Type - 1 Diabetes Mellitus:Indian and Global

Scene – Burden & Challenges.

C.V.Krishnaswami – FRCP(E) DTM&H(EDIN) FAMS.

Head of Diabetes Department,Voluntary Health Services,

Chennai, Tamil Nadu, India.

In “who has seen the wind”

CHRISTINA ROSSETTI

But when the trees bows down their heads

the wind is passing by.

Neither you nor I ;

Who has seen the wind ?

Reflections on Medical education

Frank Davidoff, M.D.

WHO HAS SEEN A BLOOD SUGAR?

Incidence of IDDM in children aged under 15

WHO 94387

Diabetes Voice. Vol. 44. March. No: 1/99. P.33

EVIDENCE FOR INCREASING PREVELANCE OF

DIABETES MELLITUS IN CHILDHOOD

Prevalence of diabetes mellitus among the cohort of children in the

child health and education study….. At age 10 years was

1.3/1000(1970), previous British birth cohort Studies 0.6/1000(1946)

Sarah Steward-Brown et al.

B.M.J.,1983;286:1855-1857

Increasing incidence of J.I.D.D.M. in the west:

5% of Diabetic clinic population

P.Forsham - (1970)

10% of Diabetics - Drury - (1976)

20% of Diabetes - Rayfield & Seto - (1978)

INCIDENCE OF INSULIN DEPENDENT DIABETES IN

ENGLAND: A STUDY IN THE OXFORD REGION ,

1985-86

P.J.Bingley and Gale(B.M.J., 1989; 298,558-60)

The overall yearly Incidence of newly diagnosed Insulin-

dependent diabetes mellitus in people under 21 was 15.6

cases/100,000….case ascertain was greater than 95%

Conclusion: The incidence of insulin dependent diabetes in

England is considerably higher than reported from

large Scale studies’

CLINICAL REVIEWS

Rise in Incidence Of Type 1 Diabetes In Infants

International Diabetes Monitor Volume 14,Number 1,2002

Epidemiology of type 1 diabetes mellitus in Switzerland : steep rise

in incidence in under 5 years old children in the past decade.

Schoenle EJ, Lang-Muritano M,Gschwend S,Laimbacher J,Mullis

PE,Torresani T,Biason-Lauber A,Molinari L, Diabetologia

2001;44:286-9

Age-Specific

incidence of type 1

diabetes mellitus in

children aged 0-14

years and 0-4 years

in Switzerland

between 1991 and

1999.

The solid line shows the average rate of change, which was

significant in both age groups: 0-14 years, slope = 0.33 + or – 0.13

(p = 0.03); 0-4 years, slope = 0.88 +or- 0.13 (p = 0.0002)

International Diabetes Monitor Volume 14,Number 1,2002

Between 1991 and 1999 only the youngest age group

contributed to the overall increase in incidence of type 1

diabetes in children.

In this prospective study (1991 – 1999) the authors found that

the annual incidence of childhood diabetes had increased from

7.8/100,000 in 1991 to 10.6/100,000 in 1999, corresponding to an

annual average increase of 5.1%. The most striking finding was

the increased incidence in the 0-4 year age group, which had

risen from 2.4 to 10.5 per 100,000, corresponding to an average

yearly increase of 23.8% (Fig 1)

There was no variation in 5-9 year or 10-14 year age groups,

meaning that the 0-4 year age group alone was responsible for

the rise in the childhood type 1 diabetes in the 10 years of

follow-up.

The present paper refers to an incident of 10.6 / 100,000 in 1999,

representing an average annual increase of 5.1%, higher than the

EURODIAB average increase of 3.5% (2.5-4.4%). But what is more

important is that only the youngest age group (0-4 years)

contributed to this increase.

Whatever the speculative explanation for the rise in incidence in the

youngest Swiss children, the phenomenon represents a challenging

burden to the health care system.

Volume 14,Number 1,2002International Diabetes Monitor

Tahoku J.exp. Mod., 1983 141 Suppl., 161-170

The Significance of Certain Epidemiological Variants in the

genesis of Juvenal Insulin-Dependent Diabetes Mellitus the need

for A Global program of Co-operation.

C.V.KRISHNASWAMI and P.CHANDRA*

Voluntary Health Services Hospital and Government Stanley Hospital, Department

of pediatrics,Government Stanley Hospital Chennai Tamilnadu

MAGNITUDE OF YOUNG DIABETES IN INDIA URBAN

POPULATION

ABSTRACT:

As there is paucity of reports in India on the prevalence of diabetes in the

young, aged <20 years, a population based survey was undertaken to assess the

same. Urban population was selected for the survey. The prevalence of diabetes

among these aged 0-20 years was assumed as 0.2%. The sample size of the total

population required to estimate it with 95% CI and + 25% precision was

calculated y random cluster sampling method. The required sample size of all the

ages was 155000 which was obtained from 30 randomly selected corporation

divisions of the city. Ten trained social workers recorded required information of

the selected families on the prescribed forms by daily house visits. This study was

conducted during 1998 – 1999. Among 156258 individuals of all ages surveyed, there

were 60310 persons aged 0-20 years. The age standardized prevalence of known

diabetes was 0.02% in those aged < 20 years. This survey indicates that diabetes of

any category is not a public health problem in those aged <20 years in Chennai

city, India.

_

_

Key words: Diabetes mellitus, Type-1 diabetes, Prevalence, Type 2 diabetes, Young population

"The essence of the practice of medicine is that it is an intensely

personal matter...the treatment of a disease may be entirely

impersonal ; the care of a patient must be entirely personal .The

significance of the intimate personal relationship between physician

and patient cannot be too strongly emphasized for in an

extraordinary large number of cases both diagnosis and treatment

are directly dependent on it...One of the essential qualities of the

clinician is interest in humanity , for the secret of the care of the

patient is in caring for the patient".

--Francis W.Peabody,1927

Chapter 1

HUMANISTIC QUALITIES IN MEDICENE

JOHN A BENSON Jr

By learning you will teach;

By teaching you will learn.Latin Proverb

The High Risk Foot in diabetes Mellitus.

Robert G.Frykberg.

Churchill Living stone 1991.

SERVICES OFFERED BY THE

VHS DIABETES DEPARTMENT

• In the NGO sector catering to the public of Chennai, TamilNadu (India) for over 35 years

The Services Include :

Regular Out-Patient services for all persons with Diabetes

SPECIAL COMPREHENSIVE FREE MEDICARE FOR ALL PERSONS with JIDDM(Type 1 DM with onset below 15 years) includes supply of Insulin HMBG monitoring / training with equipment and regular follow up with all investigations like FLOURESCEINE ANGIOGRAPHY for eyes, renal package, foot care etc., treatment of co-morbid conditions, educational and social support, job placements and rehabilitation, plus pregnancy care and delivery.

VHS DIABETES DEPARTMENT

Diabetes & pregnancy for all with GDM screening

Diabetes Foot care service

Diabetes Renal care service

Diabetes Retinopathy surveillance and prevention of

blindness program for type IDDM

Diabetes nutrition department – clinical services, diploma

training and research programmes

Diabetes specialists nurse educators service and training

certificate programme

REHABLITATION SERVICES

Diabetes Research and academics activities (Shri Prakash

CME Programme for doctor).

Public Education programme (Shri Prakash Endowment

Public Lectures).

VHS DIABETES DEPARTMENT

RESEARCH ACTIVITIES 2001-2002

Prevalence of diabetes-survey in chennai city-

collaborative work,along-with the national institute of epidemiology,chennai.

Natural History of diabetic Nephropathy in type 2 diabetes

Magnitude of young onset diabetes in south India-Are we doing enough?

Preliminary Experience in alternate Modalities of wound healing in Diabetes.

Incidence of gestational diabetes in pregnant women,chennai.

VHS DIABETES DEPARTMENT

RESEARCH ACTIVITIES 2001-2002

Study of children of people with Type 1 Diabetes

Psychological impact of Type 1 Diabetes on children of

different age group?

Mortality in Type 1 Diabetes

Study of Type 1 Diabetes and autonomic neuropathy

Study of progressive of nephropathy in Type 1

Diabetes:Retrospective/Prospective

The following projects are the basic research

projects in progress during the year

DNA Repair Mechanism in peripheral lymphocyte in

Diabetes

Telemere dynamic in health & disease

Molecular markers in Type 1 diabetes *classification of

IDDM patients

Gene mapping of children of Type 1 Diabetes :a

collaborative study

Long term follow up of the complication profile in Type 1

Diabetes

I thank the following team mates for their co-operation and selfless

service:

Dr.P.V.Asha Bai Dr.A.Srivatsa Mrs.Mala Chettri

Dr.A.Ganesan Dr.Prema Krishnaswami Dr.Meenakshi Dhamija

Dr.M.Chellamariappan Dr.T.A.Vidya Mrs.Sundari.N

Dr.G.Vijay Kumar Mr.M.Bhaskar Rao Mrs. Parvathi.R

Dr.N.S.Raji Ms. Yogambal Dr.V.Vijayalakshmi

Mrs.Ramalakshmi Mrs.Subhashini Mrs.Lalitha Subramaniam

Peter H. Forsham

The Cost of Insulin-dependent Diabetes Mellitus (IDDM) in

England and Wales

A. Graya,b, P.Fenna,c and A. McGuirea,d

Oxford Center for Health Economics Researcha, Center for

Socio-Legal Studies, Wolfson College, Oxfordb, School of

Management and Finance, University of Nottingham, and

Department of Economics, City University, London, UKd

This study estimates the direct health and social care costs of

insulin-dependent diabetes mellitus (IDDM) in England and Wales in

1992 to be 96 million, or 1021 per person in a population with IDDN

estimated at 94,000 individuals. These costs include insulin maintenance,

hospitalization, GP and out-patient consultants, renal replacement

therapy, and payments to informal carers. Expenditure is concentrated on

younger age groups, with one-third of the total expended on those aged

0-24.

Around one-half of the total costs can be directly attributed to

IDDM, with the remainder associated with the range of complications of

the disease. The single largest area of service expenditure is renal

replacement therapy. The cost estimates are most sensitive to incidence

rates of IDDM, number on dialysis and average duration of dialysis. A

further 113 million pounds may be lost each year due to premature

deaths result in lost productive contributions to the economy. The direct

and indirect costs of IDDM are therefore significant. The cost of illness

framework presented here should the economic evaluation of new and

existing treatment regimens, which may improve value for money by

reducing costs and/or increasing the quality or quantity of life for the

people with IDDM.

Key words: Insulin-dependent diabetes mellitus Cost of illness Health economics

The Cost of Insulin-dependent Diabetes Mellitus (IDDM) in

England and Wales

Table 1. IDDM in England and Wales: baseline estimated population and prevalence

19

100

100

59

55

33

18

5

0

0

1.84

0.65

2.72

2.36

a2.59

2.45

2.38

1.00

0.05

0.00

93 581

4 344

17 791

19 177

18 297

16 726

12 615

5 048

182

0

499 359

3 323

12 630

35 572

33229

51 105

71 971

104 832

131 755

60 471

9.8

0.5

2

4

4.7

7.5

13.6

20.8

35.6

31.3

50 955

6 646

6 315

8 143

7 070

6 814

5 292

5 040

3 701

1 932

All

0-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

> 80

IDDM as % of

total population

with diabetes

IDDM

prevale

nce per

1000

IDDM

population

Total

population

with

Diabetes

Diabetes

Prevalence

per 1000

Population of

England and

Wales

Age group

The question to be asked is what is the situation in India with regard

to Incidence of IDDM, the cost of treating the same and the burden

to the individual, State/Nation? If one takes a look around all the

hospitals and their Renal Units (Government and Private) the

number of cases of IDDM Renal Failure is very low indeed: So is the

number of IDDM related PDR/visual loss when one surveys all the

Ophthalmic institutions (Government and Private).

Based on the experience of working with children & young people

(with IDDM) & trying to give them lifetime comprehensive free

Medicare plus rehabilitation programs for the past 37years, I am

convinced of the urgent need for proper and detailed documentation

plus continuous follow–up of these cases throughout the country and

create a meaningful and statistically viable data base for future

research. At the Voluntary Health Service Diabetes Department, we

have started this process with online electronic medical records of all

our patients with Diabetes under the age of 40years.

We have over 400 persons with complete data of the natural history

of their diabetes & it’s progression over the past 3 ½ decades.

The second aspect would be genetic & molecular studies in these

young people and their families.

The third aspect would be setting up appropriate infrastructure to

analyze the influence of all the environmental factors involved in the

causation of Type-1 diabetes Mellitus in our country. This should

include both causative factors & probable protective ones also.

Finally if it is indeed true that the incidence of Type-1 diabetes in

children in India is very low as compared with the figures reported

from the Western World, we should make an integrated all out

scientific effort to pin point the reasons for this. The results of such

effort would be more than worthwhile for not only our children but

would benefit the children of the entire world, particularly those in

the developed world – Such an effort if successful, would be a

tremendous export product.

‘I don’t feel like a diabetic any more’: the impact of stopping insulin in patients

with maturity onset diabetes of the young following genetic testing

Maggie Shepherd and Andrew T Hattersley

Abstract – Hepatocyte nuclear factor-1 (HNF-1) maturity onset

diabetes of the young (MODY) is the commonest cause of monogenic

diabetes but is frequently misdiagnosed as type 1 diabetes. The

availability of genetic testing in MODY has improved diagnosis.

Sulphonylurea sensitivity in HNF-1 patients means that those on

insulin from diagnosis can transfer to sulphonylureas and may

improve glycaemic control. To gain insight into the implications for

patients of stopping insulin, in-depth interviews were conducted with

eight HNF-1 patients transferred to sulphonylureas after a median of

20 years on insulin. Thematic content analysis highlighted four key

themes:

‘I don’t feel like a diabetic any more’: the impact of stopping insulin in patients

with maturity onset diabetes of the young following genetic testing

Glucokinase

(MODY 2)

HNF-1 (MODY

3)

HNF-4 (MODY

1)

HNF-1

(MODY 5)

IPF-1

(MODY 4)

NEUROD1

(MODY 6)

Chromosomal

location

7p 12q 20q 17q 13q 2q

Frequency in a

large UK series

(%)

15 65 5 1 <1 0

Penetrance of

mutations at age

40(%)

Diabetes: 45

Impaired

fasting

glycaemic: 95

>90 >80 >80 >80 70 (2 families)

Onset of

Hyperglycemia

Early

childhood

(from birth)

Adolescence

Early adulthood

Similar to HNF-

1

Similar to HNF-

1

Early childhood 4th decade

Severity of

Hyperglycemia

Mild with

minor

deterioration

with age

Progressive May

be severe

Progressive

May be severe

Progressive May

be severe

Limited data Progressive

Micro vascular

complications

Rare Frequent Frequent Retinopathy

observed

Not Known Not Known

Pathophysiology Beta-cell

dysfunction

Beta-cell

dysfunction

Beta-cell

dysfunction

Beta-cell

dysfunction

Beta-cell

dysfunction

Beta-cell

dysfunction

Abnormality of

glucose sensing?

Yes No No No No No

Other phenotypic

features

Reduced birth

weight

Low renal

threshold and

sensitivity to

Sulphonylurea

Low plasma

triglycerides

Predominant

renal

phenotype;

cysts, renal

failure

Pancreatic

agencies in

homozygotes

Not known

The Natural History of Insulin-Dependent Diabetes Mellitus

ASTROLOGY-THE EVIDENCE OF SCIENCE-

PERCY SEYMOUR

I have sought…………for long years I have laboured;but I have not

found her ……where I lie down worn out the other men will stand,young

and fresh.by steps that I have cut they will climb;but the stairs that I have

built they will mount…..At the clumsy work they will laugh ……….they

will cruse me.BUT THEY MOUNT AND ON MY WORK;THEY

WILL CLIMB AND BY STAIR! THEY WILL FIND HER, AND

THROUGH ME…………

I believe that is all we can really expect from the scientific quest,but that

does not make it any less exciting-IT IS THE EXCITING OF THIS

ONGOING QUEST THAT SUSTAINS US.

By

FRANK DAVIDOFF

He who - is conceited: avoid him

He who knows not and knows not that he

- knows and knows that he knows

- knows not is a fool; instruct him.

He who knows and knows not that he knows

- is asleep ;awaken him

He who knows not and knows that he.

- knows not is a wise man-follow him

ARAB PROVERB

( From: Who has seen the Blood Sugar’?)