Type 1 diabetes. Diabetes in Children-A poor cousin of type 2 diabetes. Incidence. Diabetes Nepal Conference

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1 Type 1 diabetes Diabetes in Children-A poor cousin of type 2 diabetes Prasanna Kumar K M Dr.kmpk@gmail.com 15 FEB 2014 Kathmandu- Type 1 diabetes accounts for only about 5 10% of all cases of diabetes. Incidence of T1 DM continues to increase worldwide and it has serious short-term and long-term implications. Incidence The incidence of type 1 diabetes is rising by 3% per year, at present more than children are affected in Europe alone. Nearly 75,000 fresh children are diagnosed to have T1DM every year. No cure is available, and although one day we might be able to prevent diabetes Prasanna Kumar 1

2 Increasing prevalence Type 1 diabetes in children: Fighting for a place under the sun This increase in incidence along with enhanced access to insulin and better survival rates will lead to a higher prevalence in the near future. No definite data available in India-lack of Diabetes registry. EDITORIAL-KM Prasanna Kumar, Kishwar Azad, Bedwora Zabeen,Sanjay Kalra-TheIndian Journal of Endocrinology and Metabolism , 7,1-3. Type 1 diabetes (T1DM) is one of the most common pediatric endocrine illness. Of these, over half live in developing nations, with India being home to an estimated 97,700 children with T1DM. Diabetol Metab Syndr 2010;2:14.. J Indian Med Assoc 2008;106: Results from Karnataka Diabetes Registry At Karnal, in Haryana, the prevalence of T1DM is 26.6/100,000 in urban and 4.27/100,000 in rural areas of the district, leading to an average prevalence of 10.20/100,000 population. Karnal city has a relatively high prevalence of T1DM (31.9/100,000) KalraS, KalraB, Sharma A. Prevalence of type 1 diabetes mellitus in Karnal district, Haryana state, India The Karnataka state T1DM registry listed an incidence of 3.7/100,000 in boys and 4.0/100,000 in girls over 13 years of data collection PrasannaKumar KM, Krishna P, Reddy SC, GurrappaM, AravindSR, MunichoodappaC. Incidence of Type 1 diabetes mellitus and associated complications among children and young adults: Management A statement of the American Diabetes Association Management of type 1 diabetes is best undertaken in the context of a multidisciplinary health team and requires continuing attention to many aspects, including insulin administration, blood glucose monitoring, meal planning, and screening for comorbidconditions and diabetes-related complications. Care of Children and Adolescents With Type 1 Diabetes Ideally, every child newly diagnosed with type 1 diabetes should be evaluated by a diabetes team qualified to provide up to date pediatric-specific education and support. (Diabetes team-consists of a pediatric endocrinologist, a nurse educator, a dietitian, and a mental health professional) Prasanna Kumar 2

3 CDiC Program Status Review DAVID RUKARE Uganda David has type 1 diabetes Changing Diabetes in Children Global Scenario update Grand Total Center City / Town Recruited YTD BDH Bangalore 602 Samatuvam Bangalore 169 Diabetomics Hyderabad 441 Tapadia Hyderabad 202 MVDRC Chennai 256 TOTALL Indore 170 JEHANGIR HOSPITAL Pune 51 SARDA Aurangabad 255 DDRC Delhi 101 Wadia Mumbai 61 SSKM Kolkata Kolkata 93 AIIMS Delhi 40 PMCH Patna 19 IGICH Bangalore 151 KEM - Mumbai Mumbai 175 Barati Karnal 225 Diacare Ahmedabad 507 SPAD Kanpur 136 KIDS Bhubanesw ar 54 Hope & Care 1 NovoAid All India 231 Total 3940 Total 3940 children recruited from 20 centers & 16 Satellite center 14 children dead 100 Children Camps conducted Few more centers to be created by Q PMCH, AIIMS, SSKM and KIDS are requesting for extension of recruitment period Consensus statement to be released in the Diabetes India in Apr 13 Date 13 Presentation title Background facts Barriers for children with diabetes in developing countries Average survival time for a child with type 1 diabetes in Africa is app 11 months Most developing countries do not have any specialised care (paediatric endocrinology) Very limited data available on prevalence rates Public-private partnership Countries involved A public-private partnershipinitiative with: Initial roll-out SE ASIA Roll-out Ministries of Health Civil society WDF Roche ISPAD Bangladesh Cameroon Guinea Tanzania AFRICA Ethiopia India Dem. Rep. of Congo Uganda Kenya Prasanna Kumar 3

4 Programme design Improved Infrastructure for managing type 1 diabetes better HCP training manual Patient education materials Diabetes registry, monitoring & control Medical equipment & supplies Patient education Infrastructure 1 & equipment 2 Training of HCPs 3 Free insulin (establish supply system) Reaching out Pan India through 19 CDiC centers and 18 Satellite centers Gender Distribution of study population CDiC Results-INDIA Data from Bangalore, Mumbai,Kanpur, Delhi, Hyderabad,Ahmedabad, Indore Gender Distribution FEMALE MALE 49% 51% Gender Frequency Percent MALE FEMALE Total Table: Mean (SD) HbA1C at different visits Table: Mean (SD) HbA1C at different centres at different visits Visit N Mean Std. Deviation Visit 1 HbA1C Visit 2 HbA1C Visit 3 HbA1C Visit 4 HbA1C Visit 1 HbA1C Visit 2 HbA1C Visit 3 HbA1C Visit 4 HbA1C CENTRE N Mean SD N Mean SD N Mean SD N Mean SD Ahmedabad AIIMS Bangalore_IG CHIR BDH_ Bangalore Hyderabad Indore KANPUR SD-Standard Deviation Prasanna Kumar 4

5 Table: TSH Levels in the study population Table: Distribution of HbA1C at Visit 1 Condition Frequency Percent SUB CLINICAL HYPERTHYROIDISM (<2.4 u/ml) NORMAL ( u/ml) SUB CLINICAL HYPOTHYROIDISM ( u/ml) OVERT HYPOTHYROIDISM (>10.0 u/ml) Total HbA1C Frequency Percent <7.9% % % >10% Total Table: Distribution of HbA1C at Visit 4 HbA1C Frequency Percent <7.9% % % >10% Total HBA1c <7.9% 7.90% 9.10% <8.9% 9.26% 12.56% <9.9% 16.85% 22.70% <10.9% 13.89% 17.87% <11.9% 12.40% 12.56% >12% 37.00% 24.00% Total Table : Urinary micro albuminuria Table: Fundal findings Urinary Albumin Frequency Percent Fundus Frequency Percentage < > Total Normal DR Others Total Prasanna Kumar 5

6 Challenges optional management for a T2DM patient becomes essential in T1DM. Diagnosis- Rural vs Urban Health care delivery Physicians trained to manage T1DM- Infrastructure- Insulin- Monitoring- Admission-Complications- Ophtnalmologist- Education- Counseling- Psycho social support. Major challenges remain in the development of approaches to the prevention and management of type 1 diabetes and its complications. A T1DM child requires frequent monitoring for blood sugars and ketonuriaas well as for other complications. Emphasis on diet, calorie counting, regular physical activity, injection technique and sick day management is essential. The unique psychological needs and challenges of growing children need to be addressed. Diabetes education for T1DM Healthcare professionals Need for a structured diabetes education programme, for both patients and parents /health care providers, which focuses on T1DM management. IDEP-Indian diabetes educatorsprogramme In association with Project HOPE & IDF. Trained-4000 diabetes educators,india-post graduate diploma in Diabetes education-6 months- Diabetes care professionals, including nurses, dieticians and doctors, may not possess the specific skills required to optimally manage T1DM. May not have the time or energy to put these skills into practice. Standard of Care for T1DM The psychological stigma ofdiabetes in children Minimal care- diagnosis- Insulin- syringe- consultation Standard care-average care, monitoring, screening for complications Comprehensive care-best care-scandinavian countries It affects mainly the patient and the family as a whole. Frequent hypoglycaemicattacks and diabetic keto-acidosis hamper the child s learning processes. Life-long administration of insulin, timely and restricted food habits and complications of diabetes impose great difficulty in living normal life for patient. Prasanna Kumar 6

7 Psycho-social aspects of diabetes in children Social problems Regular interaction between parents, nurses, doctors and the school authority must be assured for close monitoring. The child must be encouraged to participate in the school and family activities. Proper education of self-care must be given to the child so that the child can cope with his/her existing disease, maintain selfconfidence, ensure self-management and adapt with the life at large. Jobs for diabetics-not many are willing to recruit diabetics though equally qualified & competent. Should be considered handicapped. Marriage- Difficult to find a match-what to tell- Howand to wham? Current scenario of children with diabetes in India & Nepal Living with type 1 diabetes mellitus- Stages of life No registry of diabetes in children- No comprehensive data available. Most of the care in private sector/ philanthropic NGO Insulin expensive- Animal- Human- analogues Monitoring expensive Training of doctors for management- diabetes educatorsscarce. Infants & Toddlers School going children Adolescents and youth Job- Private- Govt- Defence Marriage- Pregnancy Morbidity & Mortality Road ahead USA- Centre for disease control- 10 yr old boy or girl-developing diabetes-qll-18.7 & 19 life years compared to non diabetics. Focused studies show that outcomes can be improved by better management, there is no evidence of this actually happening on a world wide basis. E Gale Newer treatment approaches have facilitated improved outcomes in terms of both glycaemic control and reduced risks for development of complications. Major challenges remain in the development of approaches to the prevention and management of type 1 diabetes and its complications. Prasanna Kumar 7

8 Diabetes in children-registry To evaluate population differences in risk of disease, it is essential to develop a case registry. For example, in diabetes research, all new cases (incident) of IDDM are registered during a specified time period in a defined geographic area. DIAMOND project- SUMMARY Thank you for attention Wide disparities in socioeconomic levels, educational background, and the availability of diabetes care pose major hurdles in the management of this disease in India. Parents and family tend to view T1DM as a stigma. we need to take the lead to ensure comprehensive clinical and psychological care for all children with T1DM by PPP. NO CHILD SHOULD DIE OF DIABETES Thank You!! 38 Prasanna Kumar 8