Innovating to Tackle the Diabetes Epidemic in India

Dr. V. Mohan, Chairman, Dr. Mohan's Diabetes Specialities CentreDr. Mohan’s DSC is one-of-its-kind one-stop comprehensive diabetes treatment facility specializing in the areas of Cardiology, Diabetology, Dietetics and Physiotherapy and offers services like Specialized Diabetic Foot clinic, Daily patient education classes, Diabetic Pharmacy and many more.

In the last 3-4 decades, India has seen a rapid explosion in the number of people with diabetes and currently there are over 72 million people with diabetes and 80 million with pre-diabetes, according to the International Diabetes Federation (IDF), which has also confirmed that India will soon have the largest number of people with diabetes in the world overtaking China. All these call for interventions & actions at multiple levels to tackle the epidemic of diabetes in India.

The first challenge is to provide adequate care to those with diabetes in India. Luckily, basic medicines for diabetes are available in most parts of India and in a recent paper in the ‘Lancet Diabetes Endocrinology’ based on the Perspective Urban Rural Epidemiology(PURE) study, we showed that Metformin was available in 100 percent, sulphonylureas in 82 percent, and insulin is in 76 percent of pharmacies, in India. Our first duty is therefore to ensure at least these basic drugs are available in all healthcare outlets in urban & rural India, in all states of the country.

The largest nationwide ever done on diabetes called the ICMR-INDIAB Study for which we are the national co-ordinating centre, has shown that the diabetes prevalence is now increasing rapidly even in rural India. Thus,specialised diabetes care should be available in all parts of the country. This is where the first innovation comes-in. In the Chunampet Rural Diabetes Project, we showed that using Telemedicine we could reach diabetes prevention and healthcare to a population of over50,000 people in 42 villages in Kancheepuram district in Tamil Nadu using a mobile van(1,2). Specialists based at our centre in Chennai were able to offer specialist diabetes and eye care in remote villages in Tamil Nadu. We also found that only two percent of people needed to be referred to Chennai for management of advanced complications of diabetes, for example, laser photocoagulation for eyes or diabetic foot surgery. This is one technological innovation which can be used very effectively as India is the IT capital of the world.

While doing research on the causes of the rapid rise of diabetes, we found that in South
India, polished white rice with its very high glycemic index, and in the North India refinedwheat were the major contributors, apart from decreased physical activity. We therefore started collaborating with agricultural scientists, and after several years of research made a breakthrough. We were able to innovate and produce a high fibre white rice with a low glycemic index, first-of-its-kind. This rice has become very popular and our studies have shown that it helps to improve the diabetes control. It has also found wide acceptance in the society and is available in many of the supermarkets.

"A person with diabetes looks after the diet, exercise regularly, reduce stress, and reduce weight and appropriately go for a health check-up regularly and take all medicines regularly"

Another innovation which has come from India is in the field of diabetic retinopathy screening where several low-cost fundus cameras have been developed which are less than 25 percent of the cost of the imported fundus cameras. We showed that not only are these cameras as good as the much more expensive imported cameras, but also that using artificial intelligence software, we can detect diabetic retinopathy with a very high sensitivity and specificity(3,4). This means that now we can screen the eyes of all patients with diabetes even at remote corners of the country. Images can be sent through email or whatsapp to specialists who can grade the images and send it back to the field in a matter of minutes.

In the areas of prevention of diabetes also great strides have been made. The Diabetes Community Lifestyle Improvement Program(D-CLIP)showed that more than 30 percent of people with pre-diabetes can be prevented from getting diabetes by simple lifestyle measures, such as healthy diet, increasing physical activity and weight reduction, wherever applicable(5). We are now using mobile health(i.e.,using the mobile phone)to see whether these messages can reach a much wider section of the community. Assuming that diabetes can be prevented in 25-30 percent of people with pre-diabetes, this would mean that several million cases of diabetes would be prevented.

Prevention of diabetes possible at four levels as discussed below:
1.Primordial prevention attempts to reduce the risk factors for diabetes, for example, reducing or preventing obesity to reduce the future risk of diabetes.

2.Primary prevention targets people who are in the stage of 'prediabetes' to prevent the onset of diabetes. All people with prediabetes should be regularly screened & encouraged to pursue a healthy life-style, including a healthy diet, adequate exercise and weight reduction where appropriate in order to prevent diabetes.

3.Secondary prevention defined as preventing the complications of diabetes in those who are already diagnosed to have diabetes. This can be achieved by meticulous control of diabetes with the help of diet, physical activity, lifestyle modification & antidiabetic drugs as indicated. In fact control should include holistic care and beyond glycemic control,i.e., control of blood pressure, lipids and others.

4.Tertiary prevention of diabetes is aimed at limiting physical disability and rehabilitation measures in those who have already developed some degree of diabetic complications and preventing them from going into the end stage of these complications.

A person with diabetes looks after the diet, exercise regularly, reduce stress, and reduce weight and appropriately go for a health check-up regularly(at least 3-4 times a year) and take all medicines regularly. Why then would they not have the chance of living up to 100 years of age? These are indeed exciting times in diabetes and I am happy that we in India are taking the lead in several of the innovations in diabetes healthcare, prevention and in research.