Diabetes, with its attendant acute and long term complications, and the myriad of disorders associated with it, is a major health hazard. In keeping with the scenario of most developing countries, India has long passed the stage of a diabetes epidemic. The problem has now reached, in scientific language, "pandemic" proportions. To put it simply, it has crossed the dividing line in which it is a problem associated with individuals, no matter how large this number may be, and is now a very large public health problem, growing astronomically year after year.

We now have the dubious distinction of being home to the largest number of people with diabetes for any one country.

The picture was made even more grim by the fact that many of our people with diabetes are still undiagnosed. Almost two out of three people in urban areas and three out of four in rural regions have diabetes but do not know it!

Whilst the high rates of prevalence of complications is disturbing, the picture is rendered all the more gloomy with reports that many patients already show the presence of these complications at the time of diagnosis.

What is of considerable interest is not only is the incidence of diabetes increasing in leaps and bounds, but it appears earlier in life (with many people Type 2 diabetes being diagnosed at the age of 20-30 years), but the chronic long term complications are occurring earlier, progressing more rapidly and reaching the hard end points in diabetics who are relatively younger as compared to the picture seen in the past.

At the same time, it is well accepted that the onset and progression of many of the long term complications of diabetes can be delayed, if not avoided completely, by early diagnosis of diabetes and optimal management.

Unfortunately, this is easier said that done.

More than 98-99% of all people with diabetes in India are seen and managed by family physicians and general physicians. This figure does not seem high when compared to the U.S. where it has been estimated that around 95% of all the diabetic patients are managed by family physicians.

India is lucky in that it has a wide spread of family physicians, and it is this network which must be mobilised to make the diabetes care program accessible to the people. At the same time, one must realise that many of the family physicians even if they are trained in the allopathic branch of medicine have a poor knowledge of diabetes management.

The family physician network is further complicated by the fact that many of the family physicians are trained in the traditional systems of medicine, where not only is not much attention paid to diabetes, but it is possible that one may not necessarily agree with the concepts of diabetes care which are taught. Quackery is also widely present.

India does not have a system whereby a doctor can keep is license to practice only if he continuosly upgrades his knowledge, through rigorously laid out Continuos Medical Education programs.

As these physicians bear the burden of carrying out the day to day management of diabetes care in most patients, it is essential that they be empowered with knowledge allowing them to offer acceptable standards of care which today are lacking to a large extent. This knowledge must be made available to them.

Accessibility to a medical person may not necessarily make diabetes care available to the people, unless the physician has the knowledge to translate this accessibility into availability of diabetes care!

Most of the physicians are interested in increasing their knowledge of diabetes management so that they can offer better services to their diabetes patients. This can only happen through making such knowledge available to them.

In the absence of any initiative in this regard either by the Government or the Diabetes Associations and similar organisations, etc., it is left to people actively involved in day to day care of diabetes and well versed with the ground realities to do their utmost to fill in this void.

Nine years back when many of us came together to bring out the first ever Indian Guidelines, we were told that if India does not have any such guidelines, why not "import" them from abroad?

India is a vast and diverse country. This is something which is often forgotten. Not only is India a vast and heavily populated country, but the people who live here are ethnically heterogenous. This heterogeneity is manifested in significantly different religions, communities, castes, cultures, languages ( 18 major languages and more than 200 dialects!), food habits, life styles and in their genetic endowment. It would be true to say that India has more diversity than the whole of Europe and this diversity must be taken into account when planning any program for diabetes care in India. Moreover, the rural-urban divide between the people must also be taken into account. Around 70% of the people live in rural areas and 30% in urban surroundings. There is an ongoing rural to urban shift in the population. Even in the so-called urban milieu, one must consider the differences between those living in major cities and those living in smaller towns. It is rarely appreciated that there is a significant diversity amongst people living in rural, semi-urban and urban areas. Whilst the ultimate goals of a diabetes care program may be the same, the differences and diversity must be taken into account when drawing up specific plans and guidelines, which will be put into effect in order to achieve the objectives of the diabetes care program.

The appreciation with which the first, as well as the second Updated Guidelines published four years back were received has been overwhelming.

In past two to three years significant changes have taken place in what is considered optimal management, and that is the reason we at DIABETESINDIA felt that it was necessary not only to update the previous editions, but expand the material such that it could be used to help in the day to day management.

DIABETESINDIA sincerely hopes that this will be another important step towards providing better health care for people with diabetes in our country.