Diabetes care in India: Battling the ‘sweet’ menace

June 2010

Over the past few years, the introduction of new diabetic testing devices, insulin delivery systems and novel drug classes has metamorphosed the diabetes management approach for many diabetic patients. Saloni Vora provides an insight into these developments and enumerates the challenges that India needs to overcome in order to reduce the country’s diabetic burden.

In recent years, the number of patients being diagnosed with diabetes has increased at an alarming rate. Currently, this chronic metabolic disorder is spreading fast in the urban world and is viewed as one of the major threats to human health, besides hypertension.

Current scenario

It was only recently that China surpassed India to be the diabetes capital of the world, when a population-based national study revealed about 92.4 million adults in China being diabetic. At the same time, India’s diabetic burden is also reported to be quite high.

Informs Dr Dheeraj Kapoor, Consultant Endocrinologist, Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute, “The International Diabetes Federation estimates that the number of diabetic patients in India has substantially increased from 19 million in 1995 to 40.9 million in 2007, and this is projected to further increase to 69.9 million by 2025. Currently, up to 11 per cent of the country’s urban population and three per cent of rural population above the age of 15 suffers from diabetes.”

Dr Dheeraj Kapoor

This diabetic epidemic is closely related to the obesity epidemic and an array of factors that have been recognised  to fuel the high incidence rates of this disorder in the country. Avers Dr V Mohan, Chairman & Chief Diabetologist, Dr Mohan’s Diabetes Specialities Centre and Madras Diabetes Research Foundation, “Changing lifestyles, consuming more of junk foods, that are high in calorie, sugar and fat, decreased physical activity and increase in the stress levels are various factors contributing to an increasing number of patients being diagnosed with the disorder.”

Besides these, genetic predisposition is also  one of the major reasons for patients to suffer from diabetes. Dr Mala Dharmalingam, Professor, M S Ramaiah Medical College & Director, BEDRC,  explains, “The Asian Indian phenotype may be one of the other factors. Indians have a very high incidence of large waist circumference, also called central obesity, which results in more insulin resistance. Moreover, augmentation in the visceral abdominal fat is another reason for metabolic abnormalities like diabetes and cardiovascular risk.”

Innovations in diabetic testing devices

Although glucometers for monitoring blood glucose levels have been around for quite a while, special features have now been introduced in these testing devices to enable better service to the patient. Says Dr Kapoor, “The relatively new glucometers are easier to use, less painful in nature and eliminate  coding requirements. Further, they also provide information on blood ketone levels in addition to glucose concentrations.”

Dr Vishal Chopra

In the view of many experts, Continuous Glucose Monitoring Systems (CGMS) are likely to become more popular in the next few years. These systems provide multiple glucose readings in a day, which in turn, assists the diabetologist to modify the insulin doses, if required. Suggests Dr Kapoor, “It is speculated that within the next decade, meters may be replaced with CGMS. Though these systems are very expensive currently, they have proved useful in determining the blood sugar profile over a 24-hour period. This feature of the system is likely to decrease complications in diabetic patients by limiting problems associated with hyperglycemia and hypoglycemia.”

Highlighting the other innovations in these devices, Dr Dharmalingam says, “Many electronic diabetic testing glucose monitors are available with speech adapters, thereby allowing these patients having vision problems to hear their blood glucose test results.” She adds, “Another glucose monitor that was recently approved by the Food and Drug Administration (FDA) reads blood glucose levels through the skin every 20 minutes and requires to be calibrated only twice a day with a finger prick blood sample.”

In addition to these developments, medical devices that can help measure & compute blood glucose levels by non-invasive methods are also being commonly used. Dr Dharmalingam explains, “These devices are said to compute the blood glucose levels based on the analysis of various physiological parameters that are involved in the generation of metabolic thermal energy, and would therefore eliminate the need to obtain a blood sample. The other non-invasive methods include a sensor watch and glucose from corneal sensors.”

Treatment trends

Dr Mala Dharmalingam

Newer & better drugs: Over the past few years, many new drug classes and treatments have been launched to facilitate better diabetes management.  Avers Dr Vishal Chopra, Diabetologist, Dr L H Hiranandani Hospital, “Newer classes of drugs like incretins that help in glucose simulated insulin release are now available. Also, these drugs do not induce hypoglycemia nor do they result in weight gain. On the contrary, they may result in weight loss. Byetta (Exenatide) and recently launched Victoza (Liraglutide) are examples of these drugs and are generally administered as injections.

DPP4 inhibitors are another class of drugs that are widely used now-a-days. Adds Dr Mohan, “The class of drugs known as DPP4 inhibitors, such as Sitagliptin, Vildagliptin and Saxagliptin have been making waves, as they represent a new form of oral drug therapy.” Moreover, these medications are also weight neutral and unlikely to induce hypoglycemia.

Avers Dr Kapoor, “The newer insulin pens (disposable and permanent pens) are very easy to use, almost painless, portable and discreet in nature. They are also useful for young diabetics, who need to be given insulin at school. Moreover, an accurate dose can also be pre-set and, this feature is particularly useful for diabetic patients who have impaired vision.”

Insulin pumps are the other insulin delivery systems gaining popularity in recent times. Also referred to as artificial pancreas, these pumps represent a more physiological way of administering insulin.

Handling diabetic complications

Sophisticated techniques, equipment and drugs have been introduced to tackle these problems in a better way. Taking forward this discussion Dr Mohan opines, “The treatment for diabetic eye diseases has improved and laser photocoagulation has become a mainstay of the treatment.  Even for advanced diabetic retinopathy cases, vitrectomy and other treatments are available. Also, there are many novel medicines available today that enable better management of diabetic kidney disease.”

In Dr Chopra’s opinion, medications like Angiotensin Converting Enzyme (ACE) inhibitors, Angiotensin II Receptor Blockers (ARBs) are used to reduce the risk of developing end-stage kidney diseases.

According to Dr Kapoor, comprehensive diabetic care can be effective only if it involves the efforts of a multidisciplinary team, which comprise of the diabetologist, diabetic educator, dietician, ophthalmologist, nephrologist and podiatrist. He adds, “In big diabetic centres across the world, every diabetic patient is annually screened for the various complications and accordingly referred to the appropriate expert within the team for further management. These complications can also be prevented by ensuring tight glycaemic control and treating modifiable cardiovascular risk factors such as blood pressure, dyslipidaemia and obesity.”

Challenges

As the number of diabetic patients continue to be on the rise in India, there are various challenges that India as a country faces that need to be addressed.  Dr Dharmalingam suggests, “In India, timely identification of high-risk individuals is extremely important in order to curb the spread of diabetes. This can be done by spreading awareness regarding the importance of routine screening for diabetes and its complications through public lectures, audio visual presentations, distribution of educational pamphlets etc.”

Agrees Dr Chopra, “Presently, the health check-ups and awareness programmes are mainly being targeted to the urban areas. As a result, the benefits of these activities are not accessible to the patients living in the villages. Popular sources of information like media (print or visual) can be used to reach out to these areas.”

Dr Kapoor opines, “All along budgets have been set aside for tackling infectious diseases and malnutrition. The Government of India would need to consider diabetes as an epidemic disease and allocate funds accordingly from the Union Budget in tackling this wide spreading disorder. Compulsory free annual screening for all above the age of 35 along with educating public & primary care physicians about the disease and its complications are some of the measures that need to be taken.”

Early diagnosis:

According to Dr Mohan, this practice requires massive screening efforts in order to identify those with pre-diabetes. In this context, the Indian Diabetes Risk Score (IDRS) developed by Dr Mohan and his colleagues at the Madras Diabetes Research Foundation (MDRF) has proved very useful. By asking three simple questions namely, age, family history related to diabetes and details of physical activity & a simple waist measurement, those having diabetes or pre-diabetes in the community can be easily identified.

Future developments

Research is underway in treatment areas like stem cell therapy and immune modulators. Explains Dr Kapoor, “Stem cells are early cells that have the ability to grow into any type of cell. On the other hand, immune system modulators such as Otelixizumab can be administered to treat Type I diabetic patients in their early stages in order to prevent destruction of their remaining insulin-producing beta cells.”

Going forward, newer medicines, insulins delivery systems, better methods of monitoring blood glucose levels on a continuous basis & insulin administration are likely to emerge that will help diabetic patients manage their disease in a better manner.