Transforming India from the world’s Diabetes Capital to Diabetes Care Capital
In less than a thousand days we will be celebrating the 100th anniversary of the first injection of insulin to a person. On 11 January, 1922, 14-year-old Leonard Thompson of Toronto was inoculated with insulin extracted from the pancreases of dogs. Thompson was suffering from Type 1 diabetes, which until then was a death sentence. The end would come within months or even days.
In Type 1 diabetes the body produces little or no insulin, the hormone which takes glucose or sugar, resulting from the breakdown of carbohydrates, from the bloodstream into the cells of the body. It afflicts a minority and is known as juvenile diabetes, though more adults than children have it. In Type 2 diabetes, which is more prevalent, the body does not use insulin properly and hence cannot keep blood sugar at normal levels.
Before insulin was discovered and isolated, those with Type 2 diabetes were put on starvation diets to control blood sugar levels. The few months or years they gained were punishing.
The discovery of insulin, the mass production of the hormone first from pigs and now from genetically-engineered microbes, and the invention of drugs to regulate blood sugar levels has delayed disability and death due to diabetes.
But diabetes has assumed the proportions of an epidemic. The World Health Organization (WHO) put the number of those suffering from it globally at 422 million in 2014, up from 108 million in 1980.
Fifty-two million adults, or 7.1 percent of India’s population aged 20 years and above, have the disease. That’s the size of the population of South Korea. The incidence varies from 4.3 percent in Bihar to 10 percent in Punjab. The affliction is higher in urban India – 11.2 percent than in rural areas – 5.2 percent. Another 10.3 per cent, or 73 million adults, are at the pre-diabetes stage.
States with higher GDP seemed to have a higher incidence of diabetes. In Chandigarh, it was 13.6 percent. In rural areas too, diabetes were prevalent in individuals belonging to higher socio-economic status. In the urban parts of Chandigarh, Maharashtra and Tamil Nadu, the prevalence was also higher in persons of lower socioeconomic status.
These are the findings of the largest epidemiological study conducted by the Indian Council of Medical Research (ICMR) and INDIAB. They are based on capillary oral glucose tests administered to a representative sample of 57,000 adults across 14 states and a union territory between November 2008 and July 2015 in three stages. The sample represents 363.7 million or 51 percent of India’s adult population. The study is yet to be done in the remaining states including Delhi, Kerala, Goa and Uttar Pradesh.
Obesity, age and family history were the main factors driving the diabetes “epidemic,” though male sex and hypertension were also found to be independent risk factors.
Another study estimates the number of diabetics in India higher at 80 million. In 17 million of them, the disease is uncontrolled. Of those on therapy only 10 percent achieve active control.
Going by the ICMR study, India’s share of diabetics is 12 percent. It seems to be diabetes capital of the world. For pharmaceutical companies, medical device makers and hospitals, it is a huge opportunity for drugs, devices, hormones and therapies, at the heart of which lies the patient. How do we make India the diabetes care capital of the world?
The WHO emphasises early diagnosis. The longer a person lives with undiagnosed and untreated diabetes the higher the changes of complications like heart attack, stroke, kidney failure, leg amputation, vision loss, never damage – and premature death. The WHO says early access to basic diagnostics such as blood sugar testing should be available at primary healthcare centres. There should be systems for referrals and back-referrals as patients will need specialist assessment and treatment for complications.
Fortunately, with smart devices and mobile telephony it is possible to personalise diabetes management. Currently patients with strips and meters to measure blood sugar levels do so episodically. Unless these readings are made available to their doctors frequently and regularly, they will not be to regulate drug dosages or achieve control.
Technology now allows patients to take readings of their blood sugar levels after every meal for the required number of days and pass on the information to their doctors who can prescribe the appropriate medications. If they need less frequent observations, they can photograph the blood-testing strips and post it to their doctors with smartphones. All this information can be stored for ready retrieval.
It’s been our experience that testing for blood sugar levels tends to happen when a person has been diagnosed with diabetes, when they are warned of regular needle pricks and when they are put on insulin. The scare wears off with time and complacency sets in.
Such unsafe behaviour can be avoided with education and awareness which can happen with regular monitoring and measurement. Diabetes control, especially of Type 2, is a habit of the mind. Auto-suggestion can result in lifestyle changes.
At the wider level, we need to team up with governments and organisations so that their limited budgets can be better used to prevent or control diabetes rather than spent on the treatment of diabetes–induced diseases. At Roche Diabetes Care we have paired up with the Uttar Pradesh government to monitor pregnancy-related diabetes. It is our experience that if diabetes at the stage of pregnancy is not checked, there are high chances of the mother developing diabetes post-pregnancy. The new born is also likely to become diabetic within the first two decades of birth. We would like to team up with primary health care centres and hospitals so that people become aware of diabetes and take early steps to prevent or control it. We have developed algorithms that can predict the chances of diabetics developing chronic kidney disease.
The ICMR study says the prevalence of diabetes is likely to rise among those of low socio-economic status in urban and rural areas. This, it says, warrants effective preventive and control strategies. Public healthcare budgets in India are low and finite. By partnering with technology providers, the public healthcare system can prevent the onset of diabetes in people who are the most likely candidates, and also delay limb, nerve and organ diseases in those who have contracted it. Large-scale screening and monitoring can help in the development of treatment protocols and customised therapies. As we head towards the centenary of the discovery of the blood-sugar controlling hormone, our aim should be to ensure that fewer people need insulin supplementation, and those on it, do not skip it.
