The ABC of diabetes: Are we doing enough?

Abstract

Dear Editor, I read with considerable interest the original article titled, “The ABC of diabetes. How many patients are able to achieve the goal laid down by American Diabetes Association?” by Menon et al. published in Med J Armed Forces India 2015; 71:132–134.1 Effective management of Type 2 Diabetes Mellitus (DM) requires comprehensive approach to target not just the hyperglycemia but blood pressure and lipids to achieve significant reduction in cardiovascular risk. Large studies have shown that glycemic control alone is not sufficient to reduce the development of macrovascular complication.2 Hence the various treatment guidelines for Type 2 DM lay down targets for these important parameters. Adequacy of treatment modalities require a regular look at the targets being achieved or the lack of it. This is important to reassess protocols, improve treatment delivery; regular monitoring and regular follow up. In a short but significant step in that direction, the authors have looked at a subset of their patients and whether targets were being achieved in them.1 One hundred patients were assessed at baseline and followed up over 6 months to evaluate the improvement in achieving these targets. Criteria laid down by the American Diabetes Association (ADA) were taken in this study. Less than half (45%) patients were achieving glycemic targets, only 27% the BP targets and 37%, the lipid goals with no significant change over the 6 months of follow up. Only one patient had all parameters within target at baseline and three had at 6 months follow up. This study has been conducted in premier tertiary care centres of the Indian armed forces where quality of medical services is likely to be at par with best of centres in the country. Other parts of the country with less well equipped centers are likely to have worse results, which can only be known by a larger multicenter study over a longer period of follow up. Similar studies from the developed world have also shown low rates of success of therapy, albeit better than these figures.3 This is a significant step by the authors to audit the performance of comprehensive diabetes care programme. It is an eye opener and lays bare the weaknesses in our medical system. However, not much should be read into this study as it was a small study considering the large prevalence of Type 2 DM and various levels of healthcare that it is managed in our country. These patients were included during the months of December and January, which is usually a holiday season and patients are likely to have defaulted in diet, drug compliance and regular monitoring. However no significant improvement over the next six months suggests that this may not have been the only reason for it. Recent guidelines have brought out the concept of individualization of targets especially for glycemia and BP. As this study has not elaborated on individual goals and has taken similar targets across the board, it is likely that poor success of therapy being shown here may not be correct. In a large organization like the Armed forces, where treatment protocols are fairly standardized, primary and secondary care health delivery system is well developed and regular follow up is well ensured, we can design a larger study with an inbuilt system to assess the achievement of treatment goals periodically. This mechanism to audit comprehensive healthcare delivery in a condition like Type 2 DM which has such a significant impact on cardiovascular morbidity and mortality will be a huge step towards achieving improved health for our clientele.