The science behind Diabetology and its treatment opportunities

Thanks to the use of continuous glucose monitoring sensors which are placed on the arm, one can get an idea about the blood sugar levels throughout the day. This also avoids unnecessary needle pricks and thereby the pain is also reduced.

1. Type 2 Diabetes (T2D) has made its omnipresence slowly but steadily in the world. What are the root causes for increased growth of diabetes in the present era especially in India?

The burden of diabetes has been steadily increasing in the world. We come across alarming statistics regarding the burden of diabetes worldwide. As per the IDF Atlas 2021 the number of people with diabetes in the world is 537 million between the age of 20 – 79 years, and is set to increase by 46% by 2045. India already has the second highest number of people with diabetes (74 million), after China. With the rising rates of obesity, the prevalence of diabetes is also expected to further rise in India. Type 2 diabetes was earlier a disease of the rich of urban society and of relatively older people. Today, it has started to affect the middle class and even the lower socio-economic strata. It has also moved to the villages. Finally, it is affecting the poorer section of society as well.

Usually, diabetes fails to get under control because of dietary indiscretions or lack of exercise. In India, consumption of excess carbohydrates is very common, almost 65-75% of the diet comes from carbohydrates. Since most of the carbohydrate is refined as highly polished white rice and refined wheat, it gets easily converted into glucose. This elevates the blood sugars and makes it difficult to control diabetes. Lack of exercise is one more reason for diabetes to be uncontrolled. Lack of sleep and stress are yet other reasons, often people are not regular with their medications. All these are controllable factors.

2. What are the recent advances made in the field of T2D for its cure?

Diabetes care and management has really been transformed in recent times with the help of new innovations and research. Insulin’s discovery was the turning point in treating and managing diabetes particularly type 1 diabetes. The introduction of new technologies has helped to shape new approaches to diabetes care and management.

In the field of type 2 diabetes, the role of newer Apps which help to make better informed decisions about diet, exercise and to modify treatment have helped to control type 2 diabetes better and even to reverse it in early stages. The sub classification of type 2 diabetes into different subtypes has also helped to take precision medicine in diabetes forward by offering specific types of drugs for those with specific subtypes of type 2 diabetes. 

Applying the principles of ‘Precision Diabetes’, it is now possible to very accurately classify a patient, determine the type of diabetes he or she has and then decide the type of treatment that this patient is likely to respond to.

3. As your dictum goes that ‘Today’s Research is Tomorrow’s Practice’, Could you share some examples on how you have contributed to the advancements in the field?

There are several examples of this. For e.g., New medicines for which trials are done today become available for therapeutic use in the future. When we do randomized clinical trials on various aspects of diabetes including prevention trials, through diet, exercise, yoga etc., we develop the scientific proof needed to take this to the community level. Once these trials are completed, all diabetes guidelines in India and abroad would incorporate the findings of the research. It then gets applied into the community. Thus, it is very important to do research on a continuous basis as this will help to develop new treatments which can help to improve the lives of people with diabetes.

4. Does the inculcation of Artificial Intelligence in healthcare have any role to play in the field of diabetes?

Artificial intelligence plays an important role in the field of diabetes management. 

One area where artificial intelligence is being applied extensively is in the field of diabetic retinopathy. Artificial intelligence is now routinely incorporated to retinal cameras so that when the pictures of the retina is taken, the AI immediately tells the healthcare provider whether it is a normal retinal photograph or it has diabetic retinopathy. If there is retinopathy, it also grades its severity and informs us when we have to refer to a retinal specialist for further treatment. 

Continuous glucose monitoring (CGM): Today, there are several devices available in the market that can continuously monitor the glucose levels. These are very useful especially if the patient has fluctuating glucose levels. These (CGM) devices use painless sensors that are applied on the body of the patient to continuously monitor the glucose level.

Free Style Libre & Free Style Libre Pro: These sensors provide a tracing of continuous glucose monitoring known as ambulatory glucose profile (AGP). The patient wears a small sensor continuously during the period of profiling which is usually about 14 days. The glucose values are continuously monitored by a reader which can be sent to the doctor via wireless transmission. The readings are downloaded in the form of graphs from the device. The graphs usually provide glucose graphs for each of the 14 days based on which the diabetologist can adjust the doses of medicines. 

Knowing the natural history of diabetes, we know that people can move from diabetes to prediabetes to normal; however, they can again move back from normal to prediabetes to diabetes.

5. Does the choice of diet have any role in controlling diabetes? What are other important factors at play?

Through the ages, diet has always remained a controversial issue. Diet is also something which people are very passionate about and in some ways very difficult to change because as the saying goes ‘old habits die hard’. There is no ‘best diet’ to prevent and control diabetes. It is well known that excessive calories particularly in the form of carbohydrates lead to obesity and to type 2 diabetes. Hence for prevention of diabetes, particularly in those who are at high risk, eg. Those who have a strong family history of diabetes, it is important to cut down the calories especially the carbohydrates and substitute this with proteins preferably from plant proteins like bengal gram, green gram, black gram, soya, mushroom, milk and eggs.

It is also important to include healthy fats (mono unsaturated fats) which come from oils like groundnut oil, mustard oil, canola, gingelly oil, etc and also from nuts and seeds. If one is able to cut down the rice and chapati quantity and increase the intake of green leafy vegetables, the risk for obesity, type 2 diabetes and heart disease can be cut down considerably. In order to prevent hunger, one can include salads, vegetables, dilute soups, buttermilk, lime juice, tomato juice and other low-calorie items. We have shown through our studies, that in people with pre-diabetes by a little alteration of their diet and increasing their physical exercise by modest weight loss, diabetes could be prevented in up to 35% of people with prediabetes.

6. Can a patient with a history of T2D reverse it? If yes, then how?

The term ‘Reversal’ implies that the condition has permanently gone away or been ‘cured’. Knowing the natural history of diabetes, we know that people can move from diabetes to prediabetes to normal; however, they can again move back from normal to prediabetes to diabetes. Hence. The term ‘Remission’ is preferred to refer to those who are currently normal, after having had diabetes earlier. It is analogous to a cancer going into a Remission phase. Just like cancer, diabetes too, can come back, often with a vengeance. 

My own experience has shown that: 

Remission is possible in the following groups of people:

1. Those with short duration of diabetes (less than 10 years),
2. People who have preserved insulin reserve as shown by the C-Peptide levels,
3. Those who are obese and have significant weight to lose, are more likely to achieve remission.
4. Highly motivated people are more likely to achieve Remission. 

It is important to recognize that once complications of diabetes have already set in, it is too late to attempt remission of diabetes. In our research studies, we have shown that those who present with very severe diabetes at the time of diagnosis of type 2 diabetes, eg. with HbA1c>10%, if given a short course of insulin for just 1 month, tend to not only respond very well, but later, are also able to stop all medications and achieve remission of diabetes.

7. What is the role of digital health in the management of T2D?

Today, digital health plays a very big role in many ways in the management of diabetes. Various Diabetes Apps are also used today which helps to connect to the patient and helps to keep the sugars under good control and also try to prevent or reverse diabetes in those who are in the early stages. 

Through telemedicine, telephonic and video consultations are today possible for patients who are in very remote areas who do not have to travel. Thanks to the use of continuous glucose monitoring sensors which are placed on the arm, one can get an idea about the blood sugar levels throughout the day. This also avoids unnecessary needle pricks and thereby the pain is also reduced. Retinal cameras which were earlier unaffordable, are now made in India and have become inexpensive and therefore affordable for the majority of patients.

Recently, we, at Dr. Mohan’s Diabetes Specialities Centre launched an AI enabled digital innovations under its digital transformation called Dr. Mohan’s Digital Diabetes Revolution with the 3D Initiative. The three Ds include 1, ‘DIA’ – an AI powered chatbot to assist people through automated digital conversations, 2, ‘DIALA’ – a patient-friendly mobile app and 3, ‘DIANA’ – a healthcare application for precision diabetes care. The digital transformation initiative enables seamless and highly personalized 24/7 online care and support services for people with diabetes. It is powered by world’s leading next-gen Total Experience (TX) Automation Platform, the AI enabled virtual assistant to engage patients through integrated approach across WhatsApp, Google Business Message, Facebook Messenger and web platforms. 

8. For clinicians in India. Why should a young practitioner spend their time in medical research? What is your advice on building a successful clinical researcher for them?

It is important that young physicians and diabetologists do research work. It keeps their mind active and also helps them to document their clinical findings. There may be rare cases which they may come across which they can publish. There could be problems which are peculiar to India and doing research on that will help not only Indians, but the rest of the world also. One cannot do research without studying world literature and constantly updating your knowledge. If one does not do any research, one tends to get outdated quite soon. Finally, we will be contributing to science and thus putting India on the world map of research. Hence, even if it is a small piece of research that one is doing, one should try to contribute to the scientific literature in whatever way one can.

9. What inspires you to push boundaries on a daily basis? What is your mantra for a successful career?

I have been lucky to have been initiated to research right from the time when I joined medicine from my first MBBS itself. This has helped me to be at the cutting edge of clinical diabetes research. It also helps me to find out what are the lacunae and gaps in our knowledge and to conduct research in those areas. I was lucky to have been mentored by my father, Prof.M. Viswanathan, who was a pioneer in the field of diabetes. I am also blessed to have a great team at the Madras Diabetes Research Foundation. It is the combined effort of all the scientists who work with us which helps us to keep pushing the frontiers and to continue our work in diabetes research.

10. India has made significant advances in many sectors. Indian doctors are renowned for their clinical practices. What needs to be done for India also to lead in medical research?

Although there are a few doctors in India who have contributed significantly to medical research and helped to put India on the world map of medical research, it is still a miniscule number of people. Many more people need to get involved in medical research. If doctors are to take up medical research, they have to be initiated very early in life, even when they are doing undergraduate medicine. This will sow the seeds of research in them which will then grow into a big tree of research in the future.

If they miss the bus at this stage, it is very difficult when they grow older and have more responsibilities in life to expect them to take medical research. Incentives must also be given for doctors to do research. Research grants must be made available to them. Research methodology courses have to be conducted. They can also be incentivized to do research by promotions, monetary incentives etc. If all these are done, many more doctors will take up research in India.

11. What is your advice to policy makers when it comes to prevention of diabetes in India?

Non-Communicable Diseases (NCDs) can easily be tackled by various policy interventions. Six risk factors, namely, unhealthy diet, insufficient physical activity, smoking, excess use of alcohol (or other drug abuse) pollution and stress are the cause of most NCDs. Hence, policies should encourage healthy eating, e.g., making vegetables and fruits more easily available and affordable, improving the urban infrastructure and built environment, so that people have safe areas for walking and exercising, increasing the green neighbourhood by planting more trees, providing safe drinking water and promoting yoga, pranayama etc., can all help to reduce NCDs. There must also be intensified surveillance so that if any of the NCDs are present, they can be picked up at an early stage and treated before they become too advanced. 

Large scale public awareness programs will also help to sensitize people about the importance of NCDs which are often considered a rich man’s disease and therefore, neglected. Diabetes, for e.g., is rapidly spreading to the middle class and to the poorer sections of the society. NCD’s are no longer an urban disease as they are rapidly spreading to the rural areas. Finally, from being diseases of middle or old age in the past, they are occurring in young adults and even in children and adolescents. Tackling NCDs has therefore to be done on a war footing!

12. Any message for our readers that you would like to share.

As part of an annual checkup, for all individuals above 30 years of age, a thorough screening for all NCDs should be done. Apart from looking at the glucose levels, lipid levels, blood pressure and assessing the cardiovascular disease, a simple screening for depression and also some easily identifiable cancers like breast cancer, cancer cervix, oral cancers can be done. An ultrasound can help to pick up many silent diseases. A good clinical examination, of course, is mandatory and the first step.