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68 Cardio Diabetes Medicine 2017

tell the health care team lies. An over-restricted diet cian/ psychologist not well versed in T1D care can
can result in poor nutrition, interfering with the child’s result in poor glycemic control, complications, and
growth and development. The entire family must be poor quality of life.
taught how to “eat healthy, yet tasty”, and adjust on Therefore, the challenges faced by patients, families,
special occasions.
HCP, and society at large, are varied and may seem
Equally, the child with diabetes should have daily insurmountable. Fortunately, there have been many
play and activity, as should everyone else. However, changes and advances since the discovery of insulin
activity levels are decreasing steadily in our country, made it possible for children with diabetes to even
especially in urban areas. With diabetes, the situa- survive.
tion is worse if the child is considered “sick”, and Awareness among HCP has meant diabetes is di-
therefore discouraged from play and sports; or con- agnosed earlier, often before severe DKA develops.
versely forced into long hours of activity as a way of This means better survival, lesser costs, especially
decreasing or avoiding insulin doses.
since treatment and education can be initiated on an
Regular SBGM must be supplemented by 3-monthly outpatient basis. A few centers in India are now pro-
testing of A1C, testing for autoimmune disorders and viding gene testing for better diagnosis of neonatal
chronic complications, as well as growth and puberty. diabetes as well as MODY.
[5] Short stature and/or delayed puberty worsen body There is a greater willingness among doctors to
image and self-esteem. Hypothyroidism or celiac dis- refer to teams with expertise in pediatric diabetes,
ease may cause few/ no symptoms, and be missed and among of patients to seek such teams. Families
for long periods, further compromising health. These willing and able to travel to a city for care every 3-4
tests also add to pain, cost and inconvenience, so months, can benefit not only from better advice, but
patients may avoid or delay clinic visits, again com- also access insulin and other supplies at lower cost
promising care. Early detection and treatment of and better quality. Families can also access peer sup-
these disorders, of hypertension, and of micro- or port and information about facilities through social
macro-angiopathic complications can prevent wors- media.
ening.
Availability of better devices to administer insulin
Insulin use and BG monitoring generate sharps at the has improved diabetes care: insulin syringes with
home level. In a country where even hospitals and near-painless 31G needles; insulin pens with 0.5 unit
laboratories discard sharps carelessly, educating pa- insulin increments, 31G and 4 mm pen needles; and
tients to dispose them off safely may seem pointless. feature-rich insulin pumps. Carefully reusing syringes
It is nonetheless important we teach our patients to or pen needles (and BG lancets) 2-10 times reduces
be careful at home, and also vigilant outside, de- costs. Pumps provide insulin in the most physiologi-
manding safety from health care institutions. [6]
cal way, but need money and intelligence. A range of
The complexity of diabetes care and its impact on insulin analogs, from ultra-short acting to ultra-long
daily life of the entire family means marked psycho- acting, have made MDI easier, with glycemic control
logical stress, leading to poor self-care, marital dis- close to what CSII can achieve. Over the past few
cord, even harming behaviors. The problems affect all decades, conventional insulins have become less
aspects of diabetes care, and are particularly severe expensive, poverty has come down, mobiles have
[7]
during adolescence. They may lead to risk taking become ubiquitous, self-help groups and charita-
behavior like inducing hypoglycemia with surrepti- ble agencies (international and local) are providing
tious high doses of insulin, smoking, drugs and sex. support, so the possibility of a child dying for lack
The issues have to be recognized, and handled with of insulin is gradually decreasing. Similarly, as glu-
care, expertise and patience. In addition, issues such costrips become cheaper, and SBGM awareness in-
as discrimination, in education, jobs and marriage, creases, more children are using SBGM. Continuous
need to be flagged and tackled, at social and legal glucose monitoring systems (CGMS) of varying pric-
levels. es and accuracy becoming available to those who
can afford them, has improved glycemic control and
All this involves long hours of diabetes education, quality of life. These provide more information, and
without which diabetes care is considered substan- better memory, so reducing the stress of monitoring
dard. This is possible only if the patient has access and the need or likelihood of falsifying information.
[8]
to well-trained diabetes educators, dieticians and Closed loop pumps (“artificial pancreas”) combine
psychologists familiar with T1D. [8] Care by a general CGMS with CSII, and may provide solutions which
physician/ pediatrician/ “adult” diabetologist/ dieti-

GCDC 2017