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Indian Pediatr 2019;56: 189-190 |
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Type 1 Diabetes in India: The Numbers Show
the Way Ahead
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Anju Virmani
Senior Consultant Pediatric Endocrinologist, Max,
Pentamed and Rainbow Hospitals, New Delhi, India.
Email: [email protected]
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T he incidence and prevalence of Type 1 diabetes
(T1D) is suspected to be high in India, but in the absence of a
nation-wide registry, it is not possible to be sure of the numbers. The
Diabetes Atlas 2017 estimates that there are 128,500 children and
adolescents with diabetes in India [1]. However, extrapolating from a
prevalence of 0.54 per 1000 population in expatriate Indians in UK [2],
this figure translates roughly to a prevalence of 700,000 in a
population of 122 crores, assuming all T1D patients are diagnosed and
all survive. Where are these children disappearing? It has indeed long
been suspected that many children were dying before, or soon after
diagnosis [3], reducing prevalence sharply. However, as the country
experiences reduction in poverty, better communication and technology,
greater awareness among health care personnel (HCP), and more trained
specialists, this situation appears to be improving, with earlier
diagnosis and increased survival.
These children and their families need a lifetime of
intensive diabetes education, multiple daily insulin injections, daily
blood glucose monitoring, prevention and handling of acute
complications, screening for and managing chronic complications, safe
disposal of sharps, psychological support, and societal support rather
than discrimination. This is thus a complex, expensive, exhausting
disorder for a child and family to cope with. Unless timely and ongoing
care is provided by HCP familiar with its management, the quality of
life can be abysmal, worsened by the frequent chronic complications,
with all their costs in turn.
Given this enormous burden of controlling diabetes
–as yet we cannot prevent or cure it – much greater attention and
resources are needed by the HCP community, administrators, and industry.
Data are urgently needed for effective planning. Some large centers have
published their patient data. In 2004, Bhatia, et al. [4]
reported that out of 160 diabetics (onset <18 y), 81% had T1D, 8% type 2
diabetes (T2D), and 9% fibrocalculous pancreatic diabetes mellitus. The
mean HbA1c was 8%. Ketoacidosis and severe hypoglycemia were 5.0 and 3.3
episodes per 100 patient-years. With mean (SD) disease duration of 10.2
(4.6) y, retinopathy occurred in 22% and nephropathy in 18%. Mortality
was high at 7% over 823 patient-years of follow up.
In 617 T1D patients (onset <20 y), Ramachandran,
et al. [5] reported retinopathy in 13.4%, nephropathy in 7.1%,
sensory neuropathy in 3%, ischemic heart disease in 0.5% and peripheral
vascular disease in 0.5%. Recently, Jevalikar, et al. [6], in a
series of 577 patients (onset <25 y: part of Youth Onset Diabetes, YDR),
reported that 87.4% of T1D and 8.5% of T2D had onset before 18 years of
age. The disease duration was more than two years in only 211 (36.6%)
patients, again suggesting very high attrition rates. Retinopathy
developed in 10.1%, nephropathy in 13.4% and neuropathy in 6.2%, at
median durations of 18 y, 10.5 y and 15 y, respectively. Moreover, 11.6%
of T1D were hypothyroid, and 9.7% had celiac disease. In a recent series
of children with diabetic ketoacidosis, high rates of acute kidney
injury and mortality were reported [7].
In 2006, the Indian Council of Medical Research
(ICMR) set up a Registry of people with Youth Onset Diabetes (onset <
25y; ICMR-YDR), initially aiming to enroll all youth onset cases
residing within the geographical areas of eight collaborating centers
across India. Very quickly it was realized that this would not lend to a
nation-wide registry or even complete ascertainment, and thus the
primary objective became "to understand disease patterns or types of
youth onset diabetes, including their geographical variations within the
country and to estimate the burden of diabetes complications." Some
salient findings [8] on 5546 patients enrolled in the first phase, till
July 2011, were as follows: 63.9% had T1D and 25.3% had T2D; while T1D
predominated in very young children, T2D was substantial in Southern and
Eastern India (Chennai and Dibrugarh centers); at registration, 15.4%
(11.1% of T1D; 26.4% T2D) already had at least one chronic complication
of diabetes (retinopathy, nephropathy, neuropathy, coronary disease);
14.1% had at least one co-morbid condition (hypothyroidism, dyslipidemia,
hypertension, tuber-culosis, sepsis); and 56.1% had at least one episode
of hospitalization due to acute medical diabetes related conditions –
ketoacidosis /uncontrolled hyperglycemia (31.8%) and hypoglycemia (11%).
An update of the data from Lucknow, on 512 T1D
patients with onset before 18 years during January 1991 to June 2015, is
reported in this issue of Indian Pediatrics [9]. Their
observations partly reflect the changing face of T1D: higher proportion
with onset before 5 years of age, 97% patients on multiple daily
injections (MDI) regimen, almost half on analog basal insulin, and lower
rates of retinopathy. In other respects, things seem unchanged. The mean
HbA1C was 8.3%. Better glycemic control was associated with higher
formal education and regular follow-up. Severe hypoglycemia remained at
3.9 episodes per 100 patient-years, especially in those less than 10
years of age. Hypertension was present in 11.7%, microalbuminuria in
10.3%, and gross albuminuria in 3%. Mortality rate was high, at 1.1 per
100 patient-years over 2549 patient-years of follow-up, median diabetes
duration of 102 months, with 10 of 16 deaths directly related to
diabetes (6 due to chronic renal failure caused by diabetic
nephropathy). Two patients committed suicide in the third decade of
life.
What lessons can we draw? Glycemic control leaves
much scope for improvement even in tertiary-care centers with
multidisciplinary teams. Severe hypoglycemia occurs frequently,
especially in young children. Hypertension occurs often and early – this
matters, as it contributes to nephropathy, renal failure, and mortality.
Death occurs often and early, with diabetes a major contributor. On the
positive side, MDI is possible whatever the age, education,
socio-economic status, or residence (urban or rural). Hypertension is
easy to detect, and treatable. Hypoglycemia rates can be brought down
with technology. The pessimists may see the glass half empty, but the
optimists can see the droplets gathering into it and the level slowly
rising.
Funding: None; Conflict of interest: None
stated.
References
1. International Diabetes Federation. IDF Diabetes
Atlas, 8th edn. Brussels, Belgium: International Diabetes
Federation, 2017. Available from: http://www.diabetesatlas.org.
Accessed February 17, 2019.
2. Samanta A, Burden AC, Jones GR, Woollands
IG, Clarke M, Swift PG, et al. Prevalence of insulin-dependent
diabetes mellitus in Asian children. Diabet Med. 1987;4:65-7.
3. Virmani A, Ushabala P, Rao PV. Diabetes mortality
in a tertiary referral hospital in India. Lancet. 1990;335:1341.
4. Bhatia V, Arya V, Dabadghao P, Balasubramanian K,
Sharma K, Verghese N, et al. Etiology and outcome of childhood
and adolescent diabetes mellitus in North India. J Pediatr Endocrinol
Metab. 2004;17:993-9.
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Satyavani K, Vijay V. Vascular complications in young Asian Indian
patients with type 1 diabetes mellitus. Diabetes Res Clin Pract.
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6. Jevalikar G, Kohli C, Bansal B, Mishra SK, Wasir
JS, Singh S, et al. Childhood and youth onset diabetes: a single
center experience. Indian J Pediatr. 2016; 83:792-8.
7. Baalaaji M, Jayashree M, Nallasamy K, Singhi S,
Bansal A. Predictors and outcome of acute kidney injury in children with
diabetic ketoacidosis. Indian Pediatr. 2018;55:311-4.
8. The Indian Council of Medical Research (ICMR),
India. Executive Summary: The Indian Council of Medical Research
Registry of People with Diabetes with Young Age at Onset (ICMR-YDR),
Phase 1 (2006-2011) Report. Available from:
http://www.icmr.nic.in/sites/default/files/reports/Executive%20summary.
Accessed February 21, 2019.
9. Sudhanshu S, Nair VV, Godbole T, Bhaskar Reddy SV,
Bhatia E, Dabadghao P, et al. Glycemic control and long-term
complications in pediatric onset type 1 diabetes mellitus: A
single-center experience from Northern India. Indian Pediatr.
2019;56:191-5.
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