Need for Targeted Intervention to Tackle Type 1 Diabetes Mellitus: Case Study from Gujarat, India

Yash Patel¹*, Sushil Patel², Mayur Patel¹, Sandul Yasobant³ and Deepak Saxena³

¹All India Institute for Diabetes & Research (AIIDR), India

²Akshar Diabetes Centre, India

³Indian Institute of Public Health Gandhinagar, India

*Corresponding author: Yash Patel, All India Institute for Diabetes & Research, Opp. Jaymangal BRTS Bus Stop, 132 Feet Ring Road, Naranpura, Ahmedabad, Gujarat 380013, Gujarat, India

Received: October 09, 2019; Accepted: November 01, 2019; Published: November 08, 2019

Abstract

Type 1 diabetes mellitus has increased like type 2 diabetes, with a trend of 3–5% increase/year, globally. Although in India about 50.9 million people suffer from diabetes, there are no registry at grass root level for T1DM. Therefore, this study aims to develop a Comphrensive profiling of T1DM cases and understand the coping mechanism along with the knowledge & practices in the two cities of Gujarat, India. This retrospective case study on known cases of Type 1 Diabetes was conducted in two cities of Gujarat (Ahmedabad & Kutch) during March to August 2017. Out of 56 T1DM cases documented under this study, majority of them were residing in urban area. The detailed disease history, knowledge, attitude, practices, coping mechanisms, health seeking behaviors were documented.

Keywords: T12DM; T2DM

Background

In India, about 50.9 million people suffer from diabetes, and this figure is likely to go up to 80 million by 2025, making it the ‘Diabetes Capital’ of the world [1]. Type 1 Diabetes Mellitus (T1DM) (β-cell destruction, usually leading to absolute insulin deficiency) accounts for only 5–10% of those with diabetes, previously encompassed by the terms insulin-dependent diabetes, type I diabetes, or juvenile-onset diabetes, results from a cellular-mediated autoimmune destruction of the -cells of the pancreas [2]. T1DM has increased like type 2 diabetes, with a trend of 3–5% increase/year [3]. The exact cause of T1DM is not known. Most likely, it is an autoimmune disorder also; it can be passed down through families [4]. The prevalence of T1DM in children is 111,500 and it’s estimated that India is housing about 97,700 children with T1DM [5]. India has three new cases of T1DM per 100,000 children of 0–14 years, however; prevalence data shows 17.93 cases/100,000 children in Karnataka, 3.2 cases/100,000 children in Chennai, and 10.2 cases/100,000 children in Karnal (Haryana) [6].

The Indian Council of Medical Research funded Registry of People with diabetes, this registry is by government and called ICMR registry. It was started in the year 2006 with 10 collaborating centers across India and this registry mainly focused to provide an overview of diabetes in the young [7]. Usually an ideal disease for establishing the registry is a disease with sufficient public health importance and diabetes mellitus could be considered as an ideal disease to establish such a registry. As per the International Diabetic Federation, there is a need to revamp the preventive, promotive and appropriate curative modalities for it [8]. However, people with Diabetes with Young Age at Onset (YDR) was major focus in the registry at national or state level; there is a strong recommendation to develop a local level T1DM registry to understand the disease dynamics at different geographic level [9,10].

Therefore, this study aims to develop a Comphrensive profiling of T1DM cases and understand the coping mechanism along with the knowledge & practices in the two cities of Gujarat, India.

Materials & Methods

This retrospective case study on known cases of Type 1 Diabetes was conducted in two cities of Gujarat (Ahmedabad & Kutch) during March to August 2017. The two sites were sampled purposefully where a lead diabetic NGO was providing health care services for more than a decade. The samples included in case were enrolled with NGO for screening of complications, routine treatment and treatment of complications, counselling and dietary advice. Secondary data analysis of the line listed cases was undertaken and were contact either in person of through telephone; a camp based for further contact was also adopted as a method to seek further insights into the morbidity profile of the cases. On a specified day, the camp was conducted on both the sites; all the T1DM patients were enrolled voluntarily with a prior written consent. A total of 56 T1DM cases participated in the camps and hence are included in the this case study. A structured questionnaire was developed primarily in English and translated into vernacular language (Gujarati) and validated / pretested before being administered to the cases included in the study; to ensure uniformity in data collection, three data collectors with nursing and public health back ground were hired and trained and they administered this questionnaire and documented some of physical & biological parameters. The questionnaire focused on collecting information on socio-demographic, disease history, difficulties & coping mechanism with T1DM, knowledge, attitude & practices, health seeking behavior & treatment. Data were entered in the excel spreadsheet and descriptive analysis was conducted in SPSS version 20.

Results

Socio-demographic profile

Out of 56 T1DM cases documented under this study, majority (77%) of them were residing in urban area. More than half of participants were in the productive age group of 15-29 years. The mean age of participants was 21±10 yrs. Minimum and maximum age of participants were respectively 3 and 56 yrs (median age=23). The male and female proportion was approximately same 52% and 48% respectively. Almost all of them were literate up to higher secondary or more. About 39% of participants were students. Social stratification of participants show that majority of participants belonged to general class, only 3.6% was form schedule caste. Out of all, 37% participants were married (Table 1).

Table 1: Socio-demographic profile of participants.




  
    Socio-demographic    variables
    Frequency    (N=56) (%)
  
  
    Area
    Rural
    13 (23.2%)
  
  
    Urban
    43 (76.8%)
  
  
    Gender
    Female
    29 (51.8%)
  
  
    Male
    27 (48.2%)
  
  
    Age
    1-14 years
    15 (26.8%)
  
  
    15-29 years
    31 (55.4%)
  
  
    > 29 years
    10 (17.8%)
  
  
    Education
    Non-school going
    1 (1.8%)
  
  
    Up to Higher Secondary    Education
    29 (51.8%)
  
  
    Graduation & more
    26 (46.4%)
  
  
    Occupation
    Student
    22 (39.3%)
  
  
    Employed
    22 (39.3%)
  
  
    Unemployed
    12 (21.4%)
  
  
    Physical    exertion related to your daily activities
    Hard work
    1 (1.8%)
  
  
    Moderate work
    25 (44.6%)
  
  
    Sedentary work
    30 (53.6%)
  
  
    Religion
    Hindu
    53 (94.6%)
  
  
    Muslim
    3 (5.4%)
  
  
    Social    status
    OBC
    20 (35.7%)
  
  
    General
    34 (60.7%)
  
  
    SC
    2 (3.6%)
  
  
    Children    in HH
    No children
    29 (51.8%)
  
  
    1-3 children
    25 (44.6%)
  
  
    > 3 children
    2 (3.6%)
  
  
    Marital    Status
    NA
    24 (42.9%)
  
  
    Married
    21 (37.5%)
  
  
    Unmarried/Widow
    11 (19.6%)



Table 1: Socio-demographic profile of participants.

Disease history

Majority of participants reported age of diagnosis of T1DM between 1 to 14 years of age. Mean age at onset of T1DM found 12±8 years and median age was 10. Minimum and maximum age at onset of T1DM found respectively 3 and 36 years. On inquiring about family history of T1DM, around 18% participants had T1D family members. Further majority of participants had history of T1DM in previous generation only one respondent had history of T1DM in next generation. However, double proportion (36%) found for the history of T2DM in family member. Around 32% of participants’ had family history of T2DM.

Difficulties and coping mechanism

Only 1.7% reported about post diagnosis difference in married life however, 9% of participants declined to share information on it and rest reported no issue after diagnosed with T1DM. On the other side unmarried and participants who were eligible for marriage, only 1 out of 11 said that they were facing problem for marriage and other seven participants declined to share information on it. Further more than two third of participants (87.5%) said that their family concerned about their health. For coping up with their health, only 21% reported that they consulted doctor and 14% said that they had taken some steps towards diet change and use of insulin injection/tablets.

Knowledge, attitude & practice

Regarding knowledge, more than 80% participants had some knowledge on symptoms of T1D, which reported respectively tiredness/weakness (58.9%), polydipsia (30.6%), polyuria (30.6%), weight loss (28.6%), polyphagia (17.9%) and vertigo (5.4%). Additional knowledge on causes found poor as around 43% participants didn’t have any knowledge on causes however as per participants’ knowledge hormonal and autoimmune are most common cause for T1DM (Table 2). Further inquiring on knowledge regarding health complications due to T1DM, majority of them reported kidney failure (50%) followed by blindness (46.4%), heart problem (32.1%), hypertension (16.1%) and gangrene (16.1%).

Table 2: Knowledge, Attitude & Practice.




  
    Knowledge, Attitude &    Practice
    Frequency N=56 (%)
  
  
    Knowledge    on Symptoms of Diabetes
    Polyphagia
    10 (17.9%)
  
  
    Polydyspsea
    17 (30.6%)
  
  
    Polyuria
    17 (30.6%)
  
  
    Tiredness /weakness
    33 (58.9%)
  
  
    Weight loss
    16 (28.6%)
  
  
    Vertigo/Body Pain
    3 (5.4%)
  
  
    Don’t Know
    10 (17.9%)
  
  
    Knowledge    on causes for development
    Hormonal
    13 (23.2%)
  
  
    Obesity
    5 (8.9%)
  
  
    Heredity
    9 (16.1%)
  
  
    More sweet food consumption
    6 (10.7%)
  
  
    Autoimmune
    12 (21.4%)
  
  
    Stress
    2 (3.6%)
  
  
    Don’t know
    24 (42.8%)
  
  
    Knowledge    on Complications
    Blindness
    26 (46.4%)
  
  
    Heart problem
    18 (32.1%)
  
  
    Kidney failure
    28 (50%)
  
  
    Hypertension
    9 (16.1%)
  
  
    Gangrene
    9 (16.1%)
  
  
    Other health problem such as    mental, thyroid & UTI
    3 (5.4%)
  
  
    Don’t know
    23 (41.1%)
  
  
    Knowledge    on Diabetes curable
    Yes
    18 (32.1%)
  
  
    No
    34 (60.7%)
  
  
    Don’t know
    4 (7.1%)
  
  
    Knowledge    on Diabetes Preventable
    Yes
    30 (53.6%)
  
  
    No
    9 (16.1%)
  
  
    Don’t know
    17 (30.6%)
  
  
    If    yes, how could be prevented (N=30)
    Regular Exercise
    25 (83.3%)
  
  
    Healthy Diet
    24 (80%)
  
  
    Practicing    any kind of exercise
    Yes
    50 (89.3%)
  
  
    No
    6 (10.7%)
  
  
    What    Kind of exercises (N=50)
    Only One Exercise (Walking)
    28 (56%)
  
  
    Combination of Exercises
    22 (44%)
  
  
    How    regular are you doing (N=50)
    Daily
    35 (70%)
  
  
    Twice in a week
    4 (18%)
  
  
    Weekly
    1 (12%)
  
  
    Any    diet change/control
    Yes
    47 (83.9%)
  
  
    No
    9 (16.1%)
  
  
    What    changes kinds of changes
    Avoid sweet food
    35 (62.5%) 
  
  
    Avoid fatty / oily food
    23 (41.1%)
  
  
    Take small and frequent meal    instead of heavy meals
    15 (26.8%)
  
  
    Use of artificial sweeteners
    5 (8.9%)
  
  
    Nutritious food
    10 (17.8%)
  
  
    Daily    food habits
    Roti-sabji
    19 (33.9%)
  
  
    Rice/Rice preparation
    15 (26.8%)
  
  
    Dal
    11 (19.6%)
  
  
    Milk
    8 (14.3%)
  
  
    Different veges/salads
    9 (16.1%)
  
  
    Fruits
    9 (16.1%)
  
  
    Habit    of tobacco consumption
    Yes (Nonsmoking)
    3 (5.4%)
  
  
    No
    53 (94.6%)
  
  
    Habit    of alcohol consumption
    Yes
    0
  
  
    No
    56 (100%)
  
  
    Aware    about HbA1C report done in diabetic patients
    Yes
    34 (60.7%)
  
  
    No
    22 (39.3%)
  
  
    Next    generation planning (N=21)
    Yes
    6 (28.6%)
  
  
    No
    15 (71.4%)



Table 2: Knowledge, Attitude & Practice.

Table 2 of 1:




  
    Heath seeking behavior &    Treatment
    Frequency N=56 (%)
  
  
    1^st contact during onset of sign & symptoms
    Public Healthcare centers
    5 (8.9%)
  
  
    Private Providers
    49 (87.5%)
  
  
    NGO/ Trust Hospitals
    2 (3.6%)
  
  
    Contact    during Diagnosis
    Public Healthcare Centers
    4 (7.1%)
  
  
    Private Providers
    50 (89.3%)
  
  
    NGO/ Trust Hospitals
    2 (3.6%)
  
  
    1^st contact of treatment after diagnosis
    Private Providers
    53 (94.6%)
  
  
    Public Healthcare Centers
    2 (3.6%)
  
  
    NGO/ Trust Hospitals
    1 (1.8%)
  
  
    Your    reaction/feeling being Diagnosed with Type 1 Diabetic
    Very stressful
    19 (33.9%)
  
  
    Stressful
    21 (37.5%)
  
  
    Neither stressed nor happy
    15 (26.8%)
  
  
    Relaxed & Happy
    1 (1.8%)
  
  
    Any    other co-morbidity
    Yes
    5 (8.9%)
  
  
    No
    51 (91.1%)
  
  
    What    Kind of Co-morbidity
    Hyperthyroidism
    1 (1.7%)
  
  
    Foot gangrene
    1 (1.7%)
  
  
    Hypertension
    2 (3.6%)
  
  
    TB
    1 (1.7%)
  
  
    Are    you on medication
    Yes
    56 (100%)
  
  
    Which    type of diabetes medication
    Only allopathic tablet/Insulin
    45 (80.4%)
  
  
    Allopathic &    Ayurveda/Homeopathic
    9 (16%)
  
  
    Only Ayurveda/Homeopathic
    2 (3.6%)
  
  
    From    where do you take medicines
    Private Providers
    31 (55.4%)
  
  
    Public Hospital
    1 (1.8%)
  
  
    NGO/ Trust Hospitals
    10 (17.9%)
  
  
    Directly from medical Stores
    8 (14.3%)
  
  
    Under    insulin therapy what is your feeling
    Very satisfied
    8 (14.3%)
  
  
    Satisfied
    36 (64.3%)
  
  
    Neither satisfied nor    dissatisfied
    9 (16.1%)
  
  
    Dissatisfied
    3 (5.4%)
  
  
    Any    changes at the site of insulin delivery
    Swelling
    24 (42.9%)
  
  
    Allergy/Eczema
    3 (5.4%)
  
  
    How    regular in 	diabetes medications
    Regular
    52 (92.9%)
  
  
    Almost regular
    4 (7.1%)
  
  
    History    of hospital admission
    Yes
    22 (39.3%)
  
  
    No
    34 (60.7%)
  
  
    Do    you see yourself different from other
    Yes
    7 (12.5%)
  
  
    Have    you ever met other children with type 1 diabetes
    Yes
    31 (55.4%)
  
  
    Does    your insulin injection is painful for you
    Yes
    9 (16.1%)
  
  
    Do    you see any change of behavior/discrimination    parents/siblings/friends/school/collage
    No
    56 (100%)



Table 2 of 1:

Talking on T1DM is curable, 32% reported as it is curable however more than 50% participants also said T1DM is preventable. Most of them believed T1DM could prevented through regular exercise (83%) and healthy diet (80%). Almost 89% participants reported that practicing some form of exercises out of that 56% were practicing only walking as exercises however rest 44% were using combinations of exercises. Further, their attitude towards regular exercises also asked and 70% reported that they do exercise daily. Around 84% of participants had changed their diet pattern to cope up with T1DM which includes avoid sweet food (62.5%), avoid fatty/ oily food (41.1%), take small and frequent meal (27%), use artificial sweeteners (8.9%) and having nutritious diet (18%). Only 16.1% participants reported that they ate fruits and veggie salads in their regular diet. Habit of tobacco consumption reported 5.4% however no one reported habit of alcohol.

More than 50% of participants had awareness on confirmatory diagnostic test of HbA1C for T1DM. Only six participants out of 21 married participants reported that they were aware and practicing about next generation planning.

Health seeking behavior & treatment

For 1^st contact at onset of sign and symptoms 8.9% went to public hospital, 87.5% went to private hospital and 3.6% went to NGO/ trust hospital. For diagnosis 7.1% went to public hospital, 89% went to private hospital and 3.6% went to NGO/trust hospital. However, 1^st contact for treatment 3.6% went to public hospital, 94.6% went to private hospital and only 1.8% went to NGO/trust hospital. Almost all participants shared that they felt stressed after diagnosed with T1DM and stress scale shows that 40% felt its very stressful followed by stressful (38%), neither stressed nor happy (27%) and only 1% said relaxed and happy. Few participants also reported other comorbidity such as hyperthyroidism (1.7%), foot gangrene (1.7%), hypertension (3.6%) and TB (1.7%).

Participants were using different combinations of medicines also. Majority of them were on allopathic medicines such as insulin injection or tablets however, 16% of participants were also using combinations of medicines such as Allopathic & Ayurveda or Homeopath. Participants with insulin therapy reported their satisfaction respectively very satisfied (14.3%), satisfied (64.35%), neither satisfied nor dissatisfied (16.1%) and dissatisfied (5.4%). Around 16% found insulin as painful and on inquiring changes at the site of insulin delivery, 43% reported swelling and 5.4% reported allergy or eczema. In spite of all hurdle 93% said they were taking medicines regularly. Also 12.5% reported that they see themselves different from other and 55% of participants met other diabetic children. However, no one reported any behavior change/ discrimination from parents, school, job or friends.

Conclusion

About one third of T1DM cases reported in this study has family history of T2DM including difficulties in coping the condition. Knowledge level about the disease condition found to be poor, however health seeking behavior and treatment compliances were found to be satisfactory. There was possible mistrust in seeking the treatment and advice from the public health system, more so there needs to be a convergence with public and private health care providers. There is also a need for Health insurance coverage among people with Type 1 diabetes thete is also a need for undertaking studies to explore the coverage of Health insurance for people with Type 1 diabetes. Empowerment of the role of both the private sector and health insurance system is badly needed, aside from implementing proper management guidelines to deliver good services at different levels.

There is also a need of provision of adequate health treatment within the broad domain of existing RKSK and RBSK program run by Government of India. There is also an urgent need for developing a T1DM registry system, which could able to document the differential aspects of cases in near future.

References

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Citation: Patel Y, Patel S, Patel M, Yasobant S and Saxena D. Need for Targeted Intervention to Tackle Type 1 Diabetes Mellitus: Case Study from Gujarat, India. Austin J Endocrinol Diabetes. 2019; 6(2): 1070.

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