Modern medicine brings new hope but: Diabetes on the rise in Trinidad and Tobago

BAVINA SOOKDEO

According to the International Diabetes Federation, presently, the prevalence of diabetes is between 12 to 15 per cent of our population with at least 150,000 people having the condition. However, Dr Chad Bisambar, a diabetes specialist and endocrinologist said this number is likely to be much higher as a significant number of patients with diabetes in TT remain undiagnosed.

Diabetes is a chronic disease where the body has high blood glucose (sugar) levels because it either doesn’t produce enough insulin or can’t use insulin effectively.

Bisambar, who completed his post-graduate training at the University of Cambridge and is registered as a specialist in the UK and TT explained, “Around 90 per cent of all cases are Type 2 diabetes which, very commonly, may have no symptoms and therefore many do not know they have the condition. We have also been seeing a surge in cases among children and young adults below the age of 40 years.”

Bisambar practices at several medical institutions including Southern Medical Clinic, St Clair Medical Centre, St Augustine Private Hospital, Caribbean Skin Clinic and St Augustine Surgical Centre. He described the current trend as deeply worrying: “Right now in TT, the number of cases of diabetes is increasing at an alarming rate,” he said. “This is very concerning as diabetes is the number one cause of heart attacks, strokes, blindness, kidney failure and lower limb amputations locally.”

The major risk factors for Type 2 diabetes here include poor eating habits, lack of exercise, a family history of diabetes, being of East Indian descent and polycystic ovarian syndrome (PCOS) in women. “The International Diabetes Federation has collected data showing that over 40 per cent of adults in TT are overweight or obese which represents a significant risk factor for Type 2 diabetes locally,” he added.

Misconceptions

Addressing some of the biggest misconceptions about diabetes, Bisambar explained that many people believe they have nothing to worry about if they feel well. However, he cautioned that elevated blood glucose levels over a prolonged period of time can cause organ damage even in the absence of symptoms. He added that another common misunderstanding is once medication – particularly insulin – is started, it cannot be stopped. “Although this is true for some patients with advanced diabetes, others have been able to come off medication with the appropriate lifestyle measures including dietary changes, increased physically activity and very importantly, weight loss.”

Evolving medications

But Bisambar said medications for diabetes have evolved over the past decade. “We have seen drugs created for diabetes that also have significant protective effects on all major organs and that reduce body fat,” he explained. “These include SGLT2 inhibitors such as empagliflozin (brand name Jardiance), GLP-1 agonists such as semaglutide (available under the brand names Ozempic, Wegovy and Rybelsus) and GLP-1/GIP agonists such as terzepatide (a prescription injectable medication approved under the brand names Mounjaro).”

The doctor further noted that while traditional diabetes medications such as metformin, gliclazide and insulin were primarily designed to lower blood sugar levels, newer treatments have “also shown protective effects on the heart, kidneys, liver and brain in several major studies.” He added that SGLT2 inhibitors and GLP-1 agonists are now being recommended internationally as first- or second-line treatments for Type 2 diabetes, particularly for patients with heart or kidney disease.

“Cardiologists and kidney specialists are even using these medications for their patients who do not have diabetes,” he said, pointing out that GLP-1 agonists such as semaglutide have also been approved by the FDA to treat obesity and some patients who are overweight and at risk of heart disease. “Many believe that these drugs are only used for weight loss,” he said, “however, it is clear that they offer numerous other benefits backed by scientific evidence.”

Bisambar pointed out that he has many years of experience prescribing GLP-1 agonists, a class of drugs that has been in use far longer than many people realise. “Many believe that these medications were recently developed,” he explained, “however, the first GLP-1 agonist, exenatide, was approved for use 20 years ago.”

He noted that even the most popular drug in the class, semaglutide, was first approved by the FDA nine years ago for the treatment of Type 2 diabetes and has since gained approval for other conditions, including obesity, cardiovascular and kidney disease and most recently, metabolic-associated steatotic liver disease (formerly known as fatty liver disease). “There is also excellent evidence that these drugs can significantly reduce insulin resistance and help with the symptoms of polycystic ovarian syndrome, or PCOS,” he added. “Terzepatide (another drug in the class) is also approved to treat obstructive sleep apnea.”

Bisambar said that given their wide-ranging benefits, many of his patients use a single medication such as semaglutide to manage multiple conditions simultaneously – including Type 2 diabetes, obesity, fatty liver disease and proteinuria (a high level of protein in your urine). “This means that patients will require less medication while achieving more benefits,” he explained. “By preventing and reversing organ-damage with a single medication, the overall cost of managing diabetes and its complications will be significantly reduced” he pointed out. “Thus far I have seen excellent results with this class of medication in patients who have a variety of medical conditions.”

So how do GLP-1 agonists work? The doctor pointed out that they work in a few different ways in the body. “For patients with diabetes, these drugs send a signal to the pancreas to secrete more insulin in response to eating a meal, therefore helping to reduce spikes in blood sugars afterwards” he explained. For weight loss, he noted that they slow down the emptying of the stomach, so one feels full after eating less food. “Interestingly, the drugs also work on parts of the brain to turn off cravings and reduce ‘food noise.’ They are also being studied in patients who have different forms of arthritis and inflammatory bowel disorders due to their potent anti-inflammatory effects.”

Side effects

Bisambar explained that the most common side effects of GLP-1 medications involve the gastrointestinal system, with some patients experiencing nausea, vomiting, diarrhoea or constipation. “To reduce these side effects, it is important that patients start the medication at low dosages,” he said. “Avoiding oily and very spicy food, eating slowly and reducing the amount of food eaten at a time may help to reduce these effects. Keeping hydrated and eating fibre are also exceptionally important.”

He noted that, although rare, GLP-1 drugs have been linked to some side effects such as inflammation of the pancreas, an uncommon form of thyroid cancer and certain eye conditions. For this reason, it is very important to go through a patient’s medical history in detail before prescribing these medications.

Access remains a challenge

Despite these drug advances, Bisambar highlighted that access remains a challenge for local patients. “Currently in TT, only two GLP-1 agonists – dulaglutide and liraglutide – are registered for sale,” he said. “Although these drugs have been monumental in the treatment of diabetes, they have now been surpassed by others such as semaglutide and terzepatide, which are not yet registered for sale in the country.”

Bisambar further explained that once a prescription is issued for semaglutide or terzipatide it is the responsibility of the patient to source the legitimate product, sometimes with the help of a pharmacist. He said, “The Ministry of Health and the Customs and Excise Division may need to be involved in any importation process.” Bisambar added, “These drugs are not on the national formulary and therefore are unavailable for use in the public healthcare service. Given that the drugs must be paid for, it does represent a significant financial challenge for certain patients who may benefit from them.”

Beyond cost, misinformation has also created hesitation among patients. “Some are reluctant to try these medications due to the possibility of side effects that are purported on mainstream and social media,” Bisambar said. “Like any prescription drug, there are potential risks, but I strongly believe this class of medication is being misused and abused globally due to its weight-loss potential.” He pointed out that many people using the medications are not under the supervision of an endocrinologist, using generic or compounded formulations, or should not have been on the drug in the first instance. “This is the main reason I believe that we are seeing so much negative press about the GLP-1 agonists” he added.

Education and awareness

Outside of medication, education and awareness are key. “Both doctors and patients need to be aware of the indications for these drugs, the potential side effects and how to monitor clinically while on them.” He stressed that proper nutritional guidance is also essential.

Bisambar said his ultimate goal is to see patients with Type 2 diabetes maintain normal blood sugar levels without medication. “In an ideal setting, I would like all patients with Type 2 diabetes to achieve remission,” he explained. “With newer medications that also promote significant weight loss, we’re seeing that happen more often than before.”

He noted that excess body fat increases insulin resistance, making it harder for the body to use glucose effectively. “By reducing body fat, insulin works more efficiently and blood sugar levels fall,” he said pointing out that some of his patients have even been able to stop using insulin, blood pressure, or cholesterol medication. “These new treatments have truly revolutionised diabetes management,” he said, “and we’re now seeing higher remission rates than ever before.”

Bisambar stressed that patient education is the cornerstone of effective diabetes management. “Knowing when to get screened, what to eat, how to exercise and how to monitor blood sugar levels is essential,” he insisted, adding that it is the duty of healthcare providers to ensure patients understand their medications and how to manage the condition. “When patients are guided correctly,” Bisambar noted, “it makes self-management of diabetes and achieving goals, simpler.”

Living with diabetes

The diabetes specialist acknowledged that living with diabetes can be overwhelming both physically and mentally, as patients cope with constant monitoring, medication and financial strain. He encouraged those affected to seek support from family, doctors and groups like the Diabetes Association of TT, emphasising that a strong support system and self-care are vital for managing the condition.

Stressing that early detection is key to preventing diabetes complications, Bisambar called for a national screening programme offering free annual testing for at-risk citizens. He also advocated for faster access to specialist clinics and greater availability of advanced treatments in the public health system.

As the we mark Diabetes Awareness Month, Bisambar’s message to the people living with diabetes is to never give up. He encouraged, “We are here to help you and we will get through this together.”