Access to diabetes care: If not now, then when?

Is there a real issue about access to diabetes care? Sir Francis Peabody, renowned physician, says that the secret in the caring of the patient is in caring for the patient. In other words, despite a plethora of options, Indian patients with diabetes still do not have access to comprehensive diabetes care. The answer could lie in the word ‘care’. What does care mean? Continuous Appropriate (time in) Range without Excursions. Even 100 years after the discovery of insulin, millions of people with diabetes around the world still cannot access the care they need.

The theme for World Diabetes Day 2021-23 is ‘Access to diabetes care -- If not now, when?”. India may not be the diabetes capital of the world, but we are getting there. The numbers say it all. In December 2019, India had more than 77 million patients with diabetes, according to IDF. And this number is projected to reach more than 100 million in 2030 and more than 134 million in 2045.

Among children (0-14 years), in 1000s, it was estimated to be 95.6 (including adolescents of 0-19 years, it was estimated to be 171.3). Can we reverse this trend and become the diabetes care capital of the world? One of the measures to control this is perhaps encouraging people to eat right. We seem to be a ‘carbivorous’ nation. Our intake of carbohydrates (65%) far exceeds what a balanced diet recommends (~55%).

We need to eat more protein (at least 15-20%), more fibre, and our intake of fat needs to be balanced between saturated, mono-unsaturated and polyunsaturated fat. And we need to ‘insulinize’ ourselves early, rather than later. As it is, many patients with diabetes get diagnosed when up to 50% of beta cell (in the Islets of Langerhans in the pancreas) function is lost. Why wait when it is already late? When we are diagnosed to have diabetes, our HbA1c is already close to 9%.

In such cases, the beta cells are stunned amid the glucotoxicity and lipotoxicity. This can be quickly reversed if one were to give the patient insulin early before the beta cells become permanently dysfunctional. After all, when a person is diagnosed to have diabetes, his/her own insulin is either not being secreted in appropriate quantities or there is resistance to its action. Is diabetes an insulin replacement disorder? There is an erroneous mindset that insulin is only for those who have uncontrolled diabetes, despite oral anti-diabetic drugs. Many are still scared of the prick although the insulin injections are now almost painless. If oral insulin becomes a reality, it will be prick-less and more physiological, as it will first enter the portal circulation, go to the liver, and then to the systemic circulation.

Be that as it may, one needs to provide holistic care for the person with diabetes as diabetes too is a systemic disorder. On a world map of diabetes, India and China look bloated. It is time to switch India to getting back into shape. Else, Indians will be sitting ducks for cardiovascular disease. We need to move as it helps in maintaining the excess weight loss due to dietary modifications. Let’s (inter)change before we have to. Change is constant (besides death and taxes), but in diabetes, it is not the constant hyperglycemia that damages, as much as the rapid post-prandial glycemic excursions. It is not the fat that we can see, but it is the fat that we cannot see, the Visceral Adipose Tissue (VAT), that we need to reduce.

(The writer is Vice-President, Head, Medical Affairs-India, Biocon Biologics)