Newer Medications Available Now Are More Effective With Lower adverse Effects: Dr Naval K. Vikram
India has the second highest number of diabetics in the world and the disease is now increasingly becoming apparent among young adults and adolescents. Dr Naval K. Vikram, Professor, Metablic Research Group of the Department of Medicine at the All India Institute of Medical Sciences (AIIMS) talks at length of the cures, precautions and new research findings on diabetes in a conversation with BW Businessworld’s Manish Kumar Jha
While the Covid-19 pandemic is an immediate threat to health, diabetes continues to be a killer disease that is fast spreading among the youth. In India, the number of diabetics is expected to rise from 77 million in 2019 to 101 million by 2030. Are you concerned?
India has the second highest number of patients suffering from diabetes in the world. This is a challenge, since we still have not effectively controlled the problems of undernutrition and infectious diseases. The variety of diabetes seen in children and adolescents is mostly Type 1, which is due to autoimmune phenomenon destroying the insulin producing cells of the body. Type 2 diabetes was earlier thought of as a disease associated with aging. However, the increasing prevalence of Type 2 diabetes among young adults, as well as adolescents, is alarming. Several factors such as increasing automation, changes in dietary patterns, decreasing physical activity and increasing stress may be contributory.
The early onset of diabetes not only affects our youth in their most productive years, but also exposes them to increased risk of developing chronic complications associated with diabetes which may affect several organs of the body. It also puts an economic burden on patients because of the very limited medical insurance coverage and high out-of-pocket payments for treatment. This often hampers controlling diabetes adequately, resulting in increased acute and chronic complications.
Diabetes is about chronic high blood sugar and systematic metabolic failure, leading to multi-organ failure and premature death. You have been leading such studies at AIIMS. What is the latest cutting edge research in this area?
Even though the main abnormality in diabetes is chronic high blood sugar, successful management of diabetes involves controlling not just sugar. There are other factors like good control of blood pressure, keeping lipids in check and reducing stress, which can go a long way in prevention of complications and premature death, and be helpful in leading a productive life with the disease. Now we have anti-diabetic medications (SGLT2 inhibitors, GLP-1 agonists and DPP4 inhibitors), which not only reduce blood glucose, but also have beneficial effects on other organs such as the liver, heart and kidney, organs commonly affected due to chronic high blood glucose.
Some of these are also helpful in reducing weight in obese patients. The availability of newer insulins, both long acting and short acting, has increased the flexibility of dosing and better control of blood glucose with lower chances of hypoglycemia. Advances in insulin pumps, or the ‘artificial pancreas’ has also led to better management of blood sugar control in children and adolescents with Type 1 diabetes so that they may achieve their full potential.
Have the remarkable technological breakthrough in medical science like the use of Machine Learning and AI made any significant difference to clinical solutions for a complex disease like diabetes?
Machine Learning and AI have made considerable contributions in the care of diabetes patients. Some aspects where this has been useful include prediction of development of diabetes, glucose monitoring systems, prediction of hypoglycemic events and alerts for actions to be taken, prediction of development of and early detection of diabetes related complications. The risk of developing diabetes may be predicted using clinical, biochemical and genetic data. Hypoglycemia is a common complication arising from tight control of blood sugar. The newer insulin pumps automatically adjust the insulin dose based on continuous glucose monitoring, which can predict the possibility of hypoglycemia.
Eye involvement is a frequent complication of chronic diabetes. It may not be possible for every patient with diabetes to be screened by an ophthalmologist. A recent advance in machine learning and AI has revolutionized the early detection of diabetic retinopathy. This type of fundus camera can be used by physicians in their clinics to recognize and classify the stage of retinopathy. This camera is a portable compact device which can be used anywhere and does not require that the eyes be dilated before examination. These are being used increasingly in our country.
Does the latest research indicate that the progression of the disease can be reversed?
Diabetes is the result of adverse metabolic processes in the body. In Type 2 diabetes the abnormal process starts about five to seven years before the disease is diagnosed, by which time about 50 per cent or more of the body’s insulin producing cells are already lost. Diabetes can be prevented and controlled but not ‘cured’. Several diabetes prevention studies in other populations as well as in the Indian population have shown that strict lifestyle measures can prevent the development of diabetes in at-risk individuals. ‘Reversing’ of diabetes means that one has brought one’s blood glucose in the normal range without the use of any medications by any approach. This should be considered as remission of the disease instead of cure. Strict adherence to diet and exercise practices (DIRECT study) as well as surgical procedures (bariatric surgery, metabolic surgery) can achieve reversal of diabetes. This also prevents development of diabetes related micro and macro-vascular complications. However, one must adhere to these approaches to maintain remission.
Your original research on certain plants and their effectiveness in treating Type 2 diabetes indicated mechanisms such as stimulating or regenerating the effect on beta cells. How effective is Ayurveda in treating diabetes?
Ayurveda is the most commonly practiced alternative system of medicine in India, as well as all over the world. It encompasses knowledge of life, known and unknown, and uses various herbal preparations for the treatment of diabetes. More than 800 plants are used as traditional remedies for diabetes, but unlike in modern medicine, few of these have been evaluated using modern scientific methods. These herbs may act by increasing insulin secretion, improving insulin resistance or promoting regeneration of insulin producing cells in the body. Some of the plants used in the treatment of diabetes are shown in the table alongside.
It must be emphasized that Ayurvedic medications may be useful in the early stages of the disease and may compliment the effects of modern medications. However, they may not be effective in situations of extreme hyperglycemia or the presence of complications.
There is widespread misinformation about diabetes and false claims by medical practitioners of reversing the disease through invented mechanisms. How dangerous are these malafide remedies?
As the disease is widespread, so are the claims of its cure/ reversal by practitioners of different systems of medicine. This may happen due to lack of awareness about the disease, social stigma and high cost of treatment. Someone offering a quick-fix solution at a cheaper cost will appeal to many. But one must remember that diabetes is a chronic disease with its pathogenesis involving multiple pathways. The disease can be controlled but not cured. Use of scientifically unproven therapies may not only be ineffective in managing the disease but may worsen the disease and lead to further complications. One must ensure that the treatment they are seeking is scientifically proven and is advised by a qualified practitioner and not a quack. Effective management of diabetes requires commitment on the part of patients and physicians with long-term goals.
Should not the Indian Medical Association look into these malpractices and regulate them?
Many patients may not be aware of the authenticity of the treatment they have been prescribed. This may be due to lack of education, information or access to an alternative healthcare facility. The medical associations should proactively look into such claims and report them to the appropriate authorities so that action may be taken against people making false claims about a cure.
With the rising trajectory of diabetes in India, there is a need for more effective health policy interventions. The National Health Policy 2017 aims to address the spread of diabetes, but has not had much success yet. Do the existing strategies to control the disease need to be revised?
The National Health Mission and the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) have given the framework for screening, early detection and management of diabetes and other NCDs. The main focus of our primary health services for long has been on prevention, detection and management of undernutrition and infectious diseases. Even though these problems have reduced over the years, they are still significant. Now the burden of NCDs like hypertension, diabetes, cardiovascular diseases and cancers is increasing in all socio-economic groups. Therefore, primary health services need to be oriented towards screening and early detection of NCDs.
In most surveys conducted in India to screen diabetes almost 15 per cent to 25 per cent individuals were detected to have diabetes. Many of these individuals were asymptomatic. Indian (RSSDI) as well as international scientific associations (ADA, AACE, EASD, IDF) have given guidelines for screening individuals with risk factors for developing diabetes. Screening for diabetes can be done easily using a glucometer in the community setting. A large proportion (about three-fourths) of patients with diabetes are managed by primary care, family and general physicians in our country. Only a small proportion of the population has access to a diabetologist or endocrinologist and that too mostly in cities. There is a need to educate and train primary care, family and general physicians about the recent advances in the management of diabetes and design modules that can be easily followed by them.
Lastly, based on your years of experience and research, what would you advise diabetics and those on the verge of turning diabetic?
Diabetes is a lifestyle disease and managing lifestyle is the cornerstone for treatment of this disease. Without lifestyle changes all medical treatments may become ineffective. Diagnosis of diabetes is not a death sentence. One can lead an active and productive life with diabetes and prevent the development of complications. Patients play an important role in the management of their disease by following the advice of the care providers.
In addition to the physician, nutritionist, diabetes educators and physical training instructors play an important role in the management of diabetes. In fact, with strict changes in diet and physical activity, one can control diabetes without medications. A combination of aerobic and resistance exercise is helpful in achieving good glucose control.
The newer medications that are available now are more effective with lower adverse effects, particularly hypoglycemia. Individuals who are obese, have positive family history of diabetes or women who developed gestational diabetes are at a higher risk of developing diabetes in future. In individuals with ‘prediabetes’, where blood glucose is higher than normal but not in the range for diagnosis of diabetes, there is ten per cent risk of development of diabetes per year.
Therefore, these individuals need to be careful and change their lifestyle to prevent the disease. Some individuals may be genetically predisposed to developing diabetes. Since we cannot alter our genes, we can alter our lifestyle to mitigate the risk of developing the disease or complications. Practices to reduce stress also play an important role in both prevention and management of diabetes.
