Technological Advancements, Challenges And Future Outlook Of Diabetes Care In India
After almost a century of progress in diabetes treatment, people with diabetes are living healthier and longer lives. However, this progress has not translated into effective prevention of diabetes and the rise in the number of people with diabetes remains unchecked. While technology and medication have improved by leaps and bounds, relatively high prices still limit the availability of these innovations to most people living with diabetes.
Technological advancements in diabetes care
The past 10-15 years have been a watershed in the treatment of diabetes for two reasons. First, after 2008 Rosiglitazone scare, where the diabetes drug was suspected to have increased cardiac event risk, the US Food and Drug Administration (FDA) mandated that all future drugs for diabetes would need to prove their cardiac safety through a post marketing trial if they wanted to be sold in the US. In 2015, for the first time after this mandate, a diabetes drug Empagliflozin became the first molecule to prove cardiovascular superiority when used in addition to the standard medicines for diabetes. In the recent years, we have witnessed a literal flurry of diabetes drugs with proven cardiovascular superiority, almost all of them belonging to two particular classes of diabetes medicines –SGLT2 inhibitors (Sodium-glucose co-transporter-2) and GLP-1 (Glucagon-Like Peptide 1 Receptor) Agonists.. While this sounds attractive on paper, the main impediment to wider use of these medicines has been their high price since they are still sold under a patent and generic version of these molecules cannot be manufactured by law. The last couple of months have witnessed the launch of cheaper version of SGLT-2 inhibitors by a couple of Indian companies, even though these are drugs that are not backed by such robust evidence as has been demonstrated by the patented molecules. Hopefully, they will demonstrate similar benefits in real world experience.
The second innovation of the decade has been the slow and steady march towards digitalization of diabetes care, especially in the use of insulin. Newer and better pumps employing fuzzy logic and an automated algorithmic approach to insulin administration have become a reality and an artificial pancreas is not too far off on the diabetes horizon. A breakthrough has been the invention of low-cost continuous glucose monitoring via sensors implanted over the arm or abdomen that have the potential to eliminate finger prick checking of blood glucose.
Technological Challenges in diabetes care
However, many technological challenges need to be overcome before we can make full use of these advances. At present; continuous glucose monitors measure glucose levels in interstitial fluid rather than directly in the blood, resulting in a time lag before glucose levels are measured. Consequently, accuracy is not sufficiently reliable, with reported error rates of between 12% and 17%. Accuracy is likely to be lowest when blood glucose levels are low; hence, continuous glucose monitoring of interstitial fluid is currently recommended only as an adjunct to standard blood glucose monitoring.
In the past 5 years, genetic evaluation of diabetes has not only become common but also a lot more affordable. Now, basic evaluation for genetic forms of diabetes can be done for as low as 5-10,000 rupees, something that was unimaginable less than a decade ago. This opens the doors to precision medicine –customization of health care with tests and treatments tailored to an individual patient and his genetic make –up.
Future outlook of diabetes management in India
One area, where we have failed miserably as a country has been in the incorporation of diet and exercise in our treatment for diabetes. 2019 was the year of fad diets in India. Many people with diabetes have shown a huge interest in short-term keto diets and intermittent fasting for reversal of diabetes, while forgetting that any diet must be sustainable in the long term. A recent study by Indian Council for Medical Research indicates that India as a country is inactive with more than 54.4% of our population NOT engaging in any physical activity and less than 10% engaging in recreational physical activity.
The short-term outlook for diabetes in India remains unchanged in 2020 with possibly more incorporation of Continuous Glucose Monitoring (CGMs) into day to day diabetes care. However, the next five years will potentially witness the use of more cardiac and renal beneficial diabetes medications and an almost universal use of technology in monitoring and tracking of diabetes. Slightly farther on the horizon – maybe in the next 10-15 years will be the use of lower cost pumps, better sensors and the use of personalized medicine. However, the dream of diabetes reversal will remain a mirage until and unless we address the twin issues of inappropriate diet and non-existent physical activity. In the long run, individualized data can be used to predict which people are at risk to develop diabetes and to suggest dietary interventions, activity regimens and lifestyle choices of people at risk.
