Insulin, love and care

"Poor response" subset in a "have-not"

FREE type 1 diabetes clinic [DISHA] in India

Ms Uma Dayashankar
Samatvam Endocrinology Diabetes Center
Jnana Sanjeevini Diabetes Hospital
Bangalore, India
3-Sep-14

Ms Uma Dayashankar

Disclosures:
Nil

3-Sep-14

Horm Res 1989;31:204-209

2

Aims and Objectives

Insulin Love and Care

To identify the spectrum of glycemic control

and overall clinical responses associated
with recent provision of significant material
boost in a 3 decade long "philanthropic"
type 1 diabetes care program [DISHA].

3-Sep-14

State of Karnataka, India

Population total: 53
million
Population children:
10 million
T1DM children:
20000 30000
Project DISHA - 1987:
3000 (600 active);
rest untraceable
? dead
3-Sep-14

3-Sep-14

Jnana Sanjeevini

* www.jsindia.org

6
3-Sep-14
6

Methods
Insulin Love and Care

3 Decades: Three Phases

Project DISHA + Insulin Lifeline:

1987 2005
Project DISHA + Insulin + SHBG:

2006 - 2011
Project DISHA + CDiC / LFAC:

2011 Ongoing
Changing Diabetes in Children
Life for a Child with Diabetes

3-Sep-14

Methods
Insulin Love and Care

Project DISHA + Insulin Lifeline: 1987 - 2005

Free insulin and syringes
Health education counseling
24 hour helplines

3-Sep-14

Methods
Insulin Love and Care

Project DISHA + Insulin + SHBG: 2006 - 2011

Rationed / Limited SHBG
BG meters and 5 -10 strips / month
Basal bolus insulin [100%]
Meal time regular plus bedtime NPH

3-Sep-14

Methods
Insulin Love and Care

Project DISHA + CDiC / LFAC: 2011 - Ongoing

250 children
100 BG strips per month
Limited biochemical evaluations

TSH, quarterly HbA1c testing, annual urine albumin:

creatinine ratio

Partial manpower financial support

Part time Diabetes Educator, Physician and

Ophthalmologist

3-Sep-14

10

Results
Insulin Love and Care

CDiC / LFAC enhanced support:

2 year follow up

3-Sep-14

11

DISHA
vs
DISHA + CDiC / LFAC
Substantial Material Boost: 2011
Support

DISHA
2006 - 2011

DISHA + CDiCLFAC
2011 - onwards

Insulin
Syringes

Free
Free

Free
Free

BG Meter

Free

Free

BG Strips / mo

5 -10

100

Biochemistry

Nil

HbA1c, UAC, S
Creatinine, TSH

Manpower financial Nil

support
3-Sep-14

Limited

SAMATVAM ENDOCRINOLOGY DIABETES CENTER * JNANA SANJEEVINI DIABETES HOSPITAL

12

DISHA

vs.

DISHA + CDiC / LFAC

Follow up 18 months; [n= 160]; Ages 2 18 y

Glycemic control trends: Response patterns

Group

n [%]

HbA1c % Baseline
and trend

Base Late
line
st

A: Prior discipline
Already good

17 [11]

<8 and stable

7.3

B: Responder High 35 [22]

>8 and >3 decline

14.8 9.1

C: Responder

59 [37]

>8 and 0.6 to 3 decline

10.9 9.2

D: Non- responder
Sad !!

49 [31]

>8 and < 0.6 decline

10.4 11.5

3-Sep-14

SAMATVAM ENDOCRINOLOGY DIABETES CENTER * JNANA SANJEEVINI DIABETES HOSPITAL

7.0

13

DISHA

vs.
DISHA + CDiC / LFAC
Follow up 18 months

Percent of children achieving HbA1c target

< 8 = 29%
< 7 = 12%

3-Sep-14

SAMATVAM ENDOCRINOLOGY DIABETES CENTER * JNANA SANJEEVINI DIABETES HOSPITAL

14

DISHA

vs.

DISHA + CDiC / LFAC

Follow up 18 months
Nephropathy %
[mean UAC ratio g / mg of Creat]
Nil
58 %
[10]
Incipient
29 %
[88]
Overt
13 %
[1073]

3-Sep-14

SAMATVAM ENDOCRINOLOGY DIABETES CENTER * JNANA SANJEEVINI DIABETES HOSPITAL

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DISHA

vs.

DISHA + CDiC / LFAC

Follow up 18 months
Primary hypothyroidism
Newly detected 13%

3-Sep-14

SAMATVAM ENDOCRINOLOGY DIABETES CENTER * JNANA SANJEEVINI DIABETES HOSPITAL

16

Conclusions
Insulin Love and Care

Despite enhanced material support, a

subset of poverty associated type 1
diabetes children, do not demonstrate
improved glycemic control and overall
health.
Varying combination of detrimental
psychological, social and economic
factors probably contribute to this poorresponse.

3-Sep-14

17

Conclusions
Insulin Love and Care

Identification of these negative therapeutic

factors and other coexisting life
challenges, and efforts to mitigate the
same [ie., molecular sociology ;
psychosocial therapy; High risk type 1
diabetes clinics], are crucial to health and
survival of these children.
The long term sustenance of such
programs, and support to newly arriving
children remains a big challenge.
3-Sep-14

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Insulin, love and Care

Prof Johnny Ludviggson 1989

Beside physiological substitution of

insulin, psychosocial care is probably
the most important part of the
management of diabetes in children and
adolescents.

3-Sep-14

Horm Res 1989;31:204-209

SAMATVAM ENDOCRINOLOGY DIABETES CENTER * JNANA SANJEEVINI DIABETES HOSPITAL

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Spiritual Poverty and

Diabetes
Equation Childhood Diabetes

[Insulin] + [Love and Care]

=
HbA1c Health Happiness
3-Sep-14

Horm Res 1989;31:204-209

SAMATVAM ENDOCRINOLOGY DIABETES CENTER * JNANA SANJEEVINI DIABETES HOSPITAL

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21
3-Sep-14

Jnana Sanjeevini

* www.jsindia.org

3-Sep-14

3 September
3-Sep-14
2014

JNANA SANJEEVINI MEDICAL CENTER

JnanaSAMATVAM
Sanjeevini
* www.jsindia.org

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