Saturday, 25 May 2019

The growing problem of diabetes – The BMJ

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)

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].
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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.
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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 : 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 : Accessed on : 26 November 2018


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