The prevalence of diabetes is rapidly increasing globally in epidemic proportions, but many people with diabetes remain undiagnosed or untreated. In view of this escalating prevalence, the World Health Organization (WHO) has launched the Global Diabetes Compact (GDC) campaign to improve the diagnosis and management of people with diabetes. To this end, a set of diabetes coverage targets, focusing on 80% of people living with diabetes, to be achieved by the year 2030, were defined at the 75th World Health Assembly for the first time in May this year. These targets aim to achieve not just glycemic control, but also blood pressure and lipid management at all levels of the health care system. India has the second largest number of people with diabetes in the globe. In this article, we have proposed the concept of “glycemic guardianship”, which means activities carried out by the health care team and the health care system in partnership with the patient to ensure optimal care of diabetes. Recognizing and acknowledging our role as “glycemic guardians” of the nation will automatically pave the way to realize the targets set by the GDC.
Keywords: Diabetes, Global Diabetes Compact, coverage targets, World Health Assembly, glycemic guardians
The Global Diabetes Compact (GDC) is a campaign launched by the World Health Organization (WHO), on the 100th anniversary of the discovery of insulin, to improve prevention, treatment and care for diabetes. Marking a first, the 75th World Health Assembly recently (May 2022) voted upon a contemporary set of diabetes coverage targets, that are to be achieved by the year 2030. This puts a stamp of approval upon the aims of GDC.1
In concordance with the aims and objectives of GDC, we propose the concept of glycemic guardianship. Glycemic guardianship refers to the activities carried out by the health care team and health care system, to ensure optimal care of the person, or group of people, living with diabetes. Glycemic guardianship can be operational at a macro-(country/regional), meso-(health care system), or micro-(individual) levels. It is ideally carried out in partnership with the person(s) living with diabetes. Glycemic guardianship benefits from well laid out aims, which facilitate effective and efficient accomplishment of goals. This has been bolstered by the WHO targets, which provide an umbrella for all actions related to glycemic guardianship.
CHALLENGES AND RESPONSE
The five GDC targets cover screening and diagnosis, outcomes of care and access to affordable drugs as well as monitoring tools (Box 1). The targets reflect the need for comprehensive vasculo-metabolic management and cardiovascular risk reduction in persons with diabetes. Without specifically mentioning particular groups, they call for attention to pediatric as well as mid-life and geriatric diabetes.
Box 1. Targets for Diabetes Coverage, 2030
Diabetes should be diagnosed in 80% of people living with the condition.
Good glycemic control should be achieved in 80% of people diagnosed with diabetes.
Blood pressure should be well-controlled in 80% of people diagnosed with diabetes.
Statins should be taken by 60% of people with diabetes aged ≥40 years.
Affordable insulin treatment should be accessible to 100% of people with type 1 diabetes.
Affordable blood glucose self-monitoring should be accessible to 100% of people with type 1 diabetes.
India is no stranger to the impact of the diabetes pandemic. With the second largest population of diabetes in the globe to care for,2 the country’s health care providers work hard to screen, diagnose, manage and prevent the condition. The increasing prevalence of the disease, however, offsets the advances that have taken place in diabetes care and its delivery. This is the “Paradox of Plenty”, where plentiful diabetes counteracts the potential of plenty of drugs and interventions that are available to treat the condition.
Our policy makers and health care providers have understood that diabetes is now endemic in society, and have begun tailoring their responses accordingly. Diabetes care is embedded in the primary health care system, the National List of Essential Medicines, Indian Public Health Standards and the National Programme for Prevention of Non-Communicable Diseases.3-5 Diabetes complications find mention in the Ayushman Bharat health insurance scheme,6 though the basic uncomplicated treatment is not yet covered by it.
THE FIVE TARGETS
Every journey has a destination, and milestones are necessary to assess our progress towards our goal. A similar situation exists in health care and in diabetes management.
The five targets laid down by GDC provide a roadmap for the Indian health care system. The law of two-thirds still operates in Indian diabetes epidemiology,7 and a majority of people with diabetes remain undiagnosed, untreated or uncared for. Emphasis on screening and treatment, including not only glycemic but also blood pressure and lipid management, at every level of health care, is required. Glycated hemoglobin (HbA1c), a target for individual health, helps in risk stratification, choice of therapy and assessment of adequacy of treatment.8 Use of statins as prophylaxis for cardiovascular disease should be encouraged, along with other interventions.9
Special focus on persons living with type 1 diabetes is also needed.10 Insulin and glucose monitoring are essential for life, and these must be provided to all who need them. The Indian pharmaceutical industry is a world leader in manufacturing good quality drug at economical rates. Insulin is an essential drug, at national as well as WHO level and is now sold at Jan Aushadhi stores. Good quality glucose monitoring devices and ancillaries are also available, at economical rates. Integrated personalized diabetes management (IPDM) is being promoted, and glucovigilance has become an accepted part of diabetes care.11
Ownership of this concept should be with all diabetes care providers. Once we accept and acknowledge that we are glycemic guardians of our great nation, we will automatically begin to guard our glycemic health. This, in turn, will ensure that we accomplish the goals set by GDC, and much more.
- First-ever global coverage targets for diabetes adopted at the 75th World Health Assembly. Available at: https://www.who.int/news-room/feature-stories/detail/first-ever-global-coverage-targets-for-diabetes-adopted-at-the-75-th-world-health-assembly. Accessed August 26, 2022.
- IDF Diabetes Atlas 2021. Available at: https://diabetesatlas.org/atlas/tenth-edition/. Accessed August 26, 2022.
- Kalra S. National List of Essential Medicines, 2015: Endocrinology perspective. Indian J Endocrinol Metab. 2016;20(3):412-3.
- Kalra S, Das AK, Chowdhury S, Shah S. Indian Public Health Standards 2012 and the diabetes pharmacopoeia. Indian J Endocrinol Metab. 2013;17(Suppl 1):S1-3.
- Thakur JS, Paika R, Singh S. Burden of noncommunicable diseases and implementation challenges of National NCD Programmes in India. Med J Armed Forces India. 2020;76(3):261-7.
- Bhargava B, Paul VK. Informing NCD control efforts in India on the eve of Ayushman Bharat. Lancet. 2022;399(10331):e17-e19.
- Kalra S, Saboo B, Sahay R, Khandelwal D, Talwar V, Unnikrishnan AG. The rule of two-thirds in diabetes epidemiology. Indian J Endocrinol Metab. 2017;21(1):242-4.
- Draznin B, Aroda VR, Bakris G, Benson G, Brown FM, Freeman R, et al; American Diabetes Association Professional Practice Committee. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Suppl 1):S125-S143.
- Draznin B, Aroda VR, Bakris G, Benson G, Brown FM, Freeman R, et al; American Diabetes Association Professional Practice Committee. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Suppl 1):S144-S174.
- Kalra S, Dhingra M. Childhood diabetes in India. Ann Pediatr Endocrinol Metab. 2018;23(3):126-30.
- Kalra S, Mittal S. COVID-19 and diabetes: Covidiabetology. J Pak Med Assoc. 2020;70(6):954-5.