We searched electronic databases (PubMed, Google Scholar, Web of Science, and Embase) for articles published in English from Jan 1, 1970, to April 16, 2018, using the search terms “diabetes”, “dysglycaemia”, “complications”, “cardiovascular disease”, “nephropathy”, “neuropathy', “retinopathy”, “oral anti-diabetic medications”, “insulin”, “cost of care”, and “south Asia”. We also searched using the names of the countries included in the definition of south Asia used for the Series (Bangladesh,
SeriesClinical management of type 2 diabetes in south Asia
Introduction
In south Asians, type 2 diabetes develops at a younger average age, and progresses faster than in other ethnic groups. As a result, many diabetes complications are more prevalent and in more advanced stages in south Asian countries than in other regions. The tendency of south Asians to develop type 2 diabetes is enhanced by greater insulin resistance than in white populations, independent of generalised or truncal adiposity.1, 2 Furthermore, south Asians with even mild dysglycaemia seem to have reduced β-cell function, irrespective of age, adiposity, insulin sensitivity, or family history of diabetes.3 The consequent increased propensity to develop type 2 diabetes contributes to the growing burden of the disease in the region, adding substantial strains to poorly developed health systems and physicians already grappling with the continuing burden of communicable diseases in south Asia.4 The higher risk for dysglycaemia at a lower average BMI and the presentation of diabetes at least a decade earlier has and will continue to contribute substantially to management challenges.5
In this Series paper, we analyse challenges and opportunities in the clinical management of type 2 diabetes and its complications in south Asia. Other papers in this Series address the epidemiology and determinants of type 2 diabetes in south Asia6 and public health and health systems in the south Asian context.7 While the focus of the Series is on data in native south Asians living in the region (here defined as Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka), we also draw on knowledge from studies done in migrant south Asians living elsewhere, to allow meaningful comparisons on the causes and consequences of type 2 diabetes relative to other ethnic groups. Although the focus of this Series paper is type 2 diabetes, some data might include type 1 diabetes also.
Section snippets
Overview
Risk factor control is often poor and the burden of complications is extensive in south Asians with type 2 diabetes. Poor glycaemic control (70–80% above target for HbA1C control) has been reported in India8 and other south Asian countries, including Sri Lanka,9 Pakistan,10 and Bangladesh.11 However, in this context, there are few large, population-based studies and other data related to diabetes from countries other than India. The burden of complications in these countries is excessive, with
Acute complications
There is paucity of data regarding acute complications of diabetes in south Asia. According to data from a teaching hospital in India,72 infections are common and contribute to 41% of deaths among patients with diabetes. Complications related to coronary artery disease (16·9%) and diabetic ketoacidosis (3·4%) were other contributors to mortality, while hypoglycaemia contributed to 3·5% of deaths in patients with diabetes in the same study. Hypoglycaemia is particularly common in elderly
Reducing acute complications
Acute complications such as infections, ketoacidosis, and hypoglycaemia should be managed appropriately. In particular, selection of appropriate treatment to minimise risk, creating awareness of risk factors, and education of health-care professionals and patients regarding hypoglycaemia are important, especially in elderly patients and those with little formal education.
Anti-hyperglycaemic drugs
Because of its low cost and low hypoglycaemia risk, metformin remains a good first-line glucose-lowering drug in most
South Asian management guidelines and cost of care
In view of many south Asia-specific issues for management of type 2 diabetes, the need for separate guidelines for management has been discussed by south Asian clinicians and researchers. Specifically, it has been debated that available guidelines in many low-income and middle-income countries are inadequate in terms of clarity, applicability, execution plan, and socioeconomic contextualisation.109 Most south Asian countries, apart from Nepal, have management guidelines for type 2 diabetes;
Challenges in self-care and rehabilitation
Most of the studies regarding self-care and rehabilitation in patients with type 2 diabetes have been done in migrant south Asians living in other parts of the world. Self-care activities with respect to diet and physical activity are commonly inadequate in south Asians with type 2 diabetes. In a study done in south India, 29% of people with diabetes reported having good dietary behaviours and 19·5% reported having good exercise behaviours.26 Social stigma, taboos, and trying to comply with
Conclusion and future directions
The scale of type 2 diabetes in south Asia is unprecedented. Urgent attention is required by governments and international agencies to scale up prevention efforts and to provide a basic package of care (metformin, low-cost statins, and anti-hypertensive medications) for many people from the point of diagnosis. Additionally, many avenues of research remain to be fully explored (panel). It is important to assess the clinical benefits of earlier and more aggressive management strategies. Attention
Search strategy and selection criteria
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