Diabetes remains a major health problem in Alabama. The State’s Department of Public Health listed the ailment as the seventh-biggest cause of death here in 2019. The Centers for Disease Control and Prevention says one in five diabetes patients in the U.S. don’t know they have the disease. Denmark is working on its own rising caseload, and a possible solution.
Alabama isn’t the only place looking for new and better ways to treat this illness, however. Denmark—the small Scandinavian country nestled between Sweden and Germany–-is famous for LEGOs, bicycles, and a famous line from Shakespeare’s play “Hamlet.” It’s also a place where diabetes cases are on the rise, and local health officials are developing innovative ways to respond to this growing problem.
So I’m here in Aarhus—a small city located three hours west of Copenhagen—to find out about healthcare professionals who, working with the city government, are taking active roles to combat diabetes among at-risk populations.
My first stop was to Dr. Anneli Sandbæk at Aarhus University Hospital. Sandbæk is a trained GP and researcher, as well as a professor at Aarhus University. Since 2019, she’s been head of the Steno Center, a unit at the hospital dedicated to the care of diabetes patients and diabetes research.
“We are way behind the US still, but we can't be blind to that,” she says.
“In this region, we have perhaps 2000 persons that are younger than 40 years of age with type 2 diabetes. And we know that this group is worse off because they are probably having a higher risk of having complications or they have a higher risk of having complications at the time of diagnosis.”
Aarhus is Denmark’s second-largest city: only Copenhagen, the capital, is bigger. The growing trend of type 2 diabetes here isn’t considered a crisis. But it’s serious enough for Sandbaek and her colleagues to focus their research on the illness to stop it from becoming a public health issue. It’s a ten-year effort in partnership with the City of Aarhus that focuses on the patient profile where type 2 diabetes is becoming more common.
“We see here in Denmark, as you have seen in the US and in England and in other places, that you have more early-onset diabetes. So the people are getting younger and younger. And we all see that here in Denmark,” she says.
Diabetes comes in two forms: type 1 and type 2. Type 1 occurs when the patient can’t produce enough insulin, a hormone that regulates blood sugar. Type 1 patients require regular insulin injections to remain healthy. Meanwhile, type 2 occurs when muscle cells don’t absorb insulin properly. Type 2 can be managed by regular exercise and healthy eating habits.
At the Steno Center, Sandbæk helps manage the care of type 1 patients. They visit Aarhus University Hospital for insulin shots and treatment paid for by the country’s national health insurance system. Sandbaek says the new strategy she’s working on helps people help themselves.
“What we're actually doing is trying to work with the structure around the patients, so they are not that dependent on healthcare workers, and can actually manage their disease themselves. Instead of (as it was) a few years ago, they actually visit our patient clinic three to four times per year,” she says.
Sandbaek says the goal of Aarhus’s new strategy is to reduce hospital visits to once a year. Four hundred and fifty patients are taking part in this program. If participants have no complications and are comfortable with fewer doctor visits, they’re allowed to proceed with this type of care. Sandbaek says there are safeguards to make sure everything is going safely.
“We use lab results, we use the information about other diseases,” she says. “If the patient actually has more diseases than diabetes, then it's a complicated situation. Or does the patient report diabetes stress, for example? If we find out, we offer the patients a kind of help to manage that, because we know that it's very important that you are not stressed about your disease.”
This program includes both physical and psychological treatment, so patients in the study are not only feeling better, but have confidence in the new system. It’s a test for the city of Aarhus as well: the city is funding this plan to change the way diabetes is treated and is waiting 10 to 20 years to see if this holistic approach to patient treatment will pay off. Sandbaek says this plan is also unique because it’s not the doctors calling the shots on what’s needed, but rather the patients.
“For example, if there’s a mother who has a problem with her child, then they set the focus of the child instead of the mother,” she says.”In this collaboration, they have established a very close relationship with communities and some civil organizations, especially in those areas of Aarhus where there is a high rate of persons with type 2 diabetes and related complications.”
Those most at risk of diabetes in Denmark tend to come from low-income minority communities. These often include recent immigrants from countries like Turkey and Iran. Sussie Østerby knows these vulnerable communities well. She works with them at Globus1, a healthcare and community center located in the Aarhus suburb of Gellerup.
Sussie manages the focus groups within the larger study. These gatherings are safe spaces where locals can connect with each other and learn how to cope with their condition. There’s an interview process before anyone can participate in a group. Most of those who enter the program are women. Individuals participate in a focus group for one year.
“One of the patients was saying, ‘When I came, I knew most of the things that you have taught me, but I didn't do any. It's different when we do it together, and when we learn together, it's different.’ So maybe they feel more obliged,” Sussie says.
“It's another thing to learn in a group, I think, and to change your habits in a group, and you can discuss how this is difficult, or I did it this way, and stuff like that.”
The groups’ biggest benefits to participants? Learning healthy habits, like cooking and group exercise.
“We will go shopping together, we will do cooking together, so you learn to see how much is a ‘little’ oil, and ask, ‘Do I like these special vegetables cooked in the oven?’ and things like that,” Sussie says.
Exercises include floor-based maneuvers like wheel warm-ups, stretching, and push-ups. “It’s not old-fashioned exercise, but it's more playing, and also this target group, maybe they are not used to doing exercise in sports, training, or whatever,” Sussie says.
Another important aspect of the focus groups is learning to navigate a new and unfamiliar healthcare system where the language barrier can be a problem.
“When you don't speak enough Danish, there's a big risk that you will misunderstand things,” Sussie says. “So we can understand if you think, ‘Well, I know I have to go to the dentist, or I know I have to go and have my eyes checked, but I don't know how to book the time,’ we will be able to help people doing that. So we are like a kind of follow-up from the general practitioner and that is why working together is very important.”
Sigrun Bjørnsdottir, age 55, is a participant in a focus group at Globus1. She’s from Iceland, and works odd jobs around Aarhus. A type 2 diabetes patient, she says she’s “absolutely” found the group work to be helpful for managing her condition.
“For one thing, you’re all coming from the same standpoint. You’re getting more support than you would otherwise, because you’re all going through it together. I’ve laughed a lot—it’s not always something you do at home,” she says.
“I’m really surprised I decided to take part in this. I’m not the exercising type! I’ve been trying different things, but nothing works. This has worked, and I really look forward to exercising, which is bizarre for me.”
If this pilot study succeeds, there could be applications to how diabetes is treated in rural Alabama. Rather than driving up to an hour and a half to see a doctor, as is often the case, community-based care could be the new norm for patients in these situations.
Coming away from my journey of discovery into Aarhus’ diabetes care program, it’s striking to observe the level of government investment in public health that has a tangible impact on the lives of everyday people. It’s also remarkable that the city doesn’t expect to see the results of this study for up to 20 years.
Could such a program be replicated in Alabama? To succeed, we would need to cultivate a mentality of long-term improvements over short-term political gain. Treatment of diabetic patients would need to be front and center of the program, with real improvement to their quality of life as the measure of its success.
Denmark is renowned internationally for having a high standard of living and ranking among the happiest countries in the world. After learning about this diabetes program, I can see why: if this new way to treat diabetes works, Denmark may just stay that way.
This feature was made possible through a grant by the Caring Foundation.
