Diabetes: Shortage Of Vascular Surgeons In India Costs 80,000 Limbs Every Year

India has less than 100 vascular surgeons since the establishment of the first department of vascular surgery in 1978. The states of Orissa, Madhya Pradesh, Bihar and Manipur don't have any vascular surgeon.

No government-run hospital in the country's capital New Delhi, including the premiere All India Institute of Medical Sciences, has a department of vascular surgery. Chennai and Bangalore in the southern states of Tamil Nadu and Karnataka respectively, with 20 surgeons each, are slightly better off.

Only last year, the number of seats for post-graduate degree in vascular surgery in the country was raised from four to eight in medical colleges. Including diploma holders, the country produces only 16 vascular surgeons yearly. This, experts feel, should be trebled in two years.

"A large number of people wheeled in for amputations are either trauma victims or long-term diabetics. At least 40% of people with decade-long diabetes develop vascular problems. In a country where more than 40 million people are estimated to have diabetes, the number of people estimated to have vascular problems is large. Add to this road accident victims day and you know why there is a need to produce a greater number of vascular surgeons," says Dr Sekar, who is also the president of the Vascular Society of India. Though there are no clear statistics on amputations, it is estimated that at least one lakh people lose a limb every year. Of these, nearly, 80,000 amputations are avoidable.

Sakthiraj Ekambaram, 29, a chronic smoker, complained of pain every time he walked for more than 20 minutes. "I had to stop for a couple of minutes and walk again. The doctor sent me to the gym," he said. Luckily, Sakthiraj, decided to consult a vascular surgeon for the wound that did not heal for long. "That is when I discovered that the blood supply to my legs was very low. My feet were cold unlike other parts where blood flowed and I did not have good sensation on my feet. I underwent a procedure that saved my legs," he said. But not all patients are as lucky has Sakthiraj, says Dr Sekar.

Pulling out the case sheets of a 40-year-old patient, he continues, "A chronic diabetic, this patient had one of his limbs amputated last year. This year, he had his other leg amputated too. Almost 50% of diabetics who go in for amputation of one limb, lose their second limb in another year. A vascular disease is an indicator of a heart disease because if there are blocks in the leg, there can be blocks in the heart too," says Dr Sekar.

"When people are disabled, the burden is high on the family and the government," says Dr Ravul Jindal, the only qualified vascular surgeon in Chandigarh. "Some patients who can afford the treatment are referred to doctors in other states. The others undergo amputation surgeries. These are done by general surgeons or orthopedic surgeons to prevent infection from spreading to other parts of the body," says Dr Jindal.

The society is now waging an aggressive war with the Union health ministry and at least ten state governments urging them to start new departments in vascular surgery. Vascular surgeons say they consider several options before deciding to remove a limb.

"The blood vessels in the legs and hands are just like arteries and veins in the heart. If there is a block in arteries of the heart, it can reduce supply of blood and cause heart attack, which is death of the heart muscle. When similar things happen on the leg, it leads to death of muscles in the leg. They begin to rot (gangrene). Just like the heart, we have options of using balloons to remove blocks by a procedure called angioplasty, place drug coated thin wires in the vessels to prevent clots or even do a by-pass graft," says Dr Paresh Pai, consultant vascular surgeon at Mumbai's Lilavati Hospital. "But on most occasions, patients are refered to us very late. We want to create awareness among doctors and patients on foot care. For instance, if a wound remains unhealed for long, doctors should first check if there is adequate blood supply and restore it. For this, the patient should come in early," he says.

Representatives from the association would meet Union health minister Ghulam Nabi Azad and health secretary Sujatha Rao to discuss a road map. First, they want the ministry to increase the number of seats for post-graduate degree in vascular surgery. "At present, there are only seven training centers for vascular surgery, training 12 students every year. We want them to double the number of seats in a year and increase it by at least three times by 2012," Dr Sekar said. 

Thank you Pushpa Narayan/Times of India

Diabetes: What Really Ails China

China’s struggle with diabetes has reached epidemic proportions. This is the conclusion of a group of researchers from Tulane University, whose findings were recently published in the New England Journal ofMedicine, one of the United States’ most prestigious medical journals. 

According to the study, 92.4 million adults in China age 20 or older (almost 10% of the population) have diabetes, and 148.2 million adults have pre-diabetes, a condition that is a key risk factor for developing overt diabetes and/or cardiovascular disease. Of particular significance is the finding that the majority of cases of diabetes are undiagnosed and untreated.

These new figures indicate that China has edged ahead of India to become the country with the largest population of diabetics in the world. 

Most cases of diabetes are from so-called type 2 diabetes, a form of the disease that accounts for 90-95% of all diabetes cases among adults. It results from insulin resistance and is sometimes combined with an absolute insulin deficiency.

The diabetes epidemic is not only a serious public health problem — it can also have serious economic repercussions. A study found that estimated medical costs for diabetes and its complications were 18.2% of China’s total health expenditures in 2007. The World Health Organization (WHO) estimates that diabetes, heart disease and stroke will cost China approximately $558 billion between 2006 and 2015.

Until just over a decade ago, diabetes was relatively rare in China. However, in the last decade the problem has become much more severe. Experts believe that China’s rapid economic development — and the increased urbanization, physical inactivity, unhealthy diet and obesity that often accompany increased prosperity — is an important contributing factor in the development of the disease. 

Environmental toxins may also contribute to recent increases in the rate of type 2 diabetes. This is the opinion of some experts, who found a positive correlation between the concentration in the urine of bisphenol A, a constituent of some plastics, and the incidence of type 2 diabetes.

Obesity has been found to contribute approximately 55% to an individual’s development of type 2 diabetes. A study on the importance of lifestyle factors showed that those who had high levels of physical activity, a healthy diet, did not smoke and consumed alcohol only in moderation had an 82% lower rate of diabetes. When a normal weight was included, the rate was 89% lower.

The increased rate of childhood obesity between 1960 and 2000 is believed to have led to the increase of type 2 diabetes in children and adolescents. There were more than 60 million obese people in China, and another 200 million who were overweight, according to a 2004 nationwide survey.

In the United States, type 2 diabetes affects approximately 8% of adults. That proportion increases to 18.3% among Americans age 60 and older, according to statistics from the American Diabetes Association. In comparison, the worldwide prevalence of diabetes among all age groups was estimated to be 2.8% in 2000, and will rise to 4.4% in 2030.

Diabetes and its consequences have become a major public health problem not only in China, but in many industrialized countries as well. To avoid further damage to people’s health, it is imperative to develop and institute national strategies for preventing, detecting and treating diabetes in the general population.

Thank you Cesar Chelala/The Globalist

Surgical Procedure Can Control Type 2 Diabetes, Claims Brazilian Surgeon

A new procedure which requires surgical intervention through Ileal Transposition (or small intestinal switch) can effectively control Type 2 diabetes, a Brazilian surgeon claimed in Hyderabad, India on August 21.

Dr Aureo Ludovico de Paula, was in the city to address the first international conference and live workshop on this procedure along with his Indian counterpart Dr Surendra Ugale.

Ugale who is also the organizing secretary of the workshop said, “the new research has shown that there are some intestinal hormones which have a great effect on the pancreas and insulin secretion especially in response to food intake. Dr Paula has devised a laparoscopic operation which he claims is proving to be a cure for Type 2 diabetes.”

Paula said, “The surgery can control diabetes without insulin, arrest the metabolic syndrome of the body organ deterioration, thus avoiding future diabetic complications.”

The doctor who has performed 700 surgeries with 95% remissions said the operation involves a long segment of ilium (ending portion of small intestine) which is shifted to the upper small intestinal area, where food particles will reach it very soon on eating a meal.

This causes an immediate secretion of good hormone GLP-1 which acts on the B cells of pancreas to secrete insulin and control blood sugar.

The fall out is a biochemical process that facilitates insulin secretion in the presence of undigested food and controls Type 2 diabetes, a metabolic disorder that is marked by the failure to absorb sugar and starch due to lack of the hormone insulin, Paula said.

Type 2 diabetes is the most common form of diabetes. In this disease, either the body does not produce enough insulin or the cells ignore it.

Ugale explained that Type 2 Diabetes affects several organs. The solution therefore is to stimulate these hormones in lower intestine that in turn secrete GLP which in turn stimulates the pancreas to stimulate the insulin and get fresh beta cells.

He said patients who already have diabetes for ten years and using medication, and are suffering from five associated diseases are ideal candidates for this kind of surgical intervention which costs less than US $10,000 (in India).

The surgery not only controls high blood pressure but also improves kidney cholesterol nerves reduces excess weight and also one need not take any medicines. He also can eat normally post surgery, including sweets.

However, doctors insist that first of all in any patient they would advise lifestyle changes, exercise followed by medication, if there is diabetes and if the patient is not doing well only then surgery is advised.

Presently a centre in Mumbai and Hyderabad are performing this surgery. A centre has also come up in Coimbatore.

Over hundred doctors from all over the country and endocrinologists are participating in the two-day seminar

China Faces Diabetes Epidemic After Adopting Western Diet

China suffers from far more cases of diabetes than previously thought, placing its diabetes epidemic on the same scale as that of the United States, according to a study published in the New England Journal of Medicine.

"In the last 10 years, with the country's economy expanding quickly and people's standard of living improving, people's lifestyles have changed," said co-author Yang Wenying of the China-Japan Friendship Hospital in Beijing. "China's economic development has gone from a situation of not being able to eat enough, of poverty, to having enough food and warm clothes, and doing much less exercise."

Lifestyle changes such as increased urbanization and sedentism and "Western" diets high in fat and junk food have caused an increase in heart disease, diabetes, cancer and other "lifestyle diseases" across China. According to the new findings, there are 92 million diabetics in China, more than twice as many as the 43.2 million recently estimated by the International Diabetes Federation (IDF). Another 150 million are believed to be pre-diabetic.

This means that 10 percent of Chinese residents are diabetic, while 16 percent are at risk of developing the disease.

The new figures were calculated from a sample of more than 46,000 people over the age of 19, from 14 different provinces and municipalities across China. They launch China into first place as home to the most diabetics in the world, bumping India down to second place. The IDF estimates that 50.8 million Indians are diabetic.

Yet Anoop Misra of New Delhi-based Fortis Healthcare believes that the numbers in India are vastly underestimated as well.

"I feel that India's diabetes burden too will be a lot more than estimated," she said. "At present, while 50 million are known to be diabetic, 100 million are at the stage of pre-diabetes in India."

In both China and India, most cases of diabetes remain undiagnosed and untreated.

Thank you David Gutierrez

Indian Get Diabetes Before Europeans

Underscoring the importance of an individual's genetic make-up in disease development, a new study has confirmed the association of eight gene variants with type 2 diabetes in Indians.

With Genome Wide Association studies worldwide revealing the likely link of about 20 loci with type 2 diabetes, scientists from Centre for Cellular and Molecular Biology (CCMB) and three other institutions in the country investigated the association of eight common and well-established genetic variants with type 2 diabetes in 5,148 Indians.

The study was recently published in ‘Diabetes', a journal brought out by the American Diabetes Association.

According to Giriraj R. Chandak, senior scientist from Centre for Cellular and Molecular Biology, the onset of diabetes among Indians was a decade earlier than in Europeans and at a lower body mass index (BMI), probably because of excess fat around the abdomen.

As a result, the other health problems associated with diabetes too get manifested earlier than in Europeans or others. With each of the variants having its own impact in developing the risk for diabetes, it was found that the effect was much higher in Indians.He said there could be more than the eight variants which were so far found to be associated with diabetes in Indians.

The identified variants increased the risk of diabetes by 21 to 25 per cent. The risk of developing diabetes was found to be higher when an individual carried more than a single variant.

Stating that the study gave a clear idea of how genetics played an important role in development of diabetes, the senior scientist said, it however, remained to be seen how the gene variants interact with other lifestyle risk factors like diet and lack of exercise.

Early identification of such genetic variants could help in prediction of diabetes risk in individuals as also in developing targeted drug therapy.

The other institutes involved in the study are Institute of Genomics and Integrative Biology, Delhi, King Edward Memorial Hospital and Research Centre, Pune and Indian Statistical Institute, Kolkata.

Y Mallikarjun/The Hindu

Defeating Diabetes: India To Hold First Ever Diabetes Census

India will hold a Diabetes Census - probably the first of its kind - by the end of this year or early next year. The announcement was made by Union health minister Ghulam Nabi Azad in Mumbai on Friday, May 14.

The census would essentially mean mandatory testing of blood sugar levels. "We intend to start mandatory testing for diabetes in the age-group of 25-70 years across the country in the next two years. The idea it to figure out the actual number of the population that is actually suffering from diabetes, or is likely to suffer," said Azad.

The diabetes census will start from cities and will trickle down to villages. Mobile ambulances will go around testing the population. "In certain villages, where ambulances cannot reach, we will take the help of glucometers (device for determining glucose in blood)," said Azad.

Glucometers will cost the government an additional Rs 100 crore. The cost per patient will come to Rs 100. This includes the cost of involving a doctor and sending him to villages, Azad said. 

The Centre will seek the help of all state governments to pull off the mammoth initiative. "We will study all three categories of diabetes and decide on the next course of action accordingly," he said. State governments will help those on the borderline to bring about behavioural changes like changes in food habits and exercising," he said. 

Defeating diabetes would mean controlling a host of ailments that come with it.

Every sixth diabetic in the world is an Indian, making the country the world's diabetes capital. India has over 50.8 million diabetics out of the world's 285 million. China with 43.2 million patients comes second, followed by the US where 26.8 million people suffer from the disease.

The disease is affecting more people in the working age group and is proving to be an economic burden, according to the figures released by the International Diabetes Federation. Indeed, Asian countries carry about 60% of the global diabetes burden. 

The Lancet reports that prevalence of type 2 diabetes has rapidly increased in native and migrant Asian populations. Diabetes develops at a younger age in Asian populations than in white populations, hence the morbidity and mortality associated with the disease and its complications are also common in young Asian people.

The young age of these populations and the high rates of cardiovascular risk factors seen in Asian people substantially increase lifetime risk of cardiovascular disease. Several distinctive features are apparent in pathogenetic factors for diabetes and their thresholds in Asian populations.

The economic burden due to diabetes at personal, societal, and national levels is huge. National strategies to raise public awareness about the disease and to improve standard of care and implementation of programmes for primary prevention are urgently needed.

Azad's announcement couldn't have come a day too soon. However, it would have been better if this exercise was incorporated in the general census already underway as the enumeration would have been more rigorous.

Anyway, even this special diabetes census is most welcome. At least it will give the government what it's up against for development goals are meaningless unless there's a healthy population to lend its shoulder to the wheel as it were.

Diabetes: Avandia Drug Trial Unethical And Dangerous

The Canadian physician whose research escalated safety concerns about the Type 2 diabetes drug rosiglitazone (marketed as Avandia) is urging the US Food and Drug Administrationto call a halt to a major international trial designed to compare the safety of Avandia against another diabetes drug in the same class.

Dr David Juurlink, chief of clinical pharmacology and toxicology at Sunnybrook Health Sciences Center in Toronto, was the lead author of a 2009 study that found that compared to elderly diabetics taking a drug called pioglitazone (marketed as Actos), those taking Avandia were about 30% more likely to suffer heart failure or death.

On Tuesday, Juurlink joined with Dr Sidney Wolfe, director of health research for the consumer watchdog group Public Citizen, in calling a further clinical trial pitting the two diabetes drugs against each other "unethical" and "dangerous."

In 2007, the FDA issued two separate safety warningson Avandia and required the drug's maker, GlaxoSmithKline, to post "black box" warnings on the medicine's patient instruction sheet indicating the drug might put patients taking it at higher risk of ischemic heart attack or heart failure. The agency also ordered GSK to conduct a post-marketing safety trial of Avandia.

That planned trial is expected to draw from sites in 14 countries, including a number of newly-added developing countries such as Pakistan, India, Latvia, Chile, and Mexico, and to enroll 16,000 subjects. Called the TIDE trial, or Thiazolidinedione Intervention in Vitamin D Evaluation, was the subject of Tuesday's appeal from Juurlink and Public Citizen.

In fact, both drugs have been tagged with safety issues: In addition to raising rates of cardiovascular events, the class of Type 2 diabetes drugs known as thiazolidinediones (or TZDs) have been linked in studies to higher rates of edema, macular edema, bony fractures, anemia and acute liver injury. Older diabetes medicine such as metformin and sulfonylurea are widely believed to be safer alternatives.

At the same time, the drugs are widely used and have many defenders in the care of Type 2 diabetes.

But extensive financial ties between the drug companies that make the medicines and many of the clinicians and researchers who have defended them have prompted some to ask whether the safety debate has been tainted by industry influence.

There is scant evidence that the proposed clinical trial will yield more reliable evidence of Avandia's relative safety profile than existing research has done, Juurlink and Wolfe wrote in a Tuesday letter to FDA Commissioner Margaret Hamburg. Nevertheless, it will expose "thousands of high-risk patients with diabetes to a drug with an unfavorable safety profile and clinical advantage over its comparator," they wrote.

The "price of definitive proof" of the drug's safety hazards, they added, "will almost certainly be measured in the lives of study subjects who have been incompletely informed about the risks and benefits of participation" in the trial, they added.

Thank you Melissa Healy