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SOCIOECONOMIC BARRIERS & DISPARITIES IN DIABETES TECHNOLOGY : EXPERIENCE IN INDIA

DR.V. MOHAN, M.D., FRCP (London, Edinburgh, Glasgow & Ireland), Ph.D., D.Sc.

D.Sc (Hon. Causa), FNASc, FASc, FNA, FACE, FACP, FTWAS, MACP, FRSE

Chairman & Chief of Diabetology,

Dr. Mohan’s Diabetes Specialities Centre & Madras Diabetes Research Foundation,

Chennai, India

Email : drmohans@diabetes.ind.in, Websites : www.mdrf.in & www.drmohans.com

The number of people with diabetes globally, is rising at an alarming rate. South Asia is one of the hot spots of the diabetes epidemic. In India alone, there are over 74 million people with diabetes today. Unfortunately, 70% of the doctors in India practice in urban areas while 70% of India’s population lives in rural areas. This mismatch between the availability of health care professionals and the rapid spread of diabetes in rural areas, provides an opportunity to use technology to deliver the diabetes care to remote rural areas.

The first part of this presentation will talk about a model of successful delivery of diabetes health care in rural India. The Chunampet Rural Diabetes Program was carried out in a group of 42 villages in Kancheepuram District in Tamilnadu. Using a Mobile van, a population of 27,014 individuals (86.5% of the adult population) were screened for diabetes. All those detected with diabetes were offered a follow up care at a rural diabetes centre which was set up during the project. The results were very impressive and led to good improvement in A1c levels using low cost generic drugs.

The second use of technology was during the COVID – 19 pandemic and the lock down which was enforced in India. Thankfully, Telemedicine was also legalized in India at that time. Using technology, a system was created whereby the doctor and the patient stayed at home but blood tests were arranged at home for the patient. With the results, teleconsultation was done by doctors using the Electronic Medical Records which were made available on their mobile phones. Thus, despite the lockdown, patients managed to get their tests and diabetes consultations done remotely.

The third use of technology which will be presented is through our network of diabetes clinics across India. Even at centres where there was no ophthalmologist, retinal photographs were obtained using a low-cost retinal camera and were uploaded for centralized diabetic retinopathy grading unit where the images were read by trained retina specialists. The eye reports were sent back to the peripheral clinics in real time. Over one year period, 25,316 individuals with diabetes could have their eyes screened for diabetic retinopathy. Only 11.4 % needed referral to an ophthalmologist for further management.

In conclusion, judicious use of technology can help to bridge the socioeconomic and geographical challenges in delivering diabetes health care in developing countries.

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PRECISION DIABETES IN INDIA – WHERE ARE WE?

DR.V. MOHAN, M.D., FRCP (London, Edinburgh, Glasgow & Ireland), Ph.D., D.Sc.

D.Sc (Hon. Causa), FNASc, FASc, FNA, FACE, FACP, FTWAS, MACP, FRSE

Chairman & Chief of Diabetology,

Dr. Mohan’s Diabetes Specialities Centre & Madras Diabetes Research Foundation,

Chennai, India

Email : drmohans@diabetes.ind.in, Websites : www.mdrf.in & www.drmohans.com

Precision Diabetes includes precision diagnosis, prevention and treatment. Although Precision Diabetes is applicable to all forms of diabetes. Currently, it is more used in type 2 diabetes and Monogenic Diabetes in India.

PRECISION MEDICINE IN TYPE 2 DIABETES

Type 2 diabetes (T2D), is caused by impairment in both insulin secretion and insulin action. Till recently, T2D was considered and treated as one condition. After the work of Alquist et from Sweden describing different clusters of T2D, we also attempted clusters of T2D using clustering. We described 4 clusters of T2D which includes SIDD (Severe Insulin Deficient Diabetes) and MARD (Mild Age-Related Diabetes), which are similar to the Swedish clusters and two new clusters namely IROD (Insulin Resistant Obese Diabetes) and CIRDD (Combined Insulin Resistant and Deficient Diabetes). Insulin secretagogues would obviously be preferred for SIDD and insulin sensitizers for IROD and both groups of drugs for the combined types while MARD is the easiest to treat as it is the mildest variety. An RCT on different drugs to treat these T2D subtypes is currently in progress.

PRECISION DIABETES IN MONOGENIC DIABETES

In the case of monogenic diseases such as Maturity Onset Diabetes of Young (MODY) and Neonatal Diabetes, genetic testing has now come to the realm of clinical practice as these are single gene defects which can be easily identified by genetic testing. Our centre is an ICMR Nodal Centre for India for monogenic diabetes testing (www. http://monogenicdiabetes.in/)

Based on genetic testing, MODY is a group of clinically heterogeneous forms of beta cell dysfunction that are defined at the molecular genetic level by mutations in different genes (eg., HNF4A, GCK, HNF1A, HNF1B, etc). By correctly identifying MODY subtypes like HNF1A & HNF4A, it is possible to avoid life long insulin injections in these patients who are wrongly diagnosed to have type 1 diabetes.

One of the most gratifying clinical applications of Precision Diabetes is in the diagnosis of Neonatal Diabetes which is defined as diabetes occurring in the first 6 months of life. Several children with neonatal diabetes in India carrying the KCNJ11 and ABCC8 mutations have been successfully switched over from insulin therapy to oral sulfonylurea.

In conclusion, precision medicine has finally come to the diabetes clinic. Good clinical phenotyping can make genetic testing cost effective. It can also help change the therapy from life long insulin injections to tablets for some forms of diabetes like monogenic diabetes which can be very gratifying to the patient and his / her family.