Dr Annabel Fountain, diabetes consultant specialist, reviews the literature on diabetes. *Photo by B. Candace Ray
Dr Annabel Fountain, diabetes consultant specialist, reviews the literature on diabetes. *Photo by B. Candace Ray

Bermuda has the highest incidence of diabetes-related amputations compared to other countries in the western world, according to the Bermuda Health Council’s Health in Review report of the top 30 OECD countries (published 2011). 

Dr Annabel Fountain, consultant specialist with the Bermuda Hospitals Board, hopes to change that fact.

“Diabetes care is a subspecialty of Endocrinology,” Dr Fountain said. “It is [diabetes] a lifelong disorder and the impact on future health of good care and lifestyle makes it a potentially very rewarding patient-doctor relationship.

“It is also extremely holistic as diabetes may affect all aspects of a person’s health and their wellbeing.”

The Bermudian healthcare professional, who works out of the Chronic Disease Management Centre at Mid-Atlantic Wellness Institute, last year returned to the island after 24 years working and studying in the UK.

“I’ve always wanted to come back to Bermuda. It is my home and my people. I feel grounded here.”

Dr Fountain is instituting a three- to five-year plan for standardizing acute diabetes care services in Bermuda’s hospitals.

The criteria will be based upon the exacting standards required of healthcare facilities in the UK where Dr Fountain trained and worked, rotating through hospitals every six-to-12 months.

Dr Fountain said: “The standards of on-island care have already been dictated by the Diabetes Guidelines for Bermuda which were produced and distributed in 2009. My job is to try and make sure that information is given out and implemented… I’m doing teaching sessions at the hospital for the hospitalists, emergency physicians and intensive care staff for management of diabetes admissions.”

She is also to start working with nursing managers and physicians to perform an audit of in-patient diabetes care.

“Only when we’ve done that will we really know what the situation is in the hospital — where things are good and where they’re not so good. Without knowing that, I don’t really know what I have to change, if anything.”

Dr Fountain expects the assessment to be completed within a couple of months.

“Bermuda has very strong education programmes for people with diabetes. However, there’s a gap between what people are told and what they believe. There’s also a gap between what people know they should do and what they actually do.

“If you tell someone that KFC chicken and fries, mac and cheese, peas and rice are bad for them, and they continue [eating those foods and] drinking sodas, then the education didn’t achieve its goal.”

She admits, however, that amputation rates won’t change in the short term.

The disease process, according to the doctor, occurs over a 10- to 20-year period of poorly controlled diabetes. This leads to neuropathy, or the death of nerves in the feet, retinopathy, which affects the eyes and nephropathy, which compromises the kidneys.

The three occur simultaneously and are exacerbated by smoking and uncontrolled hypertension.

She noted the numbers of locals who have lost their sight, or suffer chronic kidney or foot disease, but now have good control of their diabetes.

“The tragic thing is that these complications are preventable.”

“They knew what to do, and they’re finally doing it, but if they had lived a healthy lifestyle from diagnosis, and as advised, then they wouldn’t be in this predicament… You can’t undo 10 years of bad diabetes control.”

In addition to her three- to five-year plan, Dr Fountain has a 30-year plan in mind, which she said might be more appropriately referred to as ‘goals’.

She said: “It’s going to be very difficult to change somebody who’s 50, [who] grew up a certain way. We’ve got to go into the schools and educate children and hopefully, parents.

“The education has to start at school age, so I will be working with the Department of Health, the Department of Education and the Bermuda Diabetes Association to achieve this.” 

King Edward VII Memorial Hospital is in the process of opening a diabetic foot clinic.

The clinic will offer a multi-disciplinary approach to care with consults by Dr Fountain and attention by a diabetic specialist nurse, chiropodist and wound care nurses and physicians, including lead clinicians, Dr Edward Schultz and Dr Basil Wilson.

“We liaise with surgeons, radiology, microbiology, and each patient gets all of those aspects assessed.”

Noting that healing of an ulcer or infection is significantly delayed if the patient has poor diabetes control, Dr Fountain said: “This team will hopefully, in the long term, reduce amputations because of the coordinated care.”

The message that diabetes is not a death sentence and that amputation and dialysis are not inevitabilities of the disease must be constantly reinforced, according to the doctor.

But three things have to occur for long-term health. Diabetics must live a healthy lifestyle by foregoing those foods, drinks and behaviours that are detrimental to them. They must take their medications regularly to improve their glycemic or blood sugar control and ensure that blood pressure and cholesterol levels are within the safety range, and they must keep in touch with their physicians.

“My role,” Dr Fountain said, “is to give people hope and empower them to make the right choices… Over the 30 years of my career here, I sincerely hope to see a difference in my community with regards to health outcomes and the incidence of diabetes itself”.

November 14  is World Diabetes Day. But throughout Diabetes Awareness Month, the Department of Health will collaborate with the Bermuda Hospitals Board and Bermuda Diabetes Association to present a symposium focusing on foot care. Events will be directed toward the public, diabetics and their caregivers and health care professionals.