DIABETES COMMERCIALISED!!

Hi everybody,

This is going to be my 100^th post on my blog. Gonna be a pretty long one..I have been thinking about future of diabetes!! No No not the diabetic patients, i mean physicians treating diabetes, what will be the fate of ever growing number of diabetes clinics. In the early 90’s Diabetes was considered a disease of the affluent, an urban epidemic but the current experience says Diabetes affects everyone , rich or poor, urban, rural or even the tribal... with a scenario like this it is obvious that there would be mushrooming of clinics and centres to treat this epidemic. End result is heavy competition! This has now come to such an ugly phase where labs start offering multiple tests at a very low rate. This situation makes me think

Have  all lab owners become too decent to forget all their profits and work for the benefit of public?

Lab reagents have all of a sudden become cheap?

If lab tests are so cheap were we all getting cheated all these years?

Or is there a real big compromise on the quality of reporting?

                Well the last one sounds logical to the reasoning mind.. if the 4^th option is the answer then how to deal with the situation in the absence of a WORKING centrally controlled monitoring system.. The answer is again simple! Don’t get fooled by ads. Go by the quality of lab. Am not supporting labs with exorbitant rates. I am just telling make sure you get good quality reports even if you pay a little more!

                Next most important aspect in Diabetes is the high degree of confusions and myths among the general population. Most common questions are

1)      When do i suspect diabetes?

2)      How to diagnose/ confirm diabetes?

3)      How does a patient go about doing this test?

4)      If am diabetic what do i do next?

5)      How does a patient monitor his/her diabetes?

6)      How much time to give your doc before switching over?

7)      How do you know that you are on the correct treatment?

8)      When do we use insulin?

There might be many more questions but i personally feel these 8 questions are more important in Diabetes. To answer all these questions without bias is a difficult task. Why??? Because each of these questions have some international guidelines as an answer. But in a country like India how much of these guidelines can be followed in routine practice? What do i do now? Well i won’t talk about guidelines here but will discuss these topics in a more practical way (obviously will keep all required guidelines in the back of my mind).

So lets start!

1)      When do i suspect diabetes?

(Every obese person is a Diabetic unless proved otherwise)

Age more than 40

Overweight  (height in cms – 100 = ideal body weight)

All people in desk jobs. Here i would like to add that guidelines say all those with less physical activity are at risk. With such rampant disorder like diabetes i feel this criteria is literally useless. Everybody should suspect diabetes whether he is a CEO of an company or Manual Labourer.

                                Family history of diabetes

                                Ladies who have had Gestational diabetes (treated at that time with just diet or with insulin. The risk is the same!)

                                Of course everybody knows, poor wound healing, blurring of vision & recurrent infections

`                               patients on steroids for other disorders like asthma, arthritis, post transplant patients etc

                                Patients with other endocrine disorders.

2)      How to diagnose/ confirm diabetes?

Tough decision both for the physician and the patient. Recent guidelines say we can use HbA1c as a diagnostic tool. But i would prefer to use the age old glucose tolerance test (GTT). Only difference is that i would prefer to take 3 samples instead of the conventional 5 samples.

Why should i prick the patient thrice?

HbA1c  estimated using HPLC method is most reliable. The fact is not many labs in our country use this method.

By doing GTT i can diagnose the earliest stage in prediabetes (known as IFG – impaired fasting glucose)

Personally i feel that by combining GTT (3intervals ) and HbA1c i can diagnose the patient’s glycemic status. If i advise the patient only fasting and post prandial blood sugar i have to repeat the test thrice to report diabetes with confidence. That would make is 6 pricks. So GTT once a year till the patient is diagnosed Diabetic is always better.

3)      How does a patient go about going this test?

Whenever you plan to do GTT – DO NOT GO ON DIET, DO NOT JOIN A GYM, SLEEP WELL BEFORE THE DAY OF TEST.  Follow a normal diet and exercise pattern. On the day of test go on empty stomach ( minimum 8-10 hours fasting). The technician will first draw bllod and then give you 75gms of glucose. DONT GULP IT ! drink it in sips. If you try to gulp it you will have nausea and vomiting. You can have water during the test period.

DO NOT SMOKE

DO NOT EXERCISE

DO NOT HAVE BREAKFAST

DO NOT HAVE TEA/COFFEE

DO NOT TRAVEL.

The second sample will be taken after 1 hour and again after 2 hours. So the total duration of test is 3 hours.

4)      If am diabetic what do i do next?

DO NOT PANIC! STAY CALM! YOU CAN MANAGE DIABETES!

In the initial consultation go through investigations of diabetes and also the baseline functions of organs that might be affected in Diabetes.

These include

Kidney

                Urine routine

                Blood urea

                Serum creatinine

                Spot microalbuminuria

Liver

                Liver function test

Blood profile

                HbA1c

                Lipid profile

                Hemogram

                Electrolytes

Heart

                Baseline ECG

Nerves

                Biothesiometry

Blood vessels

                Doppler

Eye screening

Dental screening

These investigations will help you and your doc to compare the changes from the baseline. This will go a long way in deciding the correct line of treatment. Whenever you check blood sugars always check fasting and post prandial blood sugars. Never estimate fasting or post prandial alone. The values may be misleading!

5)      How does a patient monitor his/her diabetes?

Very simple!

Buy a glucometer, calibrate it. Check your blood sugars twice weekly. Check blood sugar if you are feeling hypoglycaemic. Check blood sugars if you feel your sugar might be high.

Check HbA1c once in every 3 months

Check your lipid profile, spot microalbumin once in 6 months.

Check your liver function test, hemogram, urine complete, ECG , Doppler, biothesiometry once a year.

Get your eyes and teeth screened once a year.

Consider the cost involved in doing these tests as investments for your healthy future and not as mere expenditure.

Disclaimer – the periodicity of the test may vary depending on the medication you are taking for diabetes, hypertension and cholesterol.

6)      How much time to give your doc before switching over?

Tricky question!!!

                I might get beaten up by my colleagues for my answer! But what the heck!!

Here it goes

Actually there is no time frame .

Consider changing your doctor if

                He does not explain you Diabetes

                Does not give you proper instructions on diet

                Does not tell you how to take the tablets

                Does not mention & insist on the time gap between taking tablets and food

Does not tell you to repeat HbA1c every 3 months

Keeps changing tablets every visit despite good sugar control

Does not provide you a mode of contacting him in case of doubt. ( email or contact person in his absence)

Does not explain symptoms of hypoglycaemia and what to do at that time.

Now again coming back to time frame , before taking a decision ask yourselves one question...

have you followed all instructions given by your doc at all times? If you have neglected your doc’s advice even once then the mistake is on your part.

If you feel you have followed everything strictly then i feel 3 visits spaced 2 months apart with adequate investigations should put you on the right track.

7)      How do you know that you are on the correct treatment?

HbA1c  less than 7 or showing a decreasing trend

No or very minimal hypoglycaemic symptoms

Other parameters are also taken care of

No retinal changes during yearly reviews

No microalbuminuria

Treatment is always combined with insulin sensitizers ( unless contraindicated)

8)      When do we use insulin?

If your initial blood sugars are very high in type 2 diabetes. It is definitely possible to step down from insulin to tablets after satisfactory blood sugar control.

                Insulin is not addictive

                Insulin is not habitual, so don’t be scared!

Type 1 diabetes

Uncontrolled blood sugars

Pregnancy ( remember baby is more important)

Steroid usage

Planning for surgery

While treating ulcers , wounds, infections

Fluctuating sugars

There is also a view that using insulin intermittently will give some rest to the overworked pancreatic beta cells. There has been evidence that patients on intermittent insulin do better with oral tablets for diabetes.

                Thanks for your patient reading! I am sure that this post would have been helpful to atleast some of you. Every diabetic would have faced one of these questions some time or the other. Feel free to comment. I have presented this topic in a way i feel is simple. I hope all of you find it easy to understand.  Feel free to contact me for any queries at riyaz.arka@gmail.com