Series
Clinical management of type 2 diabetes in south Asia

https://doi.org/10.1016/S2213-8587(18)30199-2Get rights and content

Summary

Compared with other ethnic groups, south Asian people with type 2 diabetes tend to develop the disease at a younger age and manifest with higher glycaemia, dyslipidaemia, nephropathy, and cardiovascular diseases. Additionally, specific issues that can affect treatment of type 2 diabetes in south Asia include poor awareness of the disease, delay in diagnosis, inadequate treatment, the use of ineffective and often harmful alternative medicines, and frequent non-compliance with lifestyle recommendations and drug treatment. Disease development at younger ages, delayed diagnosis, and inadequate management result in early development of severe complications and premature mortality. In this Series paper, we describe the challenges associated with the increasing burden of type 2 diabetes in south Asia and discuss ways to improve clinical care of people with the disorder in the region (defined to include Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka). Treatment of diabetes in south Asia needs to be individualised on the basis of diverse and heterogeneous lifestyle, phenotype, environmental, social, cultural, and economic factors. Aggressive management of risk factors from diagnosis is necessary to reduce the risk of microvascular and macrovascular complications, focusing on provision of basic treatments (eg, metformin, low-cost statins, and blood pressure-lowering drugs) and other interventions such as smoking cessation. Strengthening of the primary care model of care, better referral linkages, and implementation of rehabilitation services to care for patients with chronic complications will be important. Finally, improvement of physicians' skills, provision of relevant training to non-physician health-care workers, and the development and regular updating of national clinical management guidelines will also be crucial to improve diabetes care in the region.

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

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,

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