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Childhood and Youth Onset Diabetes in India: 67
Profile, Changes, Progress and Future ?

health facilities, has a major impact on all aspects a day, causing patients to suffer hypo-and hypergly-
of diabetes care: survival, glycemic control, rate of cemia daily. Both low and high BG interfere with ac-
acute and chronic complications, social problems, ademics and activity - the child cannot study or play
and quality of life. properly. They prescribe U-40 insulins even to ado-
lescents and adults, causing needless pain because
The absolute numbers as well as the proportions of of the greater volume. Very few patients are taught
different types of diabetes vary widely in different premeal BG testing to adjust insulin doses: instead,
regions and socio-economic strata. Thus, since the they are “prescribed” the insulin doses, regardless of
mid-1960s, north India has reported that over 90% BG level/ food/ activity levels. Often, the only aim is
of children and youth have T1D, the south has found to get “good” A1C levels, which is quite possible if
that as many as a third may have T2D, and eastern low and high sugars average out, leaving the patient
India a higher proportion of pancreatic diabetes. Mal- miserable, but the doctor happy!
nutrition related diabetes (MRDM) seems to occur far
less, while gestational diabetes occurs far more. As Insulin requires storage at proper temperatures. This
genetic tests become more accessible, more patients means ensuring proper storage and transport - an
with confusing clinical presentation or course will be effective cold chain, and precautions at home - till the
diagnosed with specific types of diabetes. last drop is used. Making insulin available in remote
areas, and with erratic electricity i.e. refrigeration in
The challenges posed by pediatric diabetes in our a country with extremes of climate, and educating
country and elsewhere are enormous. Let us start not only patients but also everyone in the distribution
with diagnosis. A 5 year old presenting in diabetic ke- network of the importance of this aspect is a daunt-
toacidosis (DKA), with a history of recent weight loss ing challenge. [3] Technology to detect whether a vial
and bedwetting, is easily diagnosed as having T1D, has been exposed to high temperatures does exist
and getting GAD-65 or other antibodies, or C-peptide and is used routinely and widely for oral polio vac-
levels done may be unnecessary. Parents can safely cine, but unfortunately the insulin companies have
be told that the child will need multiple daily doses of not seen fit to apply this to insulin vials. Injection
insulin life-long. The obese 15 year old with acantho- technique is also vital for proper action. [4]
sis and hirsutism, found to have high blood glucose
(BG) during work up for polycystic ovarian syndrome Good glycemic control needs frequent self BG mon-
(PCOS), may also not pose any diagnostic dilemma – itoring (SBGM). [2] If the family is taught how to
she has T2D and needs metformin, with weight loss. utilize BG tests for dose adjustments, they can en-
However, what if an obese 12 year old with acantho- sure glycemic control while maintaining flexibility of
sis and skin tags, presents in DKA, with history of lifestyle. Unless taught how to balance food, activity
losing 3 kg in the past month? She is more likely to and insulin doses using BG testing, they soon stop
have T2D - here antibody or C-peptide testing may testing, since this does add to the pain, cost and in-
be helpful. Or a lean 16 year old has surprisingly well convenience of diabetes care. The physician is then
controlled diabetes, and father has a similar history? given excuses (“I forgot the diary at home”), or blank
Here testing for MODY may help. diaries, or diaries neatly filled with fabricated values
(“Doctor scolds me if the diary is blank”)! It is cru-
Next is treatment. Standard of care today is mul-
[2]
tiple doses of insulin, whether by injection (multiple cial to make sure that patients use only glucome-
daily doses of insulin or MDI), or continuous subcu- ters with memory, and bring the glucometers with
taneous insulin injection (CSII using insulin pumps), them at each clinic visit. This ensures that if the BG
on a basal bolus regimen, the doses being modu- have not been recorded, they can be retrieved from
lated by pre-meal BG testing, and if possible, taking the meter so that some assessment can be made of
carb count into account. Reasonable glycemic control glucose patterns. Conversely, if the BG values have
is possible with syringes and conventional insulins, been fudged, then the physician or educator will not
with regular insulin given before each meal, and a be misled into giving wrong advice.
longer acting insulin to cover the night. Designer A basic dictum is there is no special “diabetic diet”:
insulins can be advised to people who can afford the person with diabetes should have a sensible,
them, only if necessary. Unfortunately, many physi- balanced diet, as should everyone else. However,
cians prescribe these insulins, which cost 3-10 times misguided health care personnel (HCP) may advise
the conventional insulins, even to poor families, thus several dietary restrictions, only for the child, making
needlessly increasing the financial burden and com- normal life difficult, and school treats, festivals, func-
promising care. On the other extreme, many physi- tions, and parties huge obstacles. This can force the
cians continue to prescribe premixed insulins, twice child and family to become social recluses, and/ or

Cardio Diabetes Medicine