The Increasing Type 2 Diabetes In Young And Adolescents Is Alarming In India: AIIMS Prof Dr. Naval K. Vikram

On Health Special: Latest research and clinical breakthrough in containing diabetes in India.

While the Covid 19 Pandemic is our immediate threat which we will overcome, Diabetes remains one of the biggest and fastest growing killers toady. In India, the number of people with diabetes is expected to rise from 77 million in 2019 to 101 million in 2030. What are your concern as it is spreading thick and fast among the youth, causing enormous medical and social burden?

Naval K. Vikram: 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 body. Type 2 diabetes was earlier thought of as a disease associated with aging. However, the increasing prevalence type 2 diabetes in 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 it also exposes them to increased risk of development of chronic complications associated with diabetes which may affect several organs of the body. It also puts economic burden on patients due to very limited medical insurance coverage and high out-of-pocket payments for the care of their disease. This often hampers the adequate control of diabetes resulting in increased acute and chronic complications.    

Diabetes is all about chronic high blood sugar and systematic metabolic failure, leading to multi-organ failure and premature death. You have been leading such studies at India’s leading AIIMS. What is your understanding on the latest cutting edge research in this area?  

Naval K. Vikram: Though the main abnormality in diabetes in chronic high blood sugar, successful management of diabetes is not only controlling 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 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 can achieve their full potential. 

Has the remarkable technological breakthrough in medical science like the usage of machine Learning and AI made significant difference in clinical solutions for such complex disease like diabetes? What is the level of such research in our country in the field of Medical sciences?

Naval K. Vikram: 

Machine learning and AI have made considerable contributions in care of diabetes patients. 

Some of the aspects where this can be 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 development of diabetes may be predicted using clinical, biochemical and genetic data. Hypoglycemia is a common complication arising due to 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 the eyes to be dilated before examination. These are being used increasingly in our country. 

Has the latest research shown any indication that disease progression can be reversed?

Naval K. Vikram: Diabetes is the result of adverse metabolic process in body. In type 2 diabetes the abnormal process starts about 5-7 years before the disease is diagnosed, by which time about 50% or more of 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 his/her 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 the development of diabetes related micro- and macro-vascular complications. However, one must adhere to these approaches to maintain remission.   

Your original research on certain plant and its effectiveness in treating type 2 diabetes talks about the Mechanisms such as the stimulating or regenerating effect on beta cells. What do think of the Ayurveda in the context of modern science for diabetes?

Naval K. Vikram: 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 about 800 plants are used as traditional remedies for diabetes, but unlike the 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 body. Some of the plants used in the treatment of diabetes are given below:

Plant Based Treatment for Type 2 Diabetes --Ayurveda and Medicine

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 are widespread misinformation about Diabetes--and claims by medical practitioners to reverse the disease through their invented mechanism.  How dangerous is such falsehood against the scientific fact?

Naval K. Vikram: 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 involves 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 patient and physician and having long-term goals.  

Does it not require the Medical association to look into such claims and regulate it?

Naval K. Vikram: Many patients may not be aware about the authenticity of the treatment that 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 can be taken against people making such false claims.  

AIIMS New Delhi

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 but without much success. According to you what is needed to revamp the existing strategies and devising new measures against such malaise?

Naval K. Vikram: The National Health Mission and the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) has 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. Though the prevalence of these problems has reduced over the years, it is still significant. Now the burden of NCDs like hypertension, diabetes, cardiovascular diseases and cancers is increasing in all socioeconomic groups. Therefore, the primary health services need to be oriented towards screening and early detection of NCDs. In most of the surveys conducted in India for screening of diabetes it has been seen that almost 15-25% 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 of individuals who have risk factors for diabetes. Screening for diabetes can be done easily using a glucometer in the community setting.

 A large proportion (about 3/4th) of patients with diabetes are managed by primary care, family and general physicians in our country. 

Only a small proportion of population has access to a diabetologist or endocrinologist and that too mostly in cities. There is a need to educate and train the 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 for those who are affected and those who are at the fringe of acquiring such deadly disease- -diabetes? Could you sight best practices and habits?

Naval K. Vikram: 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. Patient has an important role in the management of his/her disease by following the advice of the care providers. In addition to the physician, nutritionist, diabetes educator and physical training instructor play an important role in 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 10% 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 development of 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 the prevention as well as management of diabetes.