The need of the hour is awareness, at both the rural and urban level as diabetes is increasing at an alarming level
Dr Vishal Gupta, Director, VG-ADVANTAGE diabetes thyroid and endocrine Centre, Mumbai and Consultant Endocrinologist, Breach Candy Hospital and Research Centre, Mumbai in an interaction with Kalyani Sharma talks about his book ‘Beyond Type 2 Diabetes Mellitus’ & diabetes management
Please tell us about your book ‘Beyond Type 2 Diabetes Mellitus’
In the presence of the global diabetes-obesity pandemic, type 2 diabetes mellitus (T2DM) remains the single largest controllable non-communicable cause of morbidity and mortality in the world. It is soon becoming the leading cause of cardio-renal complications in the world. Diabetes (No: 9) has entered the top 10 causes of mortality in the world as per the WHO’ 2020.
The book addresses the differences between elevated blood sugar and diabetes; diagnostic cut-offs of T2DM in Indians compared to the Western population, modern techniques for monitoring blood glucose (SMBG, CMBG), newer concepts of maintaining blood glucose with the concept of “time in range”; molecular mechanisms behind development of diabetes, and a detailed outline of glucose lowering therapies developed based on the pathophysiology of diabetes. It discusses the ominous diabetic dyslipidemic triad (elevated bad cholesterols (LDL, triglycerides), low good cholesterol (HDL); ‘biomarkers’ beyond the cholesterols (LDL-C) that may help improve cardiovascular outcomes and the huge unmet need despite valiant efforts to reduce LDL-C and modern therapeutic options to reduce LDL cholesterol.
The book talks about therapeutic approaches to manage hypertension with and without diabetic kidney disease, detect heart disease and/or heart failure in an otherwise normal diabetic, the controversies and myths behind assessing kidney function, the great ‘mimickers’ of kidney disease, optimal strategies to diagnose and treat diabetic kidney disease. Management and ideal approach to treating diabetics with various rheumatic (joint) conditions, optimal use and avoiding complications of steroids. It discusses causes of immune dysfunction associated with diabetes with emphasis on various bacterial, viral, and fungal infections in poorly controlled diabetes, vaccinations and reason for frequent boosters, reasons for why diabetes serves as the optimal scaffolding for COVID-19 to unfold its wrath with diabetes having a 3-fold increased risk of mortality. It provides a detailed information of various cancer associated with T2DM and optimal screening methods. It highlights the relationship of various diets with glycemic and metabolic control, optimal cooking strategies of foods to lower the glycemic index (sugar raising capacity if a food), various types of diets (PALEO, KETO, INTERMITTENT, DASH, Mediterranean), artificial sweeteners (benefits and risks). It discusses diabetes in young, diabetes management in special situations such as kidney disease, liver disease and Ramadan (periods of prolonged fast), and finally risk factor management in diabetes with special reference to exercise (optimal type, duration, benefits etc.) cholesterol lowering and blood pressure management.
As per a recent report by ASSOCHAM on “Non-Communicable Diseases in India”, hypertension, diabetes & digestive diseases are among the top three most prevalent NCDs. What is the need of the hour in this direction?
Despite our vast improvements in the understanding and treatment of diabetes and blood pressure, which often co-exist in as many 8/10 patients, we have failed to translate this into clinical benefit. Heart disease occurs in India at least 10 years before a Westerner with diabetes and elevated blood pressure driving most of these complications along with elevated cholesterol. A rural North Indian study showed that patients with an elevated BP only 12.1% received BP lowering therapy and less than 5% were optimized with regard to their BP control (<140/90mm Hg). This is probably both due to the lack of knowledge of BP targets by the healthcare provider (HCP) and resistance on the part of the Indian that fears the side-effects of the tablets. More than 75% opt to postpone BP management thinking that it remains unimportant in the risk factor management for diabetes. Unacceptance to consume several medications per day remains another challenge that is faced by the HCP.
The need of the hour is awareness, at both the rural and urban level as diabetes is increasing at an alarming level. Awareness needs to be at multiple platforms: media (TV, newspapers} being represented by a role model {who preferably has diabetes, digital-mobile apps sharing pictograms of diabetes and it’s complications, social media sharing diabetes information by role-models preferably, bill-boards & posters on public transport; and needs to address children and adolescents (schools etc) with the main focus of obesity prevention (increase activity {30minute of exercise 5 days a week}, eat healthy {atleast 3-5 serving of fruits and vegetables, avoid sugar and saturated foods as much as possible} abstain from smoking). Once awareness of the disease spreads then free detection camps at local healthcare facilities offering expert advice for the affected with appropriate life-style interventions (diabetes-gyms, diabetes cafes) and affordable medication with incentives (discounts on health-insurance) should target for diabetes control be met and to maintain regular follow-ups based on incentives.
What are the major gaps and challenges that needs to be filled as far as management & prevention of diabetes is concerned?
Prevention of diabetes needs to start in the womb, with the gynaecologist insisting that the mother maintain optimal weight gain targets for both herself and the fetus (increased risk of diabetes in youth if foetal weight at birth is less than 2.5kg or more than 4kg. Indian mothers are encouraged to gain weight with the consumption of sweetened foods and fat-rich oils with the belief that the baby’s weight will also increase.
Maintain optimal weight and body fat which needs to be inculcated during childhood with adequate exercise, avoid inactivity (more than 1 hour/week of moderate/vigorous intensity {digging, dancing-folk dance and ballroom, mowing the lawn, jogging, swimming, tennis, soccer, and climbing stairs), limiting TV/screen viewing (less than 10 hours/week), maintaining a healthy dietary pattern (consuming at least five of the following foods: fruits, nuts, vegetables, whole grains, fish, and dairy products, and less consumption of refined grains, processed meats, unprocessed red meats, and sugar-sweetened or diet beverages). Food fadism, fast-food, treats offered to children for good performance in the form of sweets & savories, technology and social media indulgence, pressures of securing a good future have increased inactivity and imposed a mental and physical burden that has prompted weight gain and risk of developing diabetes in the youth and young adult.
Do you think, Indian policy framework on NCDs still needs strengthening?
In India 1 diabetic dies every 10 seconds. Approximately 10-11% of the urban population is diabetic of which more than 30% is undiagnosed while more than 50% of the rural population remains undiagnosed. The overall standard of care for diabetes in India is poor with considerable variability in the quality of diabetes care.
Access to services: Despite the existence of community health programs, the post of medical officers lies vacant in most healthcare center’s which in turn have poor laboratory facilities.
Affordable drugs: Essential drugs for the treatment of diabetes are still too expensive for a significant proportion of patients. Government controlled prices, and the absence of patent regulations have made the Indian market less attractive for foreign anti-diabetic drug companies. Hopefully with the new patent laws in place the market scenario will change and will become attractive for foreign companies.
Quality of service: In India there is considerable variability in the quality of care and the overall standard of diabetes care by HCP’s. Lack of standardization in laboratory techniques for the measurement of blood sugar levels and HbA1c levels further adds to the problems.
What are your views on the role of technology in diabetes management & prevention? Do you think the Indian healthcare system is still recessive towards adoption of new technologies?
Cost remains the most prohibited factor in the use of modern technology for glucose monitoring with an average quarterly monthly cost exceeding the average Indians yearly income. Digital glucose monitoring systems can help remove the need for laboratory glycemic monitoring in the long run. Besides eliminating the pain from frequent glucose testing using the finger-stick, information on low or high blood glucose attacks on a 5-minute basis can be achieved real-time that can greatly improve quality of life, improve medical management decisions, and reduce future cardio-renal complications. India stays way behind western countries as the machines are expensive, with poor-post-marketing machine management support programs that is left to the doctor or chemist to manage who often don’t understand the machine logistics.
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