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The Rediff Special/Shobha Warrier
The general belief was that people died more frequently of infectious diseases like tuberculosis, typhoid and cholera in developing countries and there were not too many studies done on diabetes. The only study done was in the 1970s by the Indian Council of Medical Research, which found that only 2 per cent of the urban population had diabetes. So, people believed that India had a lower incidence of diabetes. After that, no studies were conducted in India on the subject for a long time. Then came a revelation. A number of studies were conducted on Indian migrants settled in the United Kingdom, Singapore and South Africa and it was found that the prevalence of diabetes is particularly high among South Asian migrants. The studies found that the prevalence of diabetes among Indians living in London was three to four times higher than in the white population though their level of obesity was not as high. Nobody could explain this. The usual risk factors for diabetes are obesity, sedentary life habits and increased intake of fat. Indians in the UK had similar food habits as the British. The researchers, therefore, concluded that Indians or South Asian migrants have an increased genetic tendency to diabetes. They also found a high prevalence of coronary heart disease among Indians. Even then it was believed that when Indians are in India, they have a low prevalence of diabetes, and only when they migrate to affluent countries do they become susceptible. The reason cited was the change in eating habits. But the studies could not come to a conclusion as to why the incidence of diabetes was higher among Indians than in the white population in a similar environment.
Dr Ramachandran, who was trained in population relation studies, was serving as a diabetic specialist outside India for 15 to 20 years. When he returned to India in 1986, he did a study on the prevalence of diabetes in the population of South India. It was the first time a study of that sort was conducted in any part of India. "Contrary to long-held belief, we found that there is a very high prevalence of diabetes among the urban Indian population, comparable to the migrant Indian population in England or Singapore or South Africa. We found that the prevalence was high in 1986 and going up steeply. The increase was 50 per cent every five years among the adult population in Madras. In 1986, five per cent of the adult population had diabetes and it went up to 8.6 per cent in 1992 and 12 per cent in 1997," he said. Dr Ramachandran is currently doing a national study on the subject. Asked why Indians are more susceptible to diabetes, Dr Ramachandran quipped, "If I could answer that question in one sentence, I would get the Nobel Prize! But we have identified the risk factors. One of the important factors is that Indians have this tendency for central adiposity. When you gain weight, the distribution of fat is abnormal in Indians, that is, the fat gets deposited in the abdominal area. That seems to be contributory in producing diabetes. Although the ratio of overweight people is not very high in the population, whatever fat is there in the body gets deposited in the abdomen. "The second risk factor is 'clustering'. Indians prefer to go in for arranged marriages and a majority marry within the same caste and even within the family. This consanguinity affects the gene pool because diabetes is basically a genetic disease." Dr Ramachandran said that if both parents of an individual are diabetic, the risk factor for him is 80 to 90 per cent if you are an Indian. But if you are an American and both your parents are diabetic, the risk factor is only 25 per cent. It is so because the father and mother of an American usually come from different gene pools. "Then there has been an increase in affluence among the urban Indian population and the result is that people have become sedentary. The other conventional risk factors are lack of physical activity, increased food intake and mental stress. When a person has the genetic tendency to get diabetes, the environmental factors also operate at a high level," he explained. Even in rural areas, diabetes is becoming common because these areas are getting urbanised. Dr Ramachandran selected a village, which remained a village till recently, for the study. He found that people who were earlier working as agricultural labourers are becoming construction workers, those who were walking to work are buying bicycles and mopeds, and ladies who walked to the fields and worked there have started sitting at home to look after babies and families. Suddenly, the incidence of diabetes has doubled. The predictions are alarming. Because of its large population, India has the maximum number of diabetic patients today and this trend will continue. The number of persons worldwide with diabetes was 135 million in 1995. It is estimated to rise to 300 million by 2025 with the major increase being in the developing countries. According to a study, there are 30 million diabetic patients in India now and by 2025, the number is expected to go up to 57 million. That is one-sixth of the world total! In developed countries, the majority of people with diabetes are aged 65 years and above, but in developing countries, diabetic patients are in the age group of 45 to 65 years. Dr Ramachandran said a person who has a high risk of getting diabetes can prevent the disease by taking some basic precautions. "The government's priority even now is on infectious diseases because we are a poor country. In the urban areas, cardiovascular diseases are highly prevalent and people die of heart attacks, strokes and cancer. Obesity and sedentary life habits are the risk factors for cardiovascular diseases too. If you want to reduce the incidence of cardiovascular diseases, you have to check diabetes," he said. In developing countries, what worries people is the cost of treating chronic diseases like diabetes. If a person is diabetic, he has to take pills every day throughout his life. He has get his blood tested periodically. He has to visit a doctor regularly. In case of complications, he may have to be hospitalised. These are all direct costs. But the indirect cost is that the person will be out of work when he is hospitalised. The social cost of the disease is that it decreases the quality of life. These are the economics of diabetes, which are not curable; it is a life-long disorder. "When you have more diabetic patients in the country, the economic cost of treating them also increases. The cost of diabetes in India is that a patient has to spend around Rs 4,500 a year. This is the direct cost. The indirect cost is double the direct cost. This may appear small to you, but it is not. This cost is when you have no complications. If you have any complication and you have to be admitted to hospital, the cost becomes Rs 15,000. If you want to look after all the diabetics in India, you need Rs 9000 crore [Rs 90 billion or about $2 billion] a year. That is four times the Indian health budget!" Dr Ramachandran warned. One of the worst complications diabetic patients can have is the problem of the feet. It is said that diabetic foot problem is responsible for 50 per cent of all non-traumatic amputations. So preventing it is very important. When you have diabetes for a long time, it affects the blood vessels and nerves in the feet and you lose sensation. Like leprosy patients whose hands suffer from loss of sensation, the feet of diabetic patients are affected. With loss of sensation, high pressure points or callus under the foot leads to the formation of ulcers. The skin becomes thick because of high pressure and the foot becomes ulcerated. Then the pressure under the feet rises dramatically and patients get a lot of injuries. The injuries don't heal quickly as they are diabetic. Ulcers eventually get infected and will not heal for a couple of years. Finally, the patient ends up getting his feet amputated.
"The problem in India is that many people do not use footwear at home. They remove it when they go to a temple. They also remove it when they go to somebody else's house. So we have to educate most of them about the necessity of wearing footwear at home. Many people have pictures of gods and goddesses in all rooms. So they don't wear footwear at home. "Just yesterday, I convinced an elderly lady with great difficulty. She had ulcerated her feet so many times, but she still refused to wear footwear at home. I had to finally tell her to remove all the photos and keep them in one room so that she could use footwear in all the rooms except the puja room," Dr Viswanathan said.
In collaboration with the Central Leather Research Institute, the hospital has set up a plant to manufacture this footwear. From five to eight pairs in January, the production level has gone up to about 30 pairs a month. This special footwear was designed by CLRI based on materials suggested by M V Hospital that are suitable for diabetic patients. The materials used are light in weight, like polyurethane foam. Dr Viswanathan is confident that they are going to be better and superior than leather footwear. The unique aspect of the footwear is that it is three-layered. It has a tough insole for cushioning and a midsole to absorb all the shocks and distribute the load evenly. The outsole gives good grip. "Our studies have shown that the pressure on the patient's foot is distributed equally and he does not feel pain when he wears the footwear designed by CLRI.
According to Gowtham Gopalakrishnan, one of the scientists associated with the Centre, "There is no doubt that each pair has to be patient-specific. We study the pressure contours of each patient, map the contours and design footwear to cover the areas of pressure points so that pressure is distributed equally. If the pressure is distributed equally, the patient will not feel pain." He feels that mass production also is possible. "Yes, today we make it individually. But our plan is to produce more pairs. We understood from Dr Vijay that there are generally five-six categories of diabetes. So it is possible to design and make footwear for each type in all the normal sizes. With more studies, we can achieve many such things. In diabetic patients, irrespective of the area of ulceration, the pressure gets uniformly distributed. Generally, ulceration occurs in the forefoot area. Immaterial of where the ulceration is, a special type of sole -- rocker bottom sole -- can be made to relieve the pressure on the front portion of the foot because it has got a rolling effect," Gopalakrishnan said.
CLRI has big plans if this footwear is successful. "The initial results are satisfactory. Still, it is in the embryonic stages of development. We have to do many more clinical trials and produce statistics that our design is successful. But we are confident that it will be successful," said Dr Viswanathan. Photographs: Sreeram Selvaraj |
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Dr Ramachandran, managing director of the Madras-based M V Hospital for Diabetes and Director of the Diabetic Research Centre, says, "It is a myth that the prevalence of diabetes is low among Indians in India. We initially believed so because there was no statistics available."
The M V Hospital has imported a machine which, according to Dr Vijay Viswanathan, joint director of the hospital, no other hospital in India has, to detect the pressure points in the feet. Before starting the treatment of a diabetic patient, his or her pressure points are detected so that doctors can find out what are the chances of them getting ulcers in the long run.
Till now, footwear for diabetes was made of micro-cellular rubber in India. This material is used to make footwear for leprosy patients. Many diabetic patients refused to use footwear made of micro-cellular rubber as they feared that others would mistake them for leprosy patients. That was one reason why M V Hospital thought of designing a new kind of footwear.
B N Das, assistant director and head of the Shoe Design and Development Centre, said, "We distribute the pressure on the footwear in such a way that patients do not feel uncomfortable. The friction between the shoe and the foot is drastically minimised with such footwear. But we need to do more studies to find out how far ulceration has been reduced with their use."
The difference between the developed and developing countries is that in developed countries, they change the insole of the shoe to make it comfortable to the patient. But in India, open footwear is preferred to shoes. In developed countries, doctors send their patients to a footwear maker who designs footwear for each patient. This is, however, very expensive. It costs 250 to 300 pounds a pair. But here in India, the cost works out to only around Rs 400-500. When doctors in England heard about the footwear developed by M V Hospital, they showed a keen interest in importing it.
