The Management of Type 2 Diabetes:

A Translational Proposal for a Practical day to day Management Handbook and a Patient book which is tailored to ground realities and the follow up implementation.

The creation of evidence based and highly academic guidelines is very necessary, but in the ultimate analysis, they remain an academic exercise unless steps are taken to "translate" them into practical handbooks which would help those on the ground to offer patients good diabetes care.

In most countries, the day to day management of is carried out by family practitioners and in many cases these are the only medical professionals that patients have access to. To take the case of India, and in co-ordinating this proposal with people from many countries and even regions, this is definitely the case in most countries. Thus, to ensure good care, it is essential that such family physicians as well as others be empowered to manage diabetes, its complications, related disorders such as lipid abnormalities, high blood pressure, obesity including preventive aspects to protect against T2DM, its complications especially premature ASCVD, correctly.

The picture of medical care is further compounded by the fact that many of these family physicians are not trained in the allopathic branch of medicine, but in many traditional branches such as ayurveda, unani, homeopathy, tribal medicine, and India even has a category called registered medical practitioners, akin to the barefoot doctors. In addition, many countries also do not have a system of compulsory continuing medical accredition, so even those who may have studies allopathy may have outdated knowledge. Thus, the knowledge of most of these doctors who are the first and usually the only bulwark against the ravages of diabetes and related disorders, have very poor knowledge and yet all of them utilize allopathic medications to try and manage patients. One can decry these practices, but this is the ground reality in most countries, especially in the developing and transitional countries where the major burden of T2DM is seen and will only get worse in the future.

Although evidence based and highly academic Guidelines are available, there is a general feeling and this is also the feedback which one gets in interactions with family and other physicians that they find reprints of such guidelines which are given to them by pharmaceutical companies complicated and of little or no help in the day to day management of their patients. One may disagree with this, but these are ground realities. At the same time, they are keen to learn how to manage their patients better but are put off by things such as Evidence levels A, B, C, etc. and even by maximal and minimal standards of care. This is what people feel and we cannot ignore ground realities.

What one gets from talking to these family practioners is that they want information which is simple and can be easily used in their day to day practice. As an example, is it really necessary to discuss how the sensitisers work through GLUT 4? Using Guidelines to tell them that they should lower the LDL-C levels to <100mg% and that statins should be used for this is good, but not of practical use to them. They would like to know the targets, when to use statins, the starting dose and its modulation, the side effects they should look out for and what drug interactions they should be careful about. They also want to know when to add other drugs if the targets are not reached and which drugs these should be.

Even amongst the diabetologists in many of the developing and transitional countries, there seemed to be a feeling of being left out and there was a distinct feeling that such initiatives must be all inclusive, that they would like to get involved and also that any guidelines must take into consideration ground realities.

At the same time, there are excellent handbooks which are available in countries, in languages besides English, and many also have good implementation programs which other countries and regions could use easily if this meets with their ground realities. Unfortunately, there is little, if any, mechanism available for such interactions and often much work is lost re-inventing the wheel, so to say, when this has already been done and validated in other countries. In fact countries which have already done this, can be of immense help as we can use their experience and expertise, but the main thing is that all people must feel that they have a stake in this proposal as they have taken part in its planning and so the implementation and acceptance would be wide.

So the purpose of this initiative is not to bring out another handbook from a few central sources and then ask other countries, especially the developing and transitional countries, to implement them.

The aim is to have an ongoing interaction and inputs between all of us to help our people with diabetes between all the associations who can help each other.


Methodology

What we would do is to use the available guidelines in different languages, to make up a rough draft of a "Clinical Pointers" handbook and also ask participating countries and regions to add or subtract and give their opinions on this. Thus, the rough draft would only be a working draft open to alterations and also be "inclusive" in the sense that people from all countries and associations can give their opinions.

Most of the work can be done through the email thus being cost effective. This will allow them to feel involved and definitely get our final work wide acceptance.

Once the inputs are in, the draft can then be modified and altered and again sent to the associations and key opinion leaders for further comments or acceptance.

This is an intermediate part and is such that we get feedback from the ground, and also allow the very important interactions which would allow us to help each other and thereby our patients with diabetes.

Once this is done, and we have a final draft, which may take 2-3 rough drafts, the next step would be

1) Based on this wide consensus draft, we would then make up a handbook for day to day to day management (which can be agreed to by most of the Key Opinion Leaders ) but modified by them to meet the ground realities in their country or region. This would be extremely practical and focussed on the use by family practitioners and even other physicians. Depending on the association or region, this could also be in the form of educational practical management slides, Newsletters, Case discussions etc.

2) We can then even bring out a book for patients based on the guidelines.

If necessary, both these could be in local languages English, French, Arabic, Chinese, Spanish, Portuguese, and other languages, especially the book for patients.

3) The associations and regions would send ideas and information about its implementation. Here again, international collaboration and exchange of ideas and what is being done in one country or region may be very valid for a country in a completely different region!

After all, it is not only the plan, but also the planning which is important!

This would be joint initiative of all the participating associations and opinion leaders and they would have "ownership" of the documents and education material and it would be left to them to decide how the names appear in the documents.

All involved should get equal credit and this would be truly joint initiative.

This is the first version of the rough working draft and has been done in informal consultations with people from many countries.

I hope that many of you will help out in this initiative.

I would appreciate your views, inputs and feedback on this initiative.

Please email me at : smsadikot@gmail.com

Shaukat Sadikot


Dr. S.M.Sadikot,
Vice President, International Diabetes Federation
President, DiabetesIndia,
50, Manoel Gonsalves Rd.,
Bandra(W),
Mumbai 400050,
India

Contact:
email: smsadikot@gmail.com
Tel: +919820045859