried about hav- 63.8 31.4
ing to start on insulin females (67.4%) were enrolled in the present study. In
the PAD-SEARCH study the mean age of the Filipino
S2. Starting on insulin would mean 14.8 42.2 cohort was 63.7 years and the duration of diabetes
I have not followed my treatment
was 8.9 years.7 The PAD-SEARCH study also showed a
recommendation properly
female preponderance (61.6%). Considering the age
Treatment adherence at onset and female preponderance, more efforts and
Diet 88.5 10.7 resources should be allocated to screening middle
aged and females for type 2 diabetes in Philippines.
Exercise 68.2 30.3
The mean BMI in this study (25.7 kg/m2) is slightly
Taking medications as prescribed 98.5 0.6 higher compared to DiabCare 2003 (25.4 kg/m2) and
Testing yourself 64.2 31.7 DiabCare 1998 (24.7 kg/m 2). The mean BMI in the
PAD-SEARCH study was 25.0 kg/m2. In the present
Keeping appointments with health 96.1 2.4
care professionals survey, more than half of diabetic population (52.1%)
had a BMI >25 kg/m 2 , up from 40% seen in 1998
*Answered all/ most of the time OR fully/ mainly disagree (except Q1) OR completely/
partially; Ψanswered some of the time/ not at all OR fully/ mainly agree (except Q1) OR study. Similar trends are seen in other DiabCare 2008
rarely/ never a,b,c,dExcluded answer to category: ‘don’t know/refused’ cohorts from neighboring south-east Asian countries as
well. 12 Increase in the prevalence of obesity among
Among the quality of life questions, the most the Filipino patients with type 2 diabetes is expected
notable results were that 78.6% of patients felt that to make the management of diabetes even more
their diabetes is well regulated, despite the results of difficult in future. This calls for increased efforts towards
the objective glycemic measures. Also, 65% felt tired educating patients and care givers with regard to the
of complying with their medications, and 64% felt importance of weight control and strategies towards
burned outcrop having to cope with diabetes. Among the same.
those who were not using insulin at the time of the The mean HbA1c (%) and FPG (mmol/L) values in
survey, 64% were worried about having to start on DiabCare 1998, 2003 and 2008 were 8.9 and 8.7, 8.2
insulin. and 7.8, 8.03 and 7.23 respectively. The results suggest
improvement in both HbA1C and FPG levels over the
years though the mean values still remain above the

Volume 50 Number 1 Jan.-Mar., 2012 19

 Jimeno CA, et al DiabCare 2008: Survey on Glycaemic Control and the Status of Diabetes Care

recommended targets. Table 5 gives a comparison
of HbA1C target achievers for the years 1998 and
2008 as per various guidelines showing that proportion
of patients achieving glycaemic control targets has
not improved over these last 10 years. However this
should be considered cautiously in the light of missing
HbA1c data for majority (54.3%) of the present study
population. Data shows that only 15% patients in this
2008 survey achieved the ADA HbA1c target, though
three fold more patients achieved FPG target (46%).
One of the potential explanation for this could be the
inadequate PPG control. Unfortunately PPG values were
available only for less than one fourth of the present
study population. Results thus suggest more emphasis
on frequent monitoring of PPG and its control either
with dietary modifications, OADs, short acting insulin
or premix insulin. Further, mean HbA1c in DiabCare
Malaysia 2008 was 8.7% whereas that of Singapore
was 7.8%. 12
Table V: Percentage of patients achieving glycemic targets in DiabCare
1998 and 2008
GUIDELINE TARGETS 1998
HbA1c (%)
ADA < 7% 16.0
EU < 6.5% 7.0
AP ≤ 7.5% 16.0
ADA, American Diabetes Association; EU, European Diabetes Policy Group; AP, Asia-
Pacific Type 2 Diabetes Policy Group
was seen in the screening numbers for albumin over
the past decade. Screening numbers for albumin in
1998 and 2008 were 13% vs. 45.6%. 9 As compared
to 2003 there is a rise in the proportion of patients
with serum creatinine values > 2mg/dl (7.3% vs 6%).
Also the proportion of patients with macroalbuminuria
has grown two fold since 1998 (2% vs 1%) though
the absolute number of patients is small. Proportion
of patients presenting with neuropathy symptoms has
remained similar over the past decade; 42% in 1998,
53.6% in 2003 and 45.7% in 2008. More patients had
undergone foot examination in the present study
in comparison to 2003 (81.9% vs. 64 %). Overall
there is considerable improvement in the screening
patients for diabetic complications though it is still not
optimal. In future efforts should be directed towards
further improvement in screening rates in addition to
educating patients and care givers about appropriate
management of complications.
Age at onset and duration of diabetes emerged
as significant predictor variables for all selected
complications except for macrovascular complications
2008 for which duration was significant. However, other
variables could also predict selected complications as
shown by the unadjusted odds ratio (Table VI and
15.0 VII). Hypertension was a significant predictor variable
9.1 for all complications except for serum creatinine. Thus
23.2 earlier treatment of diabetes and good control of
hypertension emerge as important factors in preventing
or controlling complications.

In the DiabCare 2008 study, the mean LDL, HDL Table VI: Odds for diabetes-related complications in type 2 diabetes
and triglycerides levels were 2.91± 1.19, 1.38 ±2.62 and mellitus
1.81±2.87 mmol/l respectively. The mean LDL, HDL and Inde- Cataract Serum Neurologi- Macrovas-
triglycerides levels were 3.05± 1.16, 1.48±0.77 and 1.36 pendent Creatinine cal Symp- cular Com-
±0.87 mmol/l in PAD-SEARCH study 2007. 8 Difference Variable >2mg/dl toms plications
could be because of the preferential inclusion of Age 0.93(0.90- 0.95 (0.91- 1.03 (1.01- 1.02 (1.00-
patients with dyslipidemia to for PAD-SEARCH study. 0.96)* 0.99)* 1.05) * 1.04)*
A rise in the proportion of patients receiving anti- Sex 2.23(1.39- 1.48 (0.63- 1.35 (0.94 0.72 (0.47-
hyperlipidemic drug is seen in 2008 as compared to 3.57)* 3.45) -1.94) 1.12)
2003 (53.9% vs. 34.4%).10 However it needs to be further Age at 1.04 (1.02- 0.97 (0.93- 1.00 (0.99- 0.99 (0.98-
improved as only half of the population received onset 1.06)* 1.01) 1.01) 1.01)
treatment for diabetic dyslipidaemia. The increasing use Duration 1.08 (1.05- 0.98 (0.92- 1.09 (1.06- 1.08 (1.04-
of anti-hyperlipidemic drug could be the reason for 1.12)* 1.05) 1.12)* 1.11)*
decrease in the proportion of patients with TG > 2.2 Hyperten- 2.45 (1.51- 0.65 (0.21- 1.63 (1.12- 2.34 (1.38-
mmol/l when compared to 2003 (27.3% vs. 19.2%).10 The sion 3.96)* 1.99) 2.37)* 3.96)*
percentage of patients with hypertension in DiabCare On insulin 0.83 (0.56- 3.79 (1.85- 1.62 (1.16- 2.14 (1.41-
2008 study was 68.4% and 64.4% of patients were 1.24) 7.72)* 2.25)* 3.27)*
on hypertensive medications. Similar to the findings
HbA1c 1.27 (0.78- 0.46 (0.12- 0.48 (0.31- 0.59 (0.34-
regarding the therapy of dyslipidemia, the increase in 2.07) 1.75) 0.74)* 1.03)
the number of individuals being treated for hypertension
FPG 0.50 (0.24- 0.29(0.05- 0.18 (0.07- 0.22 (0.06-
is a positive sign that physicians are trying to improve 1.03) 1.53) 0.41)* 0.69)*
the care of diabetic patients. However, given that
SMBG 1.27(0.86- 2.10 (1.10- 1.61 (1.17- 2.14 (1.40-
both dyslipidemia and hypertension are major risk 1.88) 3.99) * 2.23) * 3.25)*
factors for cardiovascular disease, treatment of these
Data presented as odds (95% confidence interval); *p<0.05; FPG, Fasting Plasma
two problems needs to be improved. Glucose; SMBG, Self monitoring of blood glucose
Compared to the data in 2003, an increase was Odds for binomial data: Odds for “sex” expressed as male vs female; odds for “hyper-
tension” expressed as the reciprocal of subjects with SBP ≥140 mmHg or DBP ≥90
noted in the number of patients undergoing eye mmHg or use hypertensive medication vs. non-hypertensive subjects; odds for “SMBG”
examination in the present study (61.7% vs. 52%). 10 expressed as subjects doing SMBG vs. subjects not doing SMBG; odds for “On insulin”
expressed as subjects with insulin therapy vs. subjects without insulin therapy. Age,
This indicates a positive change as it may help to Duration of diabetes, HbA1c, FPG and onset age were continuous variables
detect cataract and retinal changes at an early stage Macrovascular complications: Patients with any or all of the below mentioned complica-
tions - Angina pectoris, MI, CABG/Angioplasty/Stents, Stroke
in patients with diabetes. A notable improvement

20 Volume 50 Number 1 Jan.-Mar., 2012

 DiabCare 2008: Survey on Glycaemic Control and the Status of Diabetes Care Jimeno CA, et al

Table VII: Odds for diabetes-related complications in type 2 perceived a healthy state of well-being. Adherence
diabetes mellitus, Age at onset and diabetes duration being the to treatment questionnaire indicated an acceptable
risk factors status. However close to two thirds of the non-insulin
Independent Cataract Serum Neurological Macrovascular users were still worried about starting insulin therapy.
Variable Creatinine Symptoms Complications This calls for increasing efforts and resources towards
>2mg/dl educating patients and care givers to overcome the
Age at onset 1.08 1.04 (1.00- 1.01 (1.00- 1.01 (0.99-1.03) barriers to insulin therapy.
(1.06- 1.07)* 1.03)*
1.11)*
C onclusion
Duration 1.15 1.09 (1.03- 1.10 (1.07- 1.08 (1.04-
(1.10- 1.16)* 1.13)* 1.12)*
1.20)* DiabCare 2008 along with similar data from previous
*p<0.05. Data presented as odds (95% confidence interval). The model used to obtain
studies conducted over the last 10 years suggest a
the odds adjusts for poor status of glycaemic control among Filipino type
onset age and duration of diabetes. Macrovascular complications: Patients with any
or all of the below mentioned complications - Angina pectoris, MI, CABG/Angioplasty/
2 diabetic patients. A small proportion of patients
Stents, Stroke achieving target HbA1c despite close to half the study
population achieving FPG target emphasizes the need
The proportion of patients on OAD and insulin in for improvement in monitoring and adequate control
2003 and 2008 are given in the Table VIII. The use of PPG. Increasing obesity prevalence suggests the
of biguanides has increased since 2003 study (73.6% need for the implementation of sustained patient
vs.56 %) while use of sulphonylurea was slightly education measures on the importance of weight
reduced (56.4 % vs. 60%).10 Increased use of metformin control and the tools available for the same. Why
is line with the global recommendations supporting the majority of patients are not receiving treatment
its use. Marginal reduction in sulphonylurea use could for diabetic dyslipidemia is a cause for concern and
be due to the introduction of DPP-4 inhibitors used requires training the treating physicians on lipid targets
by close to 10% of the present study population. and optimal use of anti-hyperlipidemic agents. There
There is a considerable increase in the proportion of is considerable improvement in the screening rates for
patients using insulin (42% in 2008) in comparison to diabetes complications though it is still inadequate.
2003 (24.1%). In the current study mean daily dose Efforts on increased screening should be continued and
of insulin has also increased in comparison to 2003 treating physicians should be trained on management
study (41.28 U/day vs. 26.1 U/day). Close to half of complications. Increased use of insulin, newer insulin
of the patients on insulin were using newer insulin analogues and pen devices is a positive trend though
analogues and similar proportion of patients were using two thirds of the non-insulin users are still worried about
insulin pen devices. This shows growing awareness, starting insulin. There is an urgent need to educate
acceptance and confidence on insulin therapy among patients and prescribers to address the barriers to this
patients and prescribers. important tool in diabetes management. In summary,
the status of diabetes care in the Philippines appears
Table VIII: Proportion of patients on lifestyle modification and below the accepted standards and DiabCare 2008
therapy calls for urgent measures to improve the delivery of
quality care among the patients with Type 2 diabetes
VARIABLES 2008 2003
mellitus.
Smokers 11.8 15.4
Alcohol 8.8 14.3 Acknowledgements:
OAD 78.5 71.3 The authors would like to thank Novo Nordisk
South East Asia Oceania regional office for generously
Insulin 42 11.5
providing grant for this study and to all the expert
Regular self-mon- 46.2 16.1 panel members, investigators and staff of the various
itoring
hospitals for their support. Novo Nordisk South East
OAD, oral antidiabetic drug
Asia Oceania regional office was responsible for the
appropriate tabulation, presentation of data for this
Compared to the 2003 DiabCare study, a manuscript.
considerable improvement was noted in the proportion
of patients self-monitoring their blood glucose levels i.e. References
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