The growing problem of diabetes
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4921 (Published 22 November 2018) Cite this as: BMJ 2018;363:k4921
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With diabetes affecting half of the population of the world, it becomes a vulnerable concern globally. India with more than 62 million diabetic individuals topped the world with the highest number followed by China (20.8 million) and the USA (17.7 million). The major factor which is linked with it is lifestyle and obesity in the high-income groups. Owing to non-availability of time and tedious lifestyles, the population is heading to fast and processed food. According to studies, excess calories, mainly from refined carbohydrates and consumption of white rice due to its high glycemic index which spikes the insulin levels, are strongly linked to a risk of type 2 diabetes in the Indian population. The high prevalence of diabetes: risk factors and lifestyle diseases found in wealthy states such as Punjab, Tamil Nadu and Kerala with GDP more than 1.3 lakh respectively. The states have also the highest share of other diseases like cardiovascular diseases, obesity and high BP, showing the correlation between increased income levels and illnesses caused by lifestyle changes [1].
Since India has a higher prevalence of diabetes compared to western countries, diabetes may occur at a much lower body mass index (BMI) in Indians as compared with Europeans. Therefore, relatively lean Indian adults with a lower BMI may be at equal risk to those who are obese. Moreover, Indians are genetically predisposed to the development of coronary artery disease due to dyslipidemia and low levels of high- density lipoproteins. Hence these determinants make Indians prone to development of complications of diabetes at an early age (20- 40 years) at a faster rate [2].
We agree with the author that the low-carb and high-fat diet may be the solution to the problem of the growing burden of this disease. Unless Government takes the initiative in this regard, clinicians might not go for advice on dietary changes and prefer intensive medication. This attitude might be due to over propagation of pharma companies to earn profit by not taking any concrete steps in this regard.
References
1. https://www.firstpost.com/india/diabetes-is-indias-fastest-growing-disea...
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920109/
Competing interests: No competing interests
It is known that the function of beta cells can be exhausted by excessive stimulation. On the contrary, keeping insulin secretion at rest prevents the exhaustion. The insulin hypersecretion contributes to an increase in body weight. This indicates that, other things being equal, drugs acting without stimulation of insulin secretion are preferable: https://www.oatext.com/recent-advances-in-the-drug-therapy-of-type-2-dia...
Competing interests: No competing interests
It has recently been reported in the media that the Medicines and Healthcare products Regulatory Agency (MHRA) is considering the possibility of restricting the availability of laxatives over the counter because of the risk of their abuse by people with eating disorders. Furthermore, they want a warning on the packaging that the long term use of laxatives might be harmful. However, this initiative could have serious unintended consequences for patients with irritable bowel syndrome (IBS).
Patients with the more intrusive forms of constipation type IBS (IBS-C) usually require laxatives on a regular and indefinite basis. Many have learnt this strategy for themselves and usually buy the medication over the counter especially as, depending on the dose required, it is often cheaper than a prescription.
If they start having to have a prescription they could run into problems. This is because generations of doctors, including this one, have been wrongly taught that laxatives damage the bowel and should only be used on a short term basis. Consequently, many general practitioners are reluctant to prescribe them or even refuse to prescribe them altogether. We are constantly having to reassure GPs that the long term use of laxatives is completely safe in patients with IBS-C.
Contrary to what the government want written on laxative packaging, there is absolutely no evidence that modern laxatives available over the counter, taken at therapeutic doses, damage the bowel in any way. Some, such as macrogol, can even be used safely in pregnancy. Conversely, if an IBS-C patient doesn’t take them they will almost inevitably deteriorate to the extent that some may even need hospital admission for faecal impaction.
Thousands of IBS-C patients are currently quietly managing their symptoms without having to bother their GP. This initiative will cause unnecessary anxiety if they read on the packaging that long term use could be harmful. Moreover, it will place an unnecessary burden on GPs, some of whom, through no fault of their own as a result of improper training, may not be in a position to give appropriate advice. In addition, if they see the warning against long term use, they may be tempted to prescribe the vastly more expensive drugs that have been recently introduced for constipation or even refer the patient to secondary care. There are approximately 5.2 million adults in the UK with IBS, of whom approximately 1.7 million will have IBS-C, so the costs could be substantial.
It has been common knowledge for many years that some patients with eating disorders abuse laxatives but this initiative is only going to drive the way they procure them underground. This would also rule out the possibility of an observant pharmacist or supermarket member of staff suspecting the problem and in some cases hopefully pointing the person in the right direction. Perhaps we should be developing better ways of identifying and managing the serious problem of eating disorders rather than coming up with a ‘one size fits all’ solution which could seriously affect the lives of another group of patients and worry them that the very medication that is controlling their problem is harming them?
Eating disorders can have a potentially fatal outcome but so can IBS, with 38% of patients attending secondary and tertiary care clinics contemplating suicide as a solution to their problem (1).
Reference:
1. Miller V, Hopkins L, Whorwell PJ. Suicidal ideation in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 2004;2:1064-8.
Competing interests: No competing interests
Dear Editor,
My compliments and regards to Dr. Fiona Godlee for this who has once again hit the nail on the head [1]. It’s for sure that the incidence and prevalence of Diabetes are on the increase. This lifestyle disease is on the rise and almost getting out of hand. In order to cope with this, there perhaps is a need to be looking at this sweet-sugary problem from some other facets and perspectives than whatever is being done now.
We have to start looking at it from patients' perspectives, care givers' viewpoint, the extra load on the healthcare providers, on the ever increasing scale of healthcare facilities required to be planned in order to meet the increasing, dwindling shared healthcare resources, increasing financial implications, etc. There is already a resource crunch with the huge waiting list for kidney transplant, atherosclerotic and cardiac problems, cataracts, amputations, etc, and the interplay with co-morbidities, especially in the elderly population. Some action is needed. We can’t continue to remain oblivious and easygoing any more. Towards this end, I suppose we do need to find windows of opportunity in the interest of our patients, before the problem grows out of hand. Can we consider some other issues which can possibly brighten up the prospects of managing diabetes just a little, maybe.
• Bioavailability of combination drugs should be calibrated and monitored regularly. There appears some degree of variation in bioavailability of antidiabetic drugs (as also in other drugs as well) produced by different pharmaceutical companies. Some conformity is needed.
• The issue of fake drugs must be dealt properly [2 – 9]. Not all drugs are fake, but some of them might be, which obviously does not help any patient in any way. It might also create undue adverse pressure upon even an experienced doctor who wouldn’t know why his or her medicines are not working as per expectations & experience. This may cause unwanted frequent changes in the choice of drugs and changes in regimes /prescription. Possibly some cases may also get erroneously labeled as ‘insulin dependent’ as a result of increasing dose levels and increasing numbers of oral anti diabetic drugs which fail to keep the blood glucose levels within the desired levels.
• Cost factor may not be of consequence to those well endowed, or those who are adequately insured for their medical problems, or wherever treatment facilities are available free of cost. For the rest, the cost factor could be a major issue for oftentimes use of alternative healthcare, failure in compliance, failure to get reviewed and tested in reasonable time frames. Therefore when we see the projection of the likely number of diabetic patients in the near future, it may be worthwhile to consider getting the drug prices lowered, as also the costs of tests. Home blood sugar monitoring could become cheaper, with costs of strips reduced and their shelf lives increased considerably so as to make the drugs and testing more affordable and within easy reach especially in the third world countries where diabetes is on the rise even in the economically weaker sections of the society [10].
• Undue haste in using new drugs should by and large be avoided. Recently we read about increase in incidences of amputations that were linked to a certain group of newer antidiabetic drugs [11].
• Treatment should be individualized to get better response and end results [12].
• Effective care and management of all co-morbidities simultaneously should be well planned and executed [13].
• Prudence requires that we must also start looking at what is possible within the given circumstances, rather what should be ideal. Some consensus therefore needs to be brought in so as to redefine the present pre-diabetic and diabetic levels, which were slightly above the present levels about a decade ago. A marginal relaxation of just about one to two percent in the advocated glucose levels can bring about a drastic decrease in the ‘incidence’ of diabetics, without precipitating health problems. This could ease out some imminent pressures.
• For white collared jobs, ultra short compulsory leisure and exercise breaks can be incorporated in the daily routine, whether at work or at home. Probably every employer would want their employees to remain as healthy as is possible, and for that ultra short exercise breaks should be planned in the daily routine. Care should be taken to make these exercises a fun, and must not be seen as any punishment or extra work, which could otherwise be defeating. Output may not go down by letting the employees do some short interval supervised exercises and games. This will also overcome some extent of insulin resistance, and can simultaneously improve cardio-respiratory fitness.
• It could be worthwhile reminding your patients the A, B, C, and D in order to rein in unwarranted polypharmacy [14].
• It may also be perhaps prudent to a certain extent if aetiopathogenesis of diabetes is reconsidered in context of some of the recent suggestions [15 - 16].
Dr (Lieutenant Colonel) Rajesh Chauhan
Honorary National Professor, IMA CGP, INDIA.
MBBS (AFMC), M Med in Family Medicine (CMC Vellore), PGDGM (Geriatric Medicine), DFM Family Medicine (PGIM Colombo), FCGP (Family Medicine), FISCD (Communicable Diseases), ADHA (Hospital Administration), AFIH (Industrial Health), PGDDM (Disaster Management), DNHE (Nutrition), LLB (III)
Reference:
1. Godlee Fiona. The growing problem of diabetesBMJ 2018; 363 :k4921
2. El-Jardali F, Akl EA, Fadlallah R, et al. Interventions to combat or prevent drug counterfeiting: a systematic review. BMJ Open. 2015;5(3):e006290. Published 2015 Mar 18. doi:10.1136/bmjopen-2014-006290
3. Pashkov V, Soloviov A, Olefir A. Legal aspects of counteracting the trafficking of falsified medicines in the european union. Wiad Lek. 2017;70(4):843-849.
4. Sato D. [Counterfeit medicines--Japan and the world].
Yakugaku Zasshi. 2014;134(2):213-22.
5. Fayzrakhmanov NF. Fighting trafficking of falsified and substandard medicinal products in Russia. Int J Risk Saf Med. 2015;27 Suppl 1:S37-40. doi: 10.3233/JRS-150681.
6. Gautam CS, Utreja A, Singal GL. Spurious and counterfeit drugs: a growing industry in the developing world. Postgrad Med J. 2009 May;85(1003):251-6. doi: 10.1136/pgmj.2008.073213.
7. Ravinetto RM, Boelaert M, Jacobs J, Pouget C, Luyckx C. Poor-qualit
y medical products: time to address substandards, not only counterfeits.
Trop Med Int Health. 2012 Nov;17(11):1412-6. doi: 10.1111/j.1365-3156.2012.03076.x. Epub 2012 Aug 22.
8. Fadlallah R, El-Jardali F, Annan F, Azzam H, Akl EA. Strategies and Systems-Level Interventions to Combat or Prevent Drug Counterfeiting: A Systematic Review of Evidence Beyond Effectiveness. Pharmaceut Med. 2016;30(5):263-276. Epub 2016 Aug 19.
9. Smolka K, Gronwald K. [Operation Pangea - standing together in combat against international pharmaceutical crime]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2017 Nov;60(11):1233-1239. doi: 10.1007/s00103-017-2629-3.
10. Rajesh C, Ajay K S, Shruti C. Can we think About Better, Timely, Affordable and Cheaper Treatment Options for the Elderly Patients?. OAJ Gerontol & Geriatric Med. 2017; 1(4): 555567
11. Kmietowicz Zosia. SGLT2 inhibitors for diabetes are linked to increased risk of lower limb amputation BMJ 2018; 363 :k4828
12. Chauhan R, Parihar AKS, Chauhan S (2016) Perhaps its Time to Move on to Individually Tailored and Focused Treatment in the Aged Population. J Gerontol Geriatr Res S5:001. doi:10.4172/2167-7182.S5-001
13. Rajesh C, Shruti C, Ajay K S . Newer Ways for Managing Multi-Morbidities in Elderly Patients: Including Diabetes Hypertension, 004 and Coronary Artery Disease & Some More Problems. OAJ Gerontol & Geriatric Med. 2017; 2(5): 555596. DOI: 10.19080/OAJGGM.2017.02.555596
14. Chauhan R, Chauhan S, Singh AK (2017) Polypharmacy in Geriatrics. J Gerontol Geriatr Res 6:e147 DOI: 10.4172/2167-7182.1000e147
15. Chauhan R, Parihar AKS, ChauhanS. Type 2 Diabetes : can we think differently and improve the management and control ? Perhaps by our "BRIJ PAL TECHNIQUE". BMJ 03 June 2016. Available at : https://www.bmj.com/content/353/bmj.i2933/rr Accessed on : 26 November 2018
16. New, innovative and novel series of medical innovations almost ready for healthy aging, but no takers so far. BMJ 25 March 2018. Available at : https://www.bmj.com/content/360/bmj.k1288/rr Accessed on : 26 November 2018
Competing interests: No competing interests
The problem of diabetes is indeed huge, but the NHS itself needs to get its own house in order. I am surprised that until now no one seems to have taken seriously the fact that (at least in Scotland) nurses are even more likely to be overweight or obese than the general population.(1) Obviously shift work is not conducive to a healthy life-style: snacking in the middle of the night is no doubt hard to resist, and hospital vending machines, while some have banned sugar-laden drinks, now stock products that may be no better from the health point of view since they contain sweeteners that may be even worse than sugar.
I am not blaming the nurses. If they have a weight problem they should be offered appropriate support and counselling. They have to cope with a stressful job. Mental health is still not given enough resources to respond to the demand, especially among teenagers.
Until the NHS can respond realistically and sympathetically, the problem will only get worse. It needs to provide an example, not a disincentive.
1. Richard G. Kyle , Rosie A. Neall, Iain M. Atherton
School of Nursing, Midwifery and Social Care, Edinburgh Napier University, Edinburgh, UK. 'Prevalence of overweight and obesity among nurses in Scotland: A cross-sectional study using the Scottish Health Survey'
DOI: http://dx.doi.org/10.1016/j.ijnurstu.2015.10.015 |
Competing interests: No competing interests
We've had the solution for decades: lifestyle mainly diet addresses this. I see patients who reverse their diabetes when they cut out the known causative factors. This is NOT just sugar! It's animal protein sources and fats causing intramyocelluar lipidaemia (fat deposited in muscle cells), which secondarily blocks insulin action, causing a rise in blood sugar. Cut these foods, reverse the diabetes. Dr Neal Barnard has done a 74 week RCT demonstrating this and now my patients demonstrate it to me.
To facilitate this, we need doctor and patient education first of all. Also taxation we know will help this--it's been proven with other conditions such as smoking--and controlling the obesogenic environment. You can't have one government policy supporting these unhealthy foods and another trying to deal with the harm they cause. [And just to clarify, the current fad for low carb diets does not help long term outcomes. You can lose weight, reduce your A1cs and apparently be doing better but this is at the long term expense of increased cardiovascular disease, cancers, dementias, etc, etc.]
There is only one diet that has been shown to help long term and that is a plant based, wholefood diet, which is what we should all be recommending to patients.
Competing interests: No competing interests
India--the World Capital for Diabetes
India currently represents more than 50 percent of the world’s diabetes burden, with an estimated 72 million cases in 2017, a figure expected to almost double to 134 million by 2025.
This presents a serious public health challenge to India facing a future of high population growth, and the Government of India is attempting to provide Prime Minister Modi 's Ayushman Bharat free health insurance to half a billion people.
In India, lifestyle changes such as inactivity and the excessive consumption of high-calorie foods, both changes that accompany economic development, exacerbate diabetes risk factors.
In India, because of a lack of awareness of diabetes symptoms and risk factors compared to those in higher socio-economic groups, the poor have greater difficulty in managing the disease.
Competing interests: No competing interests
Re: The growing problem of diabetes
The discussion (responses) is interesting.
But may I please pick up just two points -
Dr Asthana from the Indian Council of Medical Research says that INDIANS are genetically predisposed to coronary artery disease.
Could she please tell us whether
1. She believes that the INDIANS are genetically homogeneous?
It was my impression that there are, in the State of India, numerous populations. A look at the pictures pf people from Nagaland, from Tamilnadu, from the Punjab, from Kashmir Valley, from Ladakh, will, I think be enough to support my point.
2. Would she consider asking her counterparts in Pakistan (which was, till August 1947, a part of the then India) whether the two organisations could conduct a comparative study?
Dr Craig’s suggestion from New Zealand (plant-based whole food) attracts me. But I suspect it is emotional attraction. It is a blanket approach. If only he were to suggest that we should switch to plant-based foods, keeping in mind that some “whole-foods of vegetable origin” can be very unbalanced in terms of nutrients, I would be with him all the way. Also, I would, unscientific ally, include algae amongst plants (stretching botanical definition rather a lot).
Competing interests: No competing interests