The Indian Council of Medical Research (ICMR) has issued draft guidelines for treatment and management of type 2 diabetes which will act as a rule book for physicians and care givers in the country. The elaborate set of norms focuses on epidemiology, diagnostic criteria, pharmacological intervention, treatment goals and complications of the disease.
Stakeholders can send comments and suggestions on the draft to the council until May 18, 2018.
The guidelines assume significance as the country has the second largest number of people with diabetes in the world. The International Diabetes Federation estimates that there are 72.9 million people with diabetes in India now, which is projected to rise to 134.3 million by 2045. The prevalence of diabetes in urban India, especially in large metropolitan cities, has increased from 2 per cent in the 1970s to over 20 per cent at present and the rural areas are also fast catching up.
Type 2 diabetes is a metabolic-cum-vascular syndrome characterised by predominant insulin resistance with varying degrees of insulin secretory defect. The Council observes that the disease, though more common in overweight and obese individuals of middle to late age, is increasingly being seen in younger age groups and in those with lower BMI as well. The Asian Indian phenotype (AIP), a peculiar constellation of abnormalities, predisposes South Asians to the development of insulin resistance. At any body mass index (BMI) and age, Asian Indians have higher body and visceral fat, waist circumference, lower skeletal muscle mass, thinner hips, short legs and profoundly higher rates of insulin resistance, metabolic syndrome and diabetes.
Treatment goals include glycemic control and prevention of acute complications; identification and management of co-morbid conditions like obesity and hypertension; prevention of microvascular complications like retinopathy, neuropathy and nephropathy;and prevention of macro-vascular complications like cardiovascular, cerebrovascular and peripheral vascular disease.
The guidelines underscore the importance of timely screening as Type 2 diabetes occurs at least a decade earlier in Indians compared to other major ethnic groups. Screening of asymptomatic individuals allows diagnosis of diabetes and prediabetes to be made at an earlier stage and provides an opportunity for screening of cardiovascular disease risk factors. Screening should be performed in all individuals above 30 years of age. It should be carried out at an earlier age in adults who have family history of diabetes and are overweight or obese.
Screening can be done by fasting plasma glucose, an oral glucose tolerance test using 75gm glucose or random plasma glucose. Glycosylated haemoglobin (HbA1c) is also recommended.
Children and adolescents aged 18 years and below should be screened for diabetes if they are overweight and have risk factors such as family history in first degree relatives, signs of insulin resistance, hypertension or dyslipidaemia. Urine glucose monitoring is recommended for estimation of ketones if blood glucose is greater than 400 mg/dl.
The norms also back self monitoring of blood glucose with Glucose Monitor to achieve better control of the disease.
Regarding calorie distribution, the council observes that as much as 55-60 per cent of energy from complex carbohydrates is an ideal recommendation. All patients with diabetes should be encouraged to take 6 small meals a day. Proteins should provide 12-15 per cent of the total energy intake for people with diabetes – similar to the recommendations for the general population. Proteins from pulses, soy, grams, peas, low fat dairy, fish and lean meats are recommended. Fats should provide 20-30 per cent of total energy intake. It is best to avoid alcohol. If used, should be taken in moderation. If alcohol is consumed, it should not be counted as part of the meal plan. However, it should be borne in mind that alcohol does provide calories, 7 kcal/ g, which are considered as ‘empty calories’. In the fasting state, alcohol may produce hypoglycaemia. Alcohol can further exacerbate fatty liver, neuropathy, dyslipidaemia and obesity and can worsen blood glucose levels. Smoking and tobacco chewing is totally prohibited.
Regarding physical activity, the recommendation is about 150 minutes of aerobic activity or its equivalent per week along with some resistance training at least twice a week and flexibility exercises. People with diabetes need an extra quick acting carbohydrate snack before the exercise and during the exercise, if the activity period extends the daily-recommended routine.
When glycemic control is not achieved with the maximum tolerable dose of a single oral agent or combination of oral drugs, the guidelines support a combination of oral drugs and insulin to achieve blood sugar control.
The Council has also noted that indigenous drugs from other systems of medicine such as Ayurveda, Homoeopathy and Unani do have blood glucose lowering effects. “Their exact mechanism of action is still not clear. There is a common belief that all herbal drugs are safe and non-toxic which is not necessarily true. In view of the widespread use of these indigenous medicines, physicians should be aware of the herb-drug interactions,” the guidelines pointed out.