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: Diabetic Retinopathy - Ignorance Lead To Blindness

By Ahssanuddin Haseeb

There are 70 million diabetics in India, 80 percent of them have vision problems about which they are either not aware or lack access to good eye care. Swapna Majumdar reports how NGOs are partnering to reach out to the marginalised and providing them better eye care and prevention.

Consider these facts:

- One in five people in India currently affected by diabetes, and the present number of 70 million diabetics expected to rise to 100 million by 2030

- Diabetic retinopathy, (a condition stemming from diabetes) , is one of the important causes of blindness

- 10 per cent of these diabetics (7 million people) have sight threatening retinopathy and in need of immediate treatment

- 25 per cent of the world's blind people live in India

Worrying as these figures may be, what is even more startling is that 90 per cent of blindness arising from diabetic retinopathy is preventable. Yet, about 80 per cent of diabetics, who suffer from eyesight problems, either don’t know how to take proper eye care or don’t have the access to services. Additionally, a significant proportion of persons with diabetes do not know that they have the disease, according to a 2016 study carried out in 11 cities in 9 states of India by the Indian Institute of Public Health (IIPH), Hyderabad.

“India is sitting at the threshold of an impending “epidemic” of sight threatening diabetic retinopathy (STDR) unless proactive measures are taken”, contended Dr GN Murthy, the lead author of the study and director, IIPH.

“Almost 28 per cent of newly detected middle-class diabetics did not know they were diabetic and only a tenth of the persons with diabetes were aware that poorly controlled blood glucose was an important risk factor for diabetic retinopathy (DR),” said Murthy, also a Professor of Public Health Eye Care and Disability, London School of Hygiene and Tropical Medicine.

Murthy, who shared findings of the study at the second World Congress of Optometry heldrecently in Hyderabad, further pointed out that previous research in India had shown that more than 50 per cent of people with diabetes had poor blood glucose control, uncontrolled hypertension and high cholesterol, all three potential risk factors for DR.

The good news, he said, was that danger of blindness from DR could be reduced by better management of these risk factors and by early detection and treatment of STDR.

However, the 2011 National Programme on the Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke being piloted in 500 districts by the central government in response to the increase in non communicable diseases (NCDs) to identify those at risk and follow up with diagnosis and treatment at the primary and community health centres, has only a passing mention of eye care for diabetics, stating that vision should be checked once a year.

In its checklist for preventing complications for diabetics, it does not mention eye care at all. In its six-point list, it states only testing for blood sugar levels, glycosylated haemoglobin levels(HbA1c), examination of feet for sensations and circulation, and, for calluses, dryness, sores, infections and injuries, Further, blood pressure needs to be checked and the patient must be helped to give up to***co if he/she continues to use to***co. The sixth and last suggestion reinforces a change in lifestyle.

Then how can awareness be increased? How can access to quality eye health be expanded? How can services be made inclusive for traditionally marginalized communities, women and rural populations, who are at greatest risk primarily because of their ignorance of the risks of blindness?

“We believe every Indian should have access to information and proper eye care. Often underprivileged communities lack people who can provide them information and test their eyes. The limited availability of trained ophthalmologists makes it more difficult,” said Vinod Daniel, CEO, India Vision Institute (IVI), a not-for-profit promoting excellence in vision care delivery. IVI is a joint initiative of the LV Prasad Eye Institute and, Brien Holden Vision Institute.

Considering the India has only 40,000 optometrists as against the 1,50,000 required according to the Indian Journal of Ophthalmology, the shortage of trained service providers means that the economically and socially disadvantaged communities including women and children, fall through the cracks.

In fact, this is why accessibility, quality vision and eye health were the key issues chosen for the second World Optometry Congress , said Professor Kevin Naidoo, the conference chair. He pointed out that the Congress, a biennial event initiated by the World Council of Optometry in partnership with the Asia Pacific Council of Optometry and the India Vision Institute, aimed at addressing the twin challenge of quality care and access.

“Data masks disparities. So when there is no access to eye care, ocular health will be impacted. Quality care is important because of several health factors including the correlation between diabetics and blindness and knowing this can be prevented,” stated Naidoo, who is also the CEO of the Brien Holden Vision Institute, Sydney.

A recent Lancet study funded by the Brien Holden Vision Institute with researchers from the Hyderabad based L V Prasad Eye Institute among others found that by 2020, prevalence rate for blindness could rise up to 0.50 per cent and 3.06 per cent for vision impairment.

Therefore, ensuring preventable blindness through timely intervention is a priority for IVI, Daniel says. “We have been engaged in reaching out to the rural communities and women and creating awareness in places where there is no one to test their eyes. So far, we have conducted 1,20,000 screening over the past five years. Sometimes a pair of spectacles is all what is needed to improve quality of life. So if our screening shows that glasses are required, we provide it free of cost to the underprivileged,” Daniel revealed.

Vision centres that provide primary eye care for a population of 50,000 is another novel initiative to reach out to the rural poor. Instituted by the LV Prasad Eye Institute , these centres are embedded in villages to enable better access and treatment.

“The underserved population carries a much greater risk for blindness and visual impairment. Lack of awareness, availability, accessibility, and affordability of services constitute major barriers for care. These centres take care of all these issues. Additionally, we train local women as technicians so that it encourages more women to test their eyes,. An example of the success of this model is that our assessment has found that in Mudhole village in Adilabad district of Telangana, 50 per cent of our eye care recipients were women and these centres have helped in bringing down the prevalence of blindness,” said GN Rao, founder and chair, L V Prasad Eye Institute.

Clearly, an integrated approach where the eye care and diabetic care services work together can effectively prevent vision loss. Leading eye care and diabetic care non-governmental organizations like Public health Foundation of India and its allied institutions like the Indian Institute for Public Health have begun working to develop sustainable models of integrated care in 10 pilot districts across India by strengthening the public-funded district health system at the district level thanks to a grant given by the Queen Elizabeth Diamond Jubilee Trust.

The ball will then be in the government’s court to use these scalable models of integrated diabetic care. It must ensure there are more optometrists and that public-funded diabetic clinics provide services for DR.

Since less than a third of diabetes doctors have basic vision charts in their clinics, and nearly half of patients lose their sight before being diagnosed, it is crucial to ensure that the basics are in place. Only then, can there be early detection and treatment and preventable blindness be really prevented.

When Diabetes And Dialysis Strike, Dual Transplants Could Draw The Line Between Life And Death

How Simultaneous Pancreas and Kidney Transplant gives Indian patients a greater chance at a longer, healthier life.

Diabetes is a particularly troubling disease for Indians.

It is an epigenetic disease - in which environmental factors, lifestyle and diet choices, trigger and compound genetic factors that puts people at greater risk of contracting the disease.

About 20% of urban populations, and about 10% of the rural population in south India are at risk of contracting diabetes, and some research says that there is prevalence of insulin resistance in Indian populations. These, combined with the high-sugar, high-fat food we eat, could trigger a large-scale epidemic. A World Health Organisation report says that about 7.8% of all Indian populations have diabetes, with associated risk factors - such as obesity, physical inactivity - at about 12% of the population.

For a country of 1.3 billion people, that’s at least 150 million (about 15 crores) people at potential risk of the disease.

Diabetes could also be a gateway for other health risk conditions. Type 2 Diabetes - which is more common across the world, and especially in India - could lead to kidney failure, blindness, among other complications.

Further statistics are even more disconcerting. A study estimated that about 8000 persons per million could be at risk of kidney failure, in India. Dr. Anil Vaidya, a Transplant Surgeon in Apollo Hospitals in Chennai, estimates that about 250 per million Indians require dialysis. Of which, he says, about 44% - or approximately 100 persons per million, have both kidney failure and diabetes.

However, there is hope.

Simultaneous Pancreas and Kidney Transplant.

“Can you cure a person with Type 2 Diabetes through transplantation? And the answer is yes! However you got to select your patient correctly,” says Dr. Anil Vaidya. Dr. Vaidya - who is also a Professor of Transplant Surgery in Oxford University, focuses on Pancreas and Kidney transplant in Apollo, although he also does other abdominal and intestinal organ transplant, and in his own words, “look at transplantation in a different angle, try to introduce new procedures, which were not available in India prior to my arrival here.” One of the new procedures he brought to India, was to include the pancreas as part of the “package” when doing kidney transplant for diabetic patients.

There are two major types of diabetes: Type 1, and Type 2.

Type 1 diabetes - or Insulin dependent diabetes - usually is an auto-immune condition in which the body detects its own insulin-secreting cells in the pancreas, and attacks it. This auto-immune disease usually affects children and young adults and is managed with regular injection of exogenous insulin.

Type 2 Diabetes - also sometimes known as Adult Onset diabetes, is where the pancreas produces Insulin, but it is either insufficient for the body to regulate sugar level, or the body has developed a resistance to Insulin. The former (with no resistance) can be cured by ‘adding’ an insulin secreting unit (transplanted pancreas) - allowing more insulin to be produced in the body.

Simultaneous Pancreas and Kidney (SPK) Transplant is the current Gold Standard of therapy for diabetics on dialysis, says Dr. Vaidya. Those diabetics already requiring a kidney transplant - could easily get a pancreas transplant during the same procedure, under the same immunosuppression medication (which allows the body to “accept” this new organ) - giving them a greater chance of fighting both diseases and living a better, longer life.

The first such procedure was performed in 1966, and about 55000 simultaneous Pancreas and Kidney transplants have been done worldwide since then. India has the most number of diabetic+dialysis patients, but a dual transplant is not the first line of defense against the disease, as doctors may not have the expertise to perform it.

But, “there is no doubt about it!” says Dr. Vaidya. World-wide data suggests that the treatment of diabetics who fulfil the selection criteria for transplantation and are on dialysis, is better with a simultaneous pancreas and kidney transplant as opposed to a cadaver kidney alone.

The advantage: longevity of the Transplanted organ

To understand longevity better, we must look at something called the ‘Half-Life’ of an organ.

‘Half-life’ of an organ is a concept especially in kidney transplantation. This roughly estimates the number of years it will take for 50% of the patients transplanted in any given year to be put on dialysis again. The longer, the better.

Many factors come into play here, but significant among those, is whether the organ has been sourced from a live donor or a cadaver donor.

In the UK, the half-life of a live-donor kidney transplant is 25 years, while the half-life of a cadaveric-donor kidney transplant is 12 years.

In other words, 50% of patients who underwent a kidney transplant using a live donor, went for 25 years without needing additional procedures or medication, and lived a much better life.

In India, the half-life of a cadaveric-donor kidney transplant, is unknown as data collection is poor. However, evidence from some centres suggest that it may be as low as 7 years.

For a middle-senior level professional - of about 40-45 years of age - who is prone to diabetes, and at risk of kidney failure, 7 years is too short a time. The actual cost of treatment, and the opportunity cost - in terms of lost time, lost opportunities for career development, is too high.

But, with Simultaneous Pancreas and Kidney Transplant, Dr. Vaidya says, the half-life, even with a cadaver donor, is 25 years. “So that is the advantage for a diabetic!”

Survival graphs of those receiving live donor kidney alone, and those receiving cadaveric kidney and pancreas, are similar. However, after 25 years, the patient who received only the kidney, is at greater risk now. The diabetes which had been under control simply with medication or with insulin injections, will have caught up with the person’s heart function and coronaries. Survival rates after 25 years, are higher for those with simultaneous pancreas and kidney transplant.

So a patient with Type 2 Diabetes has more than 25 years of a healthy, diabetes and dialysis free life to look forward to. Thus for a patient at 45 years of age, this means their quality of life is assured well past their prime, working life, and significantly into their retirement age. Combined with a healthy lifestyle, and good diet, this translates to a long, happy life. That promise - for 1,32,000 Indians - is worth every bit of effort and research into medical sciences, that Apollo, and Dr. Anil Vaidya, are currently doing.

A Structural Change
But this promise, to actually materialise for Indian patients, needs a larger, systemic effort.

The Transplantation (Human Organs and Tissues) Act of 1994, created the first nation-wide law to govern how and when transplantations can be performed. Dr. Pratap Reddy, founder and chairman of Apollo Hospitals, was the moving force behind the act. Since then, organisations such as the Mohan Foundation in Chennai, the Zonal Transplant Co-ordination Committee in Karnataka and Maharashtra, the National Organ and Tissue Transplant Organisation (NOTTO), have created a network of hospitals, research organisations, and coordination agencies that facilitate transplantation. These organisations and partnering hospitals have programmes to share organs - and to match patients needing transplants, with live and cadaver donors.

But, this is complex, and complicated. While Tamil Nadu leads the country in terms of organ donations and transplantation surgeries performed, the waiting list is long, the process to source the donor organs difficult, and the cost of the entire process is often prohibitive to a large percentage of our population.

When it comes to Simultaneous Pancreas and Kidney transplant, this is further complicated because there are two organs involved. A bottleneck is created where if the donor is in another hospital, it is likely, that the pancreas is available but kidneys from the same donor may be allocated locally to the hospital’s waiting list and may not come with the pancreas.

For Dr. Vaidya, who has 60 plus patients on his waiting list, this is a tough task. To manage expectations, to assure and comfort patients, and to co-ordinate with the various systems and procedures that govern transplantation and organ donation, takes up a lot of time. The waiting period could range anywhere between a couple of months, to up to a year and half or more.

That is a huge risk.

Diabetes and Dialysis is a dangerous combination.

The median patient survival in this case - when you do nothing, is 8 years.

A live donor kidney-alone transplant increases life expectancy to 25 years, and a kidney+pancreas transplant, is more than 25. However, for a patient on the waiting list, there is a 12% chance of dying every year, and this probability goes higher every year, and with more complications developing over time.

“So, we come back to the same question. I have this young person, sitting in front of me. I know Kidney-Pancreas is the best option for him, but he might have to wait for it. He’s on dialysis, so his clock is ticking - the 8 year clock is ticking. How much should I wait? When do I say, ‘Listen get a live donor kidney, get off dialysis. Get one ‘D’ out of the way’?” wonders Dr. Vaidya.

Pancreas are readily available in India. The question is the kidney.

Hospitals that remove organs from registered donors - cadavers, will need to send the organs to the Government pool of available organs. A hospital may remove two kidneys from a donor, in which case they can keep one for their own patients, and send the other kidney to the government pool. Given that most hospitals that share organs and perform transplant surgeries have their own waiting list, this creates an imbalance between demand and supply.

Dr. Vaidya says, “I need the kidneys to follow the pancreas. That regulation is still not in place in India.”

“To have the awareness, in the structure of transplantation, that anyone with a dual organ requirement, has priority.” This structural change, is the key to treating diabetes and dialysis in one effective procedure.

This might be perceived as an advantage for those with diabetes. Could this mean that a seriously unwell patient on dialysis, who is not a diabetic, does not get priority?

Hospitals in the West, have handled it by a system of repayment. When one hospital receives a kidney from the other, they will repay the donor hospital, at a later time, with another kidney from their pool. Other systems are being evolved to handle the mismatch between the requirements of organs, and the availability of donors. A similar system must be created and enforced in India, to benefit a larger number of patients in the country.

At Apollo, Dr. Vaidya, and the rest of the medical team, is trying to address this question. In the process, he is also creating more effective ways to identify and treat diabetes and kidney failure, and has pioneered a technique that allows him to monitor the long-term “acceptance” of the donor organ, and therefore the long term health, and quality of life, of his patients.

How To Use Exercise To Balance Your Blood Sugar: A Health Coach Explains

If you think you only have to be concerned with your blood sugar if you're a diabetic, think again. As a type 1 diabetic of 17 years and a diabetic health coach, I can tell you that yes—keeping your blood sugar in check as a diabetic is crucial for overall health. But what you might not know is how important balancing blood sugar is for everyone, regardless of whether or not you're a diabetic.

If you’ve ever experienced sugar cravings, energy slumps, brain fog, or trouble with losing weight, the solution might be looking at how to better balance your blood sugar.

Most blood sugar problems we see are a result of insulin resistance. Insulin is a hormone produced in the pancreas whose job is to help cells take in glucose to be used for energy. If we’re insulin-resistant, we’re left with blood sugar building up and excess insulin production, and both can subsequently lead to the symptoms I mentioned above.

I test my blood sugar between seven and eight times per day and know exactly which habits keep my blood sugar stable. It’s fascinating to me that on the days when I make room for outdoor exercise, it significantly affects my blood sugar in a positive way for the next 24 hours and has a positive impact on my hormone regulation.

In case you need a little convincing, here are three ways that working outside helps to balance your blood sugar:

1. Outdoor exercise reduces cortisol.

So many of us are inside working for the majority of the day. As human beings, we were created to be outside and be one with our environment. When we’re sitting in front of the computer for hours on end or rushing back and forth between meetings in our car, the body can be easily stressed out, resulting in the production of cortisol and adrenaline.

When this happens, the blood sugar in the body rises in order to supply energy for that "fight or flight" mode. The problem, though, is that if the body doesn’t actually need that extra energy, cells might become resistant to insulin. Outdoor exercise gives the body the opportunity to lower stress levels, which ultimately allows for increased insulin sensitivity, or your body's ability to transport sugar out of your blood more efficiently.

2. Outdoor exercise produces extra endorphins.

When you exercise, your body releases endorphins, or what many of us think of as feel-good hormones. Pair this with fresh air and scenery, and your body is doing a complete happy dance. Whenever you’re able to create more happiness in one area of your life, it will often trickle into another area.

Think about it: After spending half an hour outside moving and feeling great, it's pretty unlikely that you'll go home and impulsively decide to eat sugar-filled food. You’re able to make better food decisions by choosing low-glycemic carbs, healthy fats, and a fiber-filled meal with lean protein rather than simple sugars, fried foods, or takeout.

3. More light exposure results in better sleep.

Poor sleep can directly affect hormone levels in your body, which results in decreasing insulin sensitivity and increasing your sugar cravings the next day. A study that focused on the sleep quality of 49 day-shift office workers (27 in windowless workplaces and 22 in workplaces with windows) showed that the workers with windows slept on average 46 minutes more per night. The natural light from outdoors can help you have a better night's sleep, which in turn can help you balance your blood sugar levels.

Need inspiration? Here's a 20-minute outdoor workout for you to try this week.

On days when I know I’ll be inside for most hours, I make time to get outside. Here's an example of a simple workout I did just last week:

Warm up jog

5 minutes of 30 second sprints followed by 30 second recovery jog ( you can use light poles or street signs as markers).

Park bench circuit:

Alternating leg bench step ups (20)

Squat jumps (15)

Pushups (10)

High knees (50)

Tricep dips (15)

*repeat 2x

5 minute fast jog

1 minute of forward lunge hops

Cool down jog

Stretch it out!

Cut Sugary Juices, Eat Eggs, Get Good Sleep And Get Weight Loss Guaranteed

Struggling hard to lose weight even with a controlled diet? Weight loss seems to have become a global obsession. Indians are nearly spending $800 million annually on health checks; yet, success seems to be far and beyond.

On World Obesity Day, here are 10 quick fix tips to help you lose weight. Remember there are no short cuts to weight loss. You will get the benefits of a trim body only until you follow the discipline.

COOK IN COCONUT OIL: Coconut oil is said to be rich in special fats that boost metabolism. Beware, don't add it to what you're already eating, replace your cooking fats with coconut oil.

EAT EGGS FOR BREAKFAST: Any source of quality protein for breakfast can do the trick, but whole eggs can help you eat fewer calories for the next 36 hours, and lose more body fat.

DON'T DRINK SUGARY JUICES: Cut down on your intake of coke bottles and packaged juices with added sugar.

MUNCH ON HEALTHY FOODS: Keep nuts and dry fruits handy for the times when you feel hungry instead of going for fatty foods.

AEROBIC EXERCISES: Burn calories, improve your physical and mental health with cardio and aerobic exercises.

EAT MORE VEGETABLES AND FRUITS: Eating fruits and vegetables can have many advantages. Not only are they rich in fiber and water, but they also contain few calories. Moreover, it takes time to chew them, which helps to lose weight.

DRINK GREEN TEA: Green tea contains small amounts of caffeine, but it is also loaded with powerful antioxidants that enhance fat burning.

GET GOOD SLEEP: Studies show that poor sleep is one of the strongest risk factors for obesity, being linked to an 89% increased risk of obesity in children, and 55% in adults.

DRINK WATER BEFORE MEALS: Water not only keeps the skin clean and hydrated, but also boosts metabolism and burns calories.

KILL YOUR FOOD ADDICTION: Do you have unwanted food cravings that make you eat more than your metabolism needs? You must seek help and find effective treatment.

Diabetic's Ideal Diet For Everybody

There are a lot of gaps in the knowledge of diet options for a diabetic among the general population
Someone familiar with diabetes would already know that the condition requires the person to be careful about his/her physical activities as well as diet. Perhaps, diabetes is one of the most widely discussed conditions for diet planning. However, there still are a lot of gaps in the knowledge of diet for diabetics among the general population. Here are some of the essentials of an ideal diabetes diet.

Let's start with the avoid list as it is shorter. Simply put, you should not eat processed, packaged and refined foods that have little fibre and a high glycemic index as they cause the blood glucose levels to rise sharply. In other words, anything made of white flour or white rice and white sugar. Does that leave you wondering about what you should eat then?

Well, every meal should consist of vegetables and fats. Please do not get scared of fat. Just make sure that you eat good quality fat such as ghee made of cow's milk, coconut, extra virgin olive oil, and enough nuts and seeds. Accompany these with protein and grains. Some of the sources of protein are pulses, dals, leafy green, tofu, paneer, eggs, fish and chicken. The grains should be predominately whole grains like barley, bajra, rajgira, vari (samo seeds), unpolished basmati rice.

Understand that 60 per cent of the diet has to be vegetables. Do note that peas are not counted as vegetables. Also, potatoes and corn cannot be counted in because they lack fibre. Eat plenty of salads and vegetables, at least five to eight servings. The only thing that you can eat aplenty without even thinking about the glycemic index is vegetables.

Remove bad fats such as fried foods, trans fat, vanaspati and margarine from your diet. While they may not cause your blood sugar to spike, they will affect your health parameters and ability to lose weight. So limit bad fats such as chicken with skin, pork and mutton, full-fat dairy products, fried foods and solid vegetable fats that are used in cookies, savouries and other snacks. Instead munch on nuts and seeds. For example, 30 pistachios or 20 almonds have only 100 calories compared to fried savouries that have nearly 500 calories every 25 grams.

Always balance the meal by including a small amount of protein. Avoid taking too much protein as that would overload your kidneys as well as leach calcium from your body. Excess salt increases blood pressure, a condition that diabetics are already prone to. So stay away from pickles, papads, store-made chutney, packet soups, noodles and packaged chips, canned food and savouries. Do not add additional salt to cooked food and learn to flavour food with lemon juice, spices and herbs instead of salt.

Although diabetes is linked to blood sugar levels, you do not have to stay away from sugar altogether. In fact, you need to get it from natural sources like fruits,whole grains millets and unpolished basmati rice. However, refrain from adding sugar to foods. Avoid all colas, soft drinks and alcohol. And remember to stick to your meal plan even if you are eating out.

Choose foods with low glycemic index. Foods with high glycemic index are digested slowly, thus release sugar slowly and steadily in the body. This is very important for a diabetic who has to control insulin levels. Fruits should never be had with meals. It should be taken either an hour prior to meals or three hours after the meal time. To control sugar levels, especially if they are not within the recommended range, have fruits only once a day. Glycemic index is a factor even while choosing right fruits. For example, fruits such as berries, apples, pomelo, orange, plums, peaches and apricots have low glycemic index. Most dried fruits should be avoided in case of high sugar levels. However, prunes and apricots, which are low in the glycemic index, can be eaten in moderation. If your blood sugar is in control and you have a physically active lifestyle, you can occasionally have dates and figs as well.

Vitamins B12 and D3 levels help in maintaining blood sugar levels so consult your physician before taking vitamin supplements.

Herbs and spices that help:
cinnamon, especially with turmeric, 1/4th tsp daily of each
soaked fenugreek seeds, eat the seeds and drink the water
chewing on neem leaves in the morning
boiled mango leaves soaked overnight, strained and had on an empty stomach
30 ml of amla juice before meals

Vegetables with benefits:
Onion
Garlic (small quantities)
Fenugreek leaves
Bitter gourd

It is easy to follow a diabetic diet. This is how you can balance an Indian meal to suit the requirements of a diabetic's diet.

Salad (kachumber)
Vegetable (sabzi )
Leafy green like spinach and fenugreek
Pulses, dal, paneer, fish, eggs, chicken, curd, peas. These can be included as a cooked side dish
Roti /rice or millet