Diabetes

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• Diabetes
• . Disseminate, Dance and Devices
• Nihal Thomas
• 
  MD DNB (Endo) MNAMS FRACP (Endo)
• 
  Dept of Endocrinology,Diabetes and Metabolism
• 
  Christian Medical College Hospital,
• 
  Vellore

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• Establishing the Magnitude of Diabetes and
  Complications
• Developing a National Programme for
• Training Personnel and
  setting up diabetes clinics
• Strategies to Improve Lifestyle in the Masses
• Clinical Research
• Basic Science Research

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• Establishing the Magnitude of Diabetes and
  Complications
• Developing a National Programme for
• Training Personnel and
  setting up diabetes clinics
• Strategies to Improve Lifestyle in the Masses
• Clinical Research
• Basic Science Research

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How Significant is diabetes as a problem?
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What is the Magnitude of Diabetes as a
problem in India?
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If diabetes is common, does it mean that
complications are also common?How common is
diabetic neuropathy in India?
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Sites for
Peripheral Neuropathy Survey
All India Institute, New Delhi
Christian Med College,Vellore
MV Hospital, Chennai
Government General Hospital, Madurai
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Results
(Consolidated) Prevalence of neuropathy
15 (n193) Peripheral Vascular Disease 5
(n64) Infections
7.6 (n100) Minor or Major amputation 3
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• Establishing the Magnitude of Diabetes and
  Complications
• Developing a National Programme for
• Training Personnel and
  setting up diabetes clinics
• Strategies to Improve Lifestyle in the Masses
• Clinical Research
• Basic Science Research

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• Urban Management and that of the middle
  income group for Diabetes has improved markedly
  in high GDP states.
• Rural India, low GDP states and lower income
  groups have been largely untouched.
• The concept of Integrated diabetes management
  and integrated diabetes clinics has not developed
  adequately.

How Satisfactory is the management of Diabetes
in Rural India?
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Diabetes Project in Rural and Semi-urban INDIA
Sponsored by World diabetes foundation Co-PIs
CMC, Endocrinology an SLRTC Karigiri
Nihal Thomas Abraham Joseph Vijay Aruldas
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The Objective.

• To train 100 Charitable hospitals to develop
• Diabetes Clinics, improve inpatient diabetes
  care,
• enhance medical, nursing and paramedical
  practices
• in diabetes focus on laboratory and pharmacy
  to handle diabetes better.
• Focus
• Prevention and control of Diabetes Mellitus
  in rural
• and semi-urban India through an established
  network
• of Hospitals.

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The WDF Project
-STEP I

• Charitable Group of Hospitals
• CMC Vellore
• 1. Diabetes nurse educators- 2 weeks
• 2. Doctors- 10 days
• 3. Enroll the laboratories onto the CMC
  Biochemistry
• quality control programme
• Schieffelin institute of Leprosy research and
• training, Karigiri
• 1. Podiatric technicians- 2 weeks
• 2. Orthopaedic cobblers- 1 month
• 3. Developing a local community health
  programme at the hospitals
• 
  (selected for 20 larger hospitals)
• 
  

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Model Diabetes Clinic
Diabetes Educator

Diet Counseling (Dietician)

Physicians
Exercise (Physiotherapists)
Ophthalmic Examination
Group Education
Foot-care
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What do the trainees need to do on going back?

• 1.. Ensure that they are clinically thorough in
  diabetes mellitus- not just academically but
  holistically.
• 2. Start the diabetes clinic running in the
  fashion advised right away- at least once a week,
  once stable twice a week.
• 3. Ensure the laboratory is in good shape try
  and institute Lipids, U microalbumin/creat
  ratio, HbA1c.
• 4. Total Glucometrization and elimination of of
  urine sugars from the menu.
• 5. Ensure a spirit of teamwork and
  egalitarianism. Key responsibility
• of a diabetes nurse educator
• 6. Contact us for any additional resources and
  help that you need, in terms of advise on
  infrastructure, academics and personnel training.
  
• 7. Train their own doctors and nurses in what
  that have already been trained in- intensively.
• 8. Give a report as to what you are doing once
  in 6 weeks.

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The initial Key Target States for
the WDF Project

Assam, Mizoram, Manipur, Meghalya, Tripura,
Nagaland
Jharkand
Bihar
Bengal
Orissa
VELLORE
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Achieved so far..
Himachal Pradesh-1
New Delhi-1
Uttaranchal-1
Punjab-1
Assam-5 Mizoram-3 Meghalaya-2 Nagaland-2

• Trained 84 Hospitals
• 15Batches

Uttar Pradesh-4
Bihar-3
Gujarat-1
Jharkand-2
Madhya Pradesh-1
Bengal-2
Chattisgarh-3
Maharashtra-4
Orissa-1
Andhra Pradesh-9
Karnataka-3
Tamil Nadu-19
Kerala-6
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Trained Hospitals
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Leonard Hospital, Batlagundu

• Location Semi rural area of Batlagundu,
  Dindigul Dt, Tamilnadu, India.
• Owned by Sisters of the Cross of Chavanod.

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Makunda, Assam
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Paduva Hospital, Thrissur

• Catholic mission Hospital
• 16 km from Thrissur
• 50 beds rural Hospital

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Evaluation-Rating System of Hospital Diabetes
Infrastructure

• A. Green Good infrastructure/ smooth functioning
• moving towards World Diabetes
  Foundation goals.
• B. Blue Strong efforts made in attempting to
  achieve the WDF
• goal, some limitations in local
  infrastructure.
• C. Red Some efforts made in setting up clinical
  and supportive
• work- can do significantly better
• D. Grey Some effort made- but well short of WDF
  goals
• E. Black No progress. Need to initiate programme

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Presbyterian Hospital, Durtlang, Mizoram
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• Established in1928
• 260 Bedded
• Diabetic Clinic started on 5th April 2005

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Group Education, Presbyterian Hospital, Durtlang
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Teaching Insulin Self-Administration
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Foot Care Demonstration, KJP Hospital, Shillong,
Meghalaya by Miss Jane(Diabetes Nurse Educator)
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PAAlna the clinic-20/02/07
Orientation comprehensive diabetic care
prevention of complications
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Paalna- OPD section with
posters displayed
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Nurse Educator
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Foot Care Technician
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Patient Camp
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Improving Medical Technology with simple
methods
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Neuropathic Sensory Testing
1. Modified Mounted Monofilament testing

0.5g blue 2.0g purple 4.0g red 10.0g
orange 300.0g pink
2-grammes
10-grammes
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Biothesiometry
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Diet Counseling, KJP Hospital, Shillong, Meghalaya
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The Course Material
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3rd Edition A Practical Guide to Diabetes
Mellitus

• Released in November, 2006

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Introduction

• The Khowai district in West Tripura has a
  population of 70,000.
• Located 4km from Bangladeshi border
• 3 hrs from capital city of Agartala
• Mixed population
• tribals living in traditional villages
• migrants from West Bengal living in major towns
  of Khowai Town and RC Ghat ( some tribals)

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Discussion

• Diabetes Awareness
• 9 prevalence of diabetes and 31 prevalence of
  overweight in the study population
• 44 were concerned about developing diabetes in
  the future, but knew little about pathogenesis.
• Several believed it was a transmissible disease.

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The fruits of Egalitarianism, Hard work and Team
effort.
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Seven Fulltime Diabetes Nurse Educators
Patient Education CGMS and Pump Outreach
Programmes Clinical Trials Basic Science Research
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• Establishing the Magnitude of Diabetes and
  Complications
• Developing a National Programme for
• Training Personnel and
  setting up diabetes clinics
• Strategies to Improve Lifestyle in the Masses
• Clinical Research
• Basic Science Research

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Screening and Awareness Camps
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Launched in 2004
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Diabetes Walkathons
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Quizzes for the Public on Lifestyle
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SPADES


School Programmes for Awareness, Diabetes,
Education and Screening 1) School Students and
Teachers Awareness 2) Screening for early
signs of the metabolic syndrome 3) Quizzes 4)
Art Competitions 11 Schools covered
Low HDL levels are ubiquitous

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Dancing for Diabetes
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DANCE Diabetes Awareness in Nurses and
Comprehensive
Education
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• Establishing the Magnitude of Diabetes and
  Complications
• Developing a National Programme for
• Training Personnel and
  setting up diabetes clinics
• Strategies to Improve Lifestyle in the Masses
• Clinical Research
• Basic Science Research

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Prospective Clinical Trials

• 17 Ongoing in Diabetes
• 3 in-house designed
• Special areas
• Ramzan, DPPV-inhibitors, Inhaled
• 
  insulin
• 5 full time endocrine pharmacists involved

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The need of the hour in Ramzan..

• More trials with oral hypoglycaemic agents
• Double-blinded
  trials.
• Trials from India.
• Better Planned studies

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BANGLADESH 100,000,000
INDONESIA 190,000,000,
INDIA 140,000,000
PAKISTAN 130,000,000
IRAN 55,000,000
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Inhaled Insulin..
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Continuous Glucose Monitoring System (CGMS)
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• Establishing the Magnitude of Diabetes and
  Complications
• Developing a National Programme for
• Training Personnel and
  setting up diabetes clinics
• Strategies to Improve Lifestyle in the Masses
• Clinical Research
• Basic Science Research

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Low Birth Weight and Diabetes

• A 20-year old cohort of low and normal
• birth weight individuals.
• 1.Studying energy expenditure with
• Indirect Caloriemetry
• Actiheart
• 2.Glucose Disposal With insulin-glucose
• Clamp studies
• 3.Hydrogen Spectroscopy with a 3Tesla MRI on
• intramyoellar and intrahepatic fat content

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RUHSA Cohort
CHAD Cohort
30 Kilometers
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Calorie usage
Cardiac activity
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SPECTRO LIVER
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SPECTRO LIVER
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SPECTRO SOLEUS
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SPECTRO SOLEUS
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Muscle spectro - Satish
1. IMCLCH2
2.IMCLCH3
3.EMCLCH2
4.Creatine
5.EMCLCH3
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r0.58, p0.019
The Higher the Birth Weight the greater the LDL
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r0.512, p0.005
The Lower the Birth Weight the lower the energy
expenditure
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r0.417, p0.06
Total Cholesterol in relation to liver fat
content
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Birth Weight Correlates with the Total Quantity
of Body Fat on Bioimpedance
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Rajni Karol Dietician
Elizabeth Educator
Anu Eapen Radiologist
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Babu Res Officer
Roshan Physicist
Ratnadas Social Worker
Solomon Statistician
Spurgeon Registrar
?
Gitanjali Biochemist
Venkat Community Health Physician
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Acknowledgments

• All Endocrinology Staff
• Schflein Institute
• Radiology
• Biochemistry
• Nursing Services
• Community Health
• Physiology

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THANK YOU
ANY QUESTIONS?