Need for a paradigm shift in the treatment of diabetes

Need for a paradigm shift in the treatment of diabetes

Vijay Gopichandran


On 09 February 2020, we conducted an annual diabetic complications screening camp for patients with diabetes in the villages where we work. The findings of the camp, as usual, took me into a very introspective space. I was largely disheartened to see the poor blood sugar controls among most of the patients. Out of the 80+ patients that we saw on that day, only 10 had good sugar controls. I thought, “let me console myself looking at these 10 people” only to find out to my absolute dismay, that a few of them were not even patients with diabetes. They had been included in the screening by mistake! All of these patients are under treatment either with us at our clinic or with the public health system. They are under regular treatment. The camp day was spent reviewing their reports, making changes to their drugs, counseling them on what to eat, what to avoid, how to exercise, and referring them to higher specialty centers for more specialized treatment. Yesterday, my colleague and I were talking about this camp and the camp findings on our way back from the clinic. We were seated on the bus number 72, which goes from a village farther away from our village to Chengalpet. Since we are usually four or five of us traveling together, we take the last seat at the back of the bus. The bus ride is usually etched very clearly in my memory because not only are the conversations very interesting but also because the bumpy ride reminds me of the presence of each and every bone and muscle in my body, as it shakes and aches with every bump.


“When we see a patient with high blood sugar, we very readily start adjusting the medicines. Our first response is to tinker with the medicines”, said my colleague seated to my right and clutching on the seat in front to just avoid being pushed off her seat during a particularly memorable bump on the Mangalam road speed-breaker.


I couldn’t agree more. That is our first response. But control of blood sugar in a patient with diabetes is far more complex than just adjusting the medicines.  


“The way we measure lifestyle patterns in our patients is inappropriate. We need to carefully reconsider it. The western literature tells us about walking, exercise, jogging, etc. But we know many of our poor patients do heavy strenuous physical activity for a living. Should we look at physical exercise even for such patients?” she asked.


“Do you remember the elderly couple who used to walk to our clinic to visit us every week. They used to walk for more than 2 kilometers just to reach our clinic.”, she said, to make her point that people in our area are generally more physically active and will require a different type of lifestyle change.


“We need to follow up on that elderly couple. They haven’t come to the clinic of late.”, she added.


“Yes, I haven’t seen them either. We must call the social worker and find out what happened to them. Remember, how I used to tease her about appearing as the lead actress in a television serial? I miss seeing the couple too. Let us find out”, I said this and placed a call to the clinic staff.


“Can you please ask the field staff from their village to follow up on the elderly couple that used to visit our clinic every week? We haven’t seen them in quite a while” I said on the phone to the clinic staff.


She called back in just over 5 minutes and said, “Sir, the elderly woman passed away last Tuesday.”

Both my colleague and I were shocked. What a way to know that one of our patients has passed away? We were saddened by her demise, but we were also surprised that out of the blue we thought of her on the bus and followed up. Things work in very strange and unexplainable ways.


“Despite being so physically active, the elderly lady passed away. If she had passed away so suddenly without much illness, it must be a cardiac event, maybe a massive heart attack.”, we were reflecting.

When we measure physical activity levels in our patients, traditional ways of measurement are insufficient.

We often finish by just asking about walking, exercise, jogging, etc. We also give a generic prescription that patients with diabetes must go for a morning or evening walk lasting for at least 30 minutes daily for at least 5 days a week. But a more thorough evaluation of their existing level of physical activity is important. We must incorporate mode of travel, level of household work, level of physical activity at the workplace, etc. The elderly couple would be classified as sedentary if we did not carefully consider the fact that they had to walk 2 kilometers, either way, to just reach our clinic once a week. They were also probably walking a lot to get around to other places. For such people, advice to do walking every day would be irrelevant.


Another important point I learned yesterday from the field staff was shocking. Many patients who are taking treatment from the public health system go on receiving refills of their prescriptions without a blood test to monitor their sugar levels or without seeing a doctor for many months. Even those who get their periodic blood tests never get it reviewed by a physician. Many of the patients whom we saw during the camp were patients taking treatment from the public health system. For many of them, the blood test had been done after almost a year.


The public health system has done a great job of taking essential anti-diabetes medicines to the villages, to the doorsteps of the patients. However, medicines are not everything in the treatment of diabetes. They form a very small part of the treatment process. The seven major components of good self-management of diabetes are diet, exercise, medication, monitoring, self-care of feet and teeth, reducing risky behaviors such as smoking and alcohol and self-efficacy in terms of food, treatment choices. I realized that our public health system and many private providers of diabetes care are able to achieve only the medication and monitoring parts of this seven-part self-management process in the treatment of type 2 diabetes.


Diabetes is a social disease, and therefore requires social approaches to its management. Changing people’s behaviors is not easy. There is a need to actively study self-management behaviors in patients with diabetes. Diabetes cannot just be treated in hospitals and clinics. Diabetes must be treated in communities, homes, and families. A paradigm shift in diabetes treatment is required. This shift should see the movement of treatment away from hospitals to health and wellness centers, movement of control of treatment away from the health care provider to the patient, movement of the focus of treatment away from medicines towards behaviors and lifestyles. Only then, we can effectively control diabetes in our communities. We now believe more strongly than ever that solution to the problem of diabetes is in the hands of people, rather than health care providers.