Sister Mercy Inbakumari (left), diabetes educator and research nurse, leads an education session for type 1 diabetics
Diabetes Research in India: A Mission and an Adventure
by SYLVAN ROGER MAGINLEY, JR., M.D. on JULY 23, 2013
I left New York on a chilly New Year's Day to embark on a research and care mission in southern India. The experience would expose me to a fascinating culture and allow me to pursue my clinical research passion: reversing the tide of diabetes, a disease that is projected to reach epidemic proportions in India and across the globe over the next decade.
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As a research fellow in endocrinology at Einstein, I am part of Dr. Meredith Hawkins' clinical research team seeking a better understanding of global diabetes. My work focuses on the basic mechanisms concerning obesity and insulin resistance and how these mechanisms relate to diabetes development. One of our objectives is to devise and implement ways to improve diabetes care here in the Bronx.
In India I was looking to apply those lessons on a global scale by partnering with the Christian Medical College in Vellore.
Just a few days after my arrival, as I was traveling back to my temporary housing, I exited my bus earlier than I should have and realized I was lost. The initial moments were unsettling. I was in an unfamiliar setting, thousands of miles from home. A nearby auto driver saw what was happening and insisted on showing me the way, later refusing a small cash tip as a "thank you." This random act of kindness made me feel immediately welcome. I felt even more committed to helping the Indian people in their fight against diabetes.
From the onset of my stay, I found unexpected parallels between the work I do in the Bronx and that done at Vellore. Research studies in both places are done in a similar manner, which reduced the learning curve for me. My interactions with patients made a strong impression on me. I was filled with concern for their well-being—and also with questions: "Will they forget their medication?" I wondered. "Will they wear the proper footwear? Why aren't diet and exercise appealing?" These questions are similar to the ones I ask in the Bronx.
In Vellore, I was particularly interested in learning more about malnutrition-modulated diabetes, often referred to as "lean diabetes," a condition in which individuals may get quite ill, but don't have type 1 diabetes.
Lean diabetes is where India and the Bronx diverge. In the United States, the onset of diabetes later in life is often associated with increased body mass index (BMI)—the ratio of a person's weight to his or her height. Patients in India tend to have much lower BMIs.
Studying this group of Indians with lean diabetes might provide answers that could help stem the looming Indian diabetes epidemic. Our questions include: Why is the incidence of diabetes increasing so rapidly in India? Why are so many with lean body mass starting to show clinical signs of diabetes? And what other factors might be involved?
Reflecting on my experiences in India, I realize that feeling "close to home" made studying diabetes from a global perspective even more important to me. I left Vellore with a renewed sense of purpose concerning my research and a richer understanding of how the experience of diabetes can cross time zones, continents and cultures.
A young diabetic child at CMC, using a thermos to hold his insulin
Volunteering to Thwart Diabetes in India
by MICHELLE CAREY, M.D., M.P.H. on JULY 2, 2013
He arrived looking nervous but determined.
As a young man diagnosed with type 1 diabetes at the age of 14, Rajesh had been cared for since his adolescence at the diabetes clinic at the Christian Medical College (CMC) in Vellore, India. Throughout his many years as an outpatient, he had developed close relationships with many of the physicians and nurses in CMC's endocrinology department.
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But on this particular day, Rajesh was not coming for treatment. Now in his early twenties, he had volunteered to participate in a research project to better understand the physiologic differences among the various types of diabetes prevalent in South India. This study is being done to compare type 1 and type 2 diabetes with a poorly understood form of diabetes called "malnutrition modulated diabetes mellitus" that has been noted only in developing countries.
Diabetes is the most common metabolic disorder in the world. In India, the prevalence of diabetes is exploding. According to Time magazine—which cites a 2011 research study by the head of the Madras Diabetes Research Foundation and colleagues—there are an estimated 62.4 million diabetics across India, an increase of 65 percent since 2004 estimates. Based on the current trajectory, as many as 100 million Indians could have the disease by 2030.
In the face of this diabetes tsunami, Rajesh is determined to make a difference. He agreed to participate in a metabolic "clamp" study, in which glucose and insulin are infused via an intravenous catheter, and hormone measurements are taken to determine either how well a person metabolizes glucose or how sensitive a person is to insulin.
A huge amount of time and resources had been invested to develop the infrastructure to allow participants such as Rajesh to take part in this study. CMC had established a partnership with Albert Einstein College of Medicine four years earlier, and over that time the groundwork had been laid to study participants with different kinds of diabetes using sophisticated metabolic research techniques.
Rajesh was contributing to a project with the goal of providing deeper insight into the physiology of diabetes for development of future treatment and prevention strategies. As a visiting endocrine fellow from Einstein, I was part of the continuing partnership between our two institutions. My role was to assist with the research studies and data analysis. As Rajesh settled in, I helped Ms. Mercy, the head nurse, and Dr. Ron, one of CMC's endocrine fellows, set up for the day's study.
Like most patients and study participants at CMC, Rajesh did not arrive alone; he was accompanied by his wife, dressed in a colorful yellow sari and carrying a bag of snacks, who would remain close by Rajesh's side for the duration of the six-hour study. Initially, both Rajesh and his wife were shy, and simply smiled or nodded in response to the study team's inquiries and explanations. But the team's efficient movements and welcoming manner quickly put the two at ease, and soon they were chatting and joking with each other and the team members.
Rajesh's wife worked as a maker of beedis, a type of hand-rolled cigarette commonly smoked in India; she had recently been hired for a new job and was excited. They were hoping to start a family soon, but wanted to wait until they had some savings put aside.
Rajesh said that he had participated in a support group (started by a visiting medical student from Einstein) for patients with type 1 diabetes at CMC, and he had spoken at several meetings about the challenges of living with this potentially devastating chronic disease.
By the end of the day Rajesh was glowing with pride that he had successfully completed a study that had the potential to help other patients with diabetes. "It wasn't that hard!" he commented. Rajesh left with his wife, telling the team he'd see us soon at his next appointment at the diabetes clinic.
I reflected that Rajesh's long-standing relationship with the endocrinology department at CMC had fostered a level of trust that allowed him to overcome his anxiety about being a research participant. Such relationships are the key to continuing CMC's and Einstein's work in trying to better understand the causes and progression of diabetes in South India.
Members of the Global Diabetes Institute from India and Einstein. From left: Dr. Maya Thomas; Dr. Nandini Nair; Dr. Michelle Carey; Dr. Donal O'Gorman; Prof. Meredith Hawkins; Dr. Roshan Livingstone; Prof. Nihal Thomas; Prof. Daniel Stein
Common Diabetes Barriers: From the Bronx to South India
by MICHELLE CAREY, M.D., M.P.H. on JUNE 20, 2013
"Language, time and space."
These were the barriers to providing effective diabetes education to patients that were repeatedly cited in a meeting of diabetologists, diabetic nurses and diabetes educators at a major academic medical center. Diabetes patients came to the clinic speaking a number of different languages, and often different dialects, which the doctors and nurses in the diabetes clinic had to switch among as fluently as possible. Family members accompanying patients were often called upon to do their best to translate. Visit times were necessarily limited by the long line of patients sitting in the waiting area. And clinic space was in demand, both for group education sessions and for one-on-one visits.
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The only difference between this particular meeting and similar ones I've participated in previously is that this meeting was taking place at Christian Medical College (CMC) in Vellore, India. The medical team members were all from India, as were the patients, but the concerns and challenges faced by the diabetes team at CMC were exactly the same as those frequently recounted by diabetes care providers here in the Bronx.
At CMC, providers struggled with the many languages patients from different states throughout India speak; Tamil, Malayalam, Kannada and Hindi were the major ones spoken by patients at this South Indian hospital, while among themselves the medical team members communicated in English. In the Bronx, diabetes patients speak Spanish, Albanian, Vietnamese, Tagalog, Igbo and a range of other languages from around the world, with English serving as a fragile lingua franca, often not suitable for discussing complex care plans or explaining the larger concepts essential to effective diabetes management.
Time is also one of our biggest challenges in the Bronx, with ever-increasing amounts of documentation required per diabetes visit, and seemingly ever-increasing numbers of diabetes patients in need of appointments. Space is a perennial problem in our crowded clinics as well.
As an Endocrine Fellow from Albert Einstein College of Medicine visiting CMC Vellore for the first time, I expected to find similarities in the approach to diabetes management between India and the Bronx. Care standards are similar at major academic centers worldwide, and medications may go by slightly different names, but the classes of therapeutic agents available are the same.
But I was startled by how perfectly the stresses and barriers faced by the diabetes team in Vellore mirrored those faced by our diabetes team in the Bronx. After the meeting at CMC, care team members approached me to ask my thoughts on the challenges they described, and to compare their problems to ours in the United States. They were equally surprised when I told them our challenges are exactly the same, word for word.
The meeting and subsequent discussions highlighted our two institutions' mutual mission of improving diabetes care and education worldwide, and underscored the interconnectedness among physicians, nurses, educators and patients working to make headway against the global diabetes epidemic.
The author (center) with Mercy Inbakumari, left, and Ron Thomas, M.D., right, in the metabolic clamp room at CMC, Vellore
Knowledge and Will to Fight Diabetes in India
by POOJA RAGHAVAN, M.D. on FEBRUARY 7, 2013
It felt good to be back on Indian soil, the place where I first entered this world. The Indian air was thick and hot, cars and motorbikes honked in the background. As I exited the auto-rickshaw and entered the hospital, I noticed the enormous line of patients waiting to be seen in the diabetes clinic.
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The women wore traditional sarees and salwar kameez (blousy trousers and tunics), the men dressed in pants and dhotis (draped cloth knotted around the waist). Most wore slippers, some were barefoot. All were diabetic. Good as it was to be "home", I was disturbed by the thought that there are so many more people in the rural countryside without access to insulin or proper diabetic care.
Although I grew up in the U.S., I was born in Chennai, about a 3-hour drive from the internationally renowned Christian Medical College (CMC) in Vellore where I'm working as part of my post-doctoral research fellowship with Einstein's Global Diabetes Institute (GDI). As of 2011, the global prevalence of diabetes is currently estimated at 343 million. Projections are stark. The International Diabetes Foundation estimated by 2030, 100 million Indians will have diabetes.
I've always been aware of the long-term care needed to manage diabetes. My father was diagnosed with prediabetes when I was young. My grandmother, though she was thin all her life and is still well and alive in her 80s, has been a diabetic for over 40 years. Early on I came to learn that one of the genetic and environmental downfalls of my Indian heritage was the looming threat of diabetes. But not everyone had the same knowledge.
I met a particularly wonderful young woman during one of my clinics, who said hello to me in Tamil, her native language and mine as well. I envied her outfit, a colorful maroon and green salwar, with intricate stitching detail at the neckline. I learned quickly that she was a rather non-compliant type 1 diabetic.
Eager to understand why the young patient was not taking her insulin, the attending physician asked: "Why did you forget to take your insulin? Did you forget to put on your clothes before coming here?" she asked.
"No, I didn't forget to do that," the young woman answered shyly, looking at the floor.
"No, you didn't, because I see you're wearing a very nice salwar. So why did you forget your insulin? Taking insulin should be second nature to you," the doctor continued. The young woman sat silently for a moment, and then offered an explanation in a muffled voice: "The power went out for a few hours like it does every evening, and I was tired after studying and fell asleep. I forgot my insulin completely."
The doctor and nurse educator nodded in understanding, and proceeded to spend an hour teaching the young woman about her disease, explaining that her body doesn't make insulin. They reminded her of the importance of compliance in terms of long-term health. The young woman shook their hands at the end of the appointment, clearly pleased to have people that cared about her health. She smiled and waved at me as she left the room, and I couldn't help but smile back, pleased to be reminded of why I went into medicine to begin with.
Although she originally hadn't understood the full impact of her decision on her health, the young woman appeared to finally understand the nature of her disease and how to control it. Perhaps, with continued education, we can send more patients back out into the world armed with the knowledge and resources to treat their condition and live better, healthier lives.