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Diabetes: `Diagnosis is the key in India' -- Dr C. B. Sanjeevi, Professor, Dept of Molecular Medicine, Karolinska University, Stockholm

Rasheeda Bhagat

THE methodology for classifying diabetics in India as insulin dependent or not needs to undergo a change, with a crucial test, now not available in India, being brought in as a standard diagnostic technique, says Dr C. B. Sanjeevi, a Professor at the Dep artment of Molecular Medicine at the Karolinska University in Stockholm.

In an interview to Business Line, on the eve of a major international meet on diabetes he is organising in Chennai, he said that if India adopted the new line of classifying diabetes, it would find that a much larger percentage of diabetics need to switc h from medicine/tablets to insulin.

Excerpts from the interview:

Have the diagnostic techniques for diabetes undergone a change? And are we in India able to keep pace with the latest techniques?

There are two kinds of diabetes. One is auto immune diabetes; where the body's immune system damages the insulin-producing beta cells in the pancreas. This immune mediated destruction of the beta cells predominantly takes place in children, as also in ad ults. Because of the destruction of the beta cells, insulin production does not take place and the blood sugar level goes up.

From the clinical picture, or the symptoms which patients display, clinical diagnosis can be made between insulin-dependent diabetes (IDDM) and non-insulin dependent diabetes (NIDDM). The old WHO method of classification, given in 1985, classifies diabet es based on clinical diabetes but this does not see how the disease was formed and what has caused the destruction of the beta cells. It just looks at the patients based on clinical symptoms which are suggestive of IDDM.

So, this is not the best diagnostic method...

No. In 1997, according to the etymological classification, diabetes was classified Type I and Type II, with the former being caused clearly by the immune-mediated destruction of the beta cells in the pancreas. Any diabetes that is not related to the immu ne destruction of these cells is Type II. The first group requires insulin; the second does not.

But when you do not know what is causing the damage, many people who are Type I tend to get classified under Type II. Those diagnosed as Type I must get insulin. The problem is that to make this diagnosis, we have to do a special blood test to measure ce rtain anti-bodies that are directed towards the beta cells. But that test is not available in India. So, to doctors most patients might appear like NIDDM, and he will treat them as such by prescribing tablets.

But that would be wrong...and what harm is it likely to cause the patient?

If the damage to the beta cells is caused by immune destruction, it means the patient's beta cells are slowly dying. So if you give him tablets...these beta cells are already sick and the tablets make them work harder so they die faster. The result is th at the tablets will not work after some time in such patients who are in the wrong category. They will have to be put on insulin and they will remain on insulin.

But you say this test is not available in India. So how can doctors make the distinction?

There are some clinical clues which can help, but the definite thing is the test.

Is this test available all over the developed world?

Oh yes, everywhere.

Then why not in India where some of our hospitals boast of state-of-the-art diagnostic facilities?

Either people have not realised the need; or they think that the set-up cost -- about Rs 30 lakh -- is higher than the performance cost. There might not be immediate returns as a certain number of samples have to be tested to meet the cost of investment.

According to your estimate, what would be the percentage of those in the wrong category in India?

In India, about one per cent of diabetics are in the IDDM category, about 95 per cent in the NIDDM category and 3-4 per cent have malnutrition-modulated diabetes, which is peculiar to developing countries.

But going by the research I have done with diabetologists like Dr A. Ramachandran (Diabetes Research Centre, Chennai), Dr V. Sesiah (Apollo Hospitals) and some work in eastern and northern India, I find that 30-35 per cent of Indians belong to the IDDM c ategory.

Looking at the revised classification, those diabetics who have immune-mediated destruction of pancreas, who necessarily require insulin, add up to 30-40 per cent, and the remaining about 60 per cent. The picture is changing now and the test becomes very important.

You are painting a scary scenario by saying that a much larger percentage of diabetics in India need to be on insulin...

According to the classification by the American Diabetes Association -- whatever it recommends is taken as a very important recommendation by the WHO -- first you have to diagnose a diabetic by measuring the blood sugar level and then classify him either Type I or Type II. For that the auto anti-bodies test has to be done to find out whether or not the destruction of beta cells in the pancreas is going on. Only those who are anti-body negative can be called Type II and put on tablets. The others have to be given insulin.

What is the prevalence of diabetes in Sweden vis-a-vis India?

In Sweden, 7-8 per cent of the population is diabetic. In India 2-3 per cent of the rural population has diabetes against 10 per cent in urban India and this number is increasing. Sweden and Finland have the maximum incidence of juvenile diabetes.

Why is that be so?

There are several theories. In India we have a lot more infectious and parasitic diseases that seem to be altering the immune system. But in places like Sweden and Finland the level of hygiene is so high and infectious diseases so low that the auto-immun e diseases are more.

How far away are we from a cure for diabetes?

The way research and clinical trials are progressing, I would say we are not very far away. In the next five years we should have it.

You mean a cure?

`Cure' has to be defined in two ways. You can cure only a person who has already developed the disease. Cure can be provided only by islet transplantation in patients whose beta cells are completely knocked out...From cadavers, just like heart, kidneys a nd liver, pancreas too can be used. But since pancreas lies at the bottom of the abdomen, it takes time to reach it and the cells are dying slowly.

How soon should they be taken out?

There is a doctor in Canada in the University of Alberta who has found that if you go to the pancreas first when a cadaver is available, you get four-five times higher recovery of beta cells. He has an excellent technique by which he can isolate the isle t cells from the pancreas.

From one cadaveric pancreas, how many people can benefit?

One or two, depending on the beta cells you recover.

How many does one person require?

I do not know the exact number, but it will be a couple of million. But once the islet isolation is done, the transplantation technique does not require opening up of the abdomen, as in a kidney or liver transplant. These cells can be transplanted throug h an injection and they go and sit in the appropriate place in the body!

What is the success rate?

It is a big success story published in the New England Medical Journal a few months ago. They have done transplantation in 11 children in Canada and all of them have been cured. They have no diabetes and no need for insulin. After an 18-month follow-up, this is the finding.

This has become such a big success story that the NIH in the US and Juvenile Diabetes Foundation have poured an enormous amount of money and the former US President, Mr Bill Clinton, gave $100 million to adopt this technique in 10 different universities in the US.

How expensive is this technique?

The expense part is only the immuno-suppressants. Even these are not the conventional ones,..steroids with side-effects. These are not so expensive and do not cause side-effects.

What about prevention?

At the Chennai meet (an international Immunology Congress of the Diabetes Society beginning on Tuesday), we will be talking about vaccines which have entered clinical trials. Vaccines have been tested on human beings with good results.

How expensive will such a vaccine be?

Well, it depends on who makes it and what the market will be like.

How soon will it be available?

My guess would be that in the next five years we would be very close to a vaccine.

Pic.: Dr C. B. Sanjeevi, Professor, Dept of Molecular Medicine, Karolinska University, Stockholm.

Picture by Shaju John