Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Book Review
Case Report
Clinical Images
Clinical Images/Spotters
Current Issue
Editorial
Editorial Commentary
Fellow’s Corner
Images (Radiology/Radioisotope Scans/Fluoroscopy Images, etc.)
Invited Review
Mini Review
News ISPAE elections
Obituary
Original Article
Ped-Endo-Journal Scan
Pediatric Endocrine Trainees Section (Open-Forum)
President’s page
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Book Review
Case Report
Clinical Images
Clinical Images/Spotters
Current Issue
Editorial
Editorial Commentary
Fellow’s Corner
Images (Radiology/Radioisotope Scans/Fluoroscopy Images, etc.)
Invited Review
Mini Review
News ISPAE elections
Obituary
Original Article
Ped-Endo-Journal Scan
Pediatric Endocrine Trainees Section (Open-Forum)
President’s page
View/Download PDF

Translate this page into:

Editorial
2 (
2
); 46-47
doi:
10.25259/JPED_39_2022

Type 1 diabetes in limited resource settings: Where are we and where do we need to go?

Consultant Pediatric Endocrinologist, Department of Pediatrics, Rainbow Children’s Hospital, Hyderabad, Telangana, India
Corresponding author: Leena Priyambada, Department of Pediatrics, Rainbow Children’s Hospital, Hyderabad, Telangana, India. leenapriyambada@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Priyambada L. Type 1 diabetes in limited resource settings: Where are we and where do we need to go? J Pediatr Endocrinol Diabetes 2022;2:46-7.

“If access to health care is considered a human right, who is considered human enough to have that right?” – Professor Paul Farmer

Globally, more than 8 million people live with type 1 diabetes (T1D), with India having the second highest prevalence.[1] In 2021, nearly one-fourth of the world’s mortality due to T1D was in South Asia. As per the just released T1D index,[1] the remaining life expectancy of a 10-year-old child newly diagnosed with T1D is projected to be 24 years in India and 12 years in Ethiopia compared to 57 years in the USA and 64 years in Australia. Moreover, almost two-thirds of the deaths in young people with T1D are estimated to be due to non-diagnosis. Many of these numbers are extrapolations due to the non-availability of data in low-income countries and low-middle-income countries. This situation is appalling and unacceptable. Two things come out of this. First, campaigning for increasing awareness of T1D is the need of the hour. Second, registries provide valuable insights and creating them must be given importance.

Not surprisingly, diabetic ketoacidosis (DKA) is more frequent in limited resource settings (LRS). Even if DKA is timely diagnosed, access to healthcare facilities and trained healthcare personnel (HCP) may be suboptimal. Equipment and practices for safe intravenous (IV) fluid and IV insulin (IVI) may be scarce. It may not be possible to quickly shift to a referral center (sick child, no finances, difficult transport, due to long distance, civil or political unrest, floods, and pandemics to name a few).

Few studies successfully describe use of subcutaneous insulin (SCI) (mostly analogs) in DKA (mostly uncomplicated mild to moderate), which were used as evidence base in the ISPAD guidance for SC insulin in DKA.[2] Analogs may not be universally available. Regular (R) and/or pre-mixed insulin are frequently the only insulin available in LRS public hospitals.[3]

The article by Ayyavoo et al.[4] in this issue adds valuable information regarding the use of R insulin as a SCI in severe DKA.

With telemedicine, it may take just a phone call to connect with an expert to start appropriate fluids and insulin in DKA. With the less complicated nature of management with SCI, the peripheral HCP may not hesitate to initiate treatment, as against IVI. Cost-effectiveness[4,5] and practicability of treatment in wards (and not ICUs) are alluring.

Hypoglycemia and hypokalemia have been associated with poorer outcomes in DKA in LRS.[6] Clinical and biochemical monitoring, especially for electrolytes and blood glucose (BG), and robust protocols for potassium supplementation remain crucial.[7] The cost and availability of BG test strips are more challenging than those of insulin. A suggestion, when BG test strips are insufficient while treating DKA, is to do less frequent testing (maybe every 3–4 h) during the initial DKA management when BG is expected to be high, to save strips for later when the likelihood of hypoglycemia is higher (Virmani et al. management of children and adolescents with diabetes in limited resource settings, unpublished).

Understandably, there are limitations in the study by Ayyavoo et al.[4] because of the retrospective nature of study and data analysis. The authors themselves may have been a little unsure of outcomes initially, and SC insulin in the ward for their children with DKA may have been the only option. The resources available to record data may have been limited. However, their observations lead the way to plan future prospective studies with defined endpoints which will provide hard “evidence.” Where available, IVI remains the standard of care for the management of DKA.[7]

Following resolution of DKA, comprehensive management for optimal glycemia is equally important.

All is not doom and gloom. LRSs are often characterized by resilience and ability to adapt. Remote regions now have access to web connectivity and information. Prices of conventional and biosimilar insulin and BG test strips are coming down consistently, especially in countries like India, due to increased manufacturing capacity and competitive pricing strategies. Organizations such as ISPAD and ISPAE are constantly working toward greater awareness among all stakeholders. Online pediatric diabetes education programs by ISPAE have been successful and popular.[8]

A lot more remains to be done. Campaigns to increase T1D awareness among the general public and HCPs remain foremost. Training of allied HCPs apart from doctors, 24 h helpline, may be as a hub and spoke model; interactive step-by-step flowcharts for the management of DKA as posters or electronic sources in primary health centers for easy reference could be some. T1D registries in LRS need to be created. Governments are key stakeholders in providing structured national health policies for T1D[9] and ensuring diabetes care supplies, in consultation with HCPs and importantly, persons with T1D who surely deserve to live happy and healthy with productive lives.

Acknowledgment

Sincere acknowledgments to Dr. Anju Virmani, Consultant Pediatric Endocrinologist, Rainbow Children’s Hospital, New Delhi, for reviewing this editorial and giving feedback.

References

  1. , , , , , , et al. Global incidence, prevalence, and mortality of Type 1 diabetes in 2021 with projection to 2040: A modelling study. Lancet Diabetes Endocrinol. 2022;10:741-60.
    [CrossRef] [Google Scholar]
  2. , , , , , , et al. ISPAD clinical practice consensus guideline: Diabetic ketoacidosis in the time of COVID-19 and resource-limited settings-role of subcutaneous insulin. Pediatr Diabetes. 2020;21:1394-402.
    [CrossRef] [PubMed] [Google Scholar]
  3. Available from: https://www.janaushadhi.gov.in/productlist.aspx [Last accessed on 2022 Oct 30]
  4. , , . Treatment of diabetic ketoacidosis with subcutaneous regular insulin in a non-ICU setting is effective and highly economical: A single-center experience. J Pediatr Endocrinol Diabet. 2022;2:50-5.
    [Google Scholar]
  5. , , , , , , et al. Estimated cost-effectiveness of subcutaneous insulin aspart in the management of mild diabetic ketoacidosis among children. JAMA Netw Open. 2022;5:e2230043.
    [CrossRef] [PubMed] [Google Scholar]
  6. , , , , . Diabetic ketoacidosis management and treatment outcome at medical ward of shashemene referral hospital, Ethiopia: A retrospective study. Clin Med Insights Endocrinol Diabetes. 2021;14:11795514211004957.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , , , , , et al. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2022;23:835-56.
    [CrossRef] [PubMed] [Google Scholar]
  8. , , , , , , et al. A Comprehensive and Completely Virtual Pediatric Diabetes Educator Training Model which is Affordable, Accessible, and Hence “IDEAL” (ISPAE Diabetes Education And Learning) for Developing Countries and other Limited-resource Settings In: Presented at ISPAD Annual Sciantific Meeting. .
    [Google Scholar]
  9. , , . Model of care for Type 1 diabetes in India: Integrated approach for its incorporation in future national health care policy. Lancet Reg Health Southeast Asia. 2022;3:100014.
    [CrossRef] [Google Scholar]

Fulltext Views
662

PDF downloads
11
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections