Diabetes mellitus: socio economic considerations                                                                Content        Next
	Diabetes Mellitus is a burden not onJy to the individual but the society as a whole. It has been observed that the socio-economic problems inherent to this disease have been reduced over the later half of this century essentially because of modern therapeutic interventions. The present article outlines the cost approximation of diagnostic and therapeutic advents related to diabetes and its complications and an overview of methods to tackle them, as well as an understanding of the social stigmas and restrictions related to these patients.     Whenever a diabetic suspect attends a medical OPD there are a fixed set up of investigations which are immediately done and then pertinent ones planned out. The cost approximates given below were collected from M.Y.Hospital, Indore (as public sector) and Indore Pathology Association (as private sector). For the new suspect     1. Urine R/M 2. FBS and PPBS 3. GTT and 4. Glycosylated Haemoglobin, together would amount to roughly Rs. 400/- in private sector and about Rs. 100/- in Govt.sector. After this comes a series of further evaluation of the diabetic status as related to end organ damage ——These include     1. Regular ophthalmological checkups: This would include fundus examination and detection of retinopathy and lenticular opacities to which diabetics are quite prone. On detection of background retinopathy the patient has to come for regular follow-ups and undergo stringent diabetes control and on detection of proliferative retinopathy laser photocoagulation has to be undertaken. This depending on private setup costs approximates between Rs. 15,000/- to 20,000/- IOL implants for cataracts may be done at Govt. set ups as Rs. 1,500/- to 2,000/- and privately at about 5,000/- to 7,000/-.       2. Diabetic nephropathy is another major problem with many patients ending up in ESRD (End stage renal disease). Regular check ups at nephrology clinics with investigations like Blood urea/Sr. creatinine/Micral test/24 hr urinary protein estimation, Serum electrolytes and creatinine clearance assays may cost upto Rs. 500/-(private) or Rs. 150 to 200/- at Govt hospital levels. Then comes the cost of dialysis which is around Rs.1000/- for the first time and then Rs.150/- (at Govt. levels) or Rs. 1500/- each time at private levels. The cost of renal transplantations and tackling attending complications along with post-op immunosuppressive therapy may come up to Rs. 100,000/- Rs.5,000? (monthly thereafter) at private levels and about Rs. 20,000/- + Rs.1000 thereafter at Govt. hospital levels respectively.     3. Macro angiopathy leading to cardiovascular complications is another life threatening problem. For this baseline investigations like ECG/ Lip id profile and Risk ratio determination/ echocardiography (diabetes may cause LV dysfunction) TMT/MRI, angio or coronary angiography may have to be considered for individual patient requirements and the cost may be up to Rs. 8,000/- at private level or upto Rs.2,000/ at Govt set ups.       4. Management of recurrent infections mainly urogenital and respiratory need regular MOPD visits and cost of chest X-ray/Urine or vaginal swab c/s/sputum examination and courses of antibiotics are again expensive. Diabetes being prone to tuberculosis, courses of ATT, regular sputum examination and skiagrams may cost in the tune of Rs.2,000/- for an entire course.     5. Foot problems in diabetics are an important cause of morbidity. Ulcers and unmanaged cases ending into gangrene are common presentations. Pus c/s studies surgical debridement and dressings again under adequate antibiotics cover may fetch Rs. 500/- to Rs.1000/- including follow ups at chiropody units even in Govt. settings.       6. Follow up expenses : Regular medical check up including BP/fundus examination etc. on MOPD basis both for early detection and management of complications, may demand a fortune on private levels. The diabetic needs to check urine sugar and capillary blood sugar on domicilliary basis and glucostix/diastix costs for such regular testing comes to around Rs. 7,500 / per year.    The next most important problem is the decision of type of diet, its availability and costs.       A very common question commonly faced by physicians is 'Doctor, what should be my diet? Now since the problem of metabolism in diabetics is inadequate utilisation of carbohydrates, a diet poor in it and rich in proteins and liberal fat (under insulin/OHA cover) as per work schedule/Ht/Wt/Age/Sex of the individual is recommended. Daily requirement varies between 1800-2400 cal for sedentary to moderate work and 2500-3000 cal for strenuous activities for average male/female accordingly. There are however certain principles regarding the diabetic diet     1. Total calories should be sufficient for the age group. The specific food content may          vary but protein/fat and carbohydrates proportions may be same.     2. This caloric requirement should be calculated as per ideal of age ' for the patient and         not for actual weight. By this we could actually reduce the weight in obese and increase         the weight in the under nourished.     3. The carbohydrate content should not exceed 225 gms i.e. about 800 cal.     4. The diet must contain adequate vitamins and minerals.     5. The diet should be such that it aids adequate utilisation by insulin.       It is however ideal to hospitalise the patient of uncontrolled diabetics, bring down his cal. requirement to only Basal Metabolic levels and supply insulin to control hyperglycaemia. At discharge the food intake may be made to the ideal weight. Decrease of total calories as a temporary measure is of particular importance in the therapy of children or young adults who had diabetes for a short time and in whom a remission of disease may be anticipated.       Thus diabetic diets do not add up to the usual cost of meals and the only thing is a rearrangement of foods. In India of all diabetics 98% are NIDDM and of these only a third are obese and thus for the others stringent methods of weight control are unnecessary. Below are given a list of common Indian foods with their calorie content.     Ingredients Calories / 100 gms or Cal per measure mentioned A CREALS   1. Cornflakes (25 grns=l cup). 95 2. 3 tbs Rice 70 3. Suji 348 4. 5 small diapaties 400 5. 2 slices bread 120 6. 1 Bun 280 7. 1 cup oat meal 330 8. 1 mediant size dosa 130 9. Dalia 215 10. 2 idlis 200 11. Puri + Sabji 245 12. Parantha Plain (2) 275 B. PULSES   1. Ghana Dal 372 2. Moong ki Dal 334 3. Masur ki Dal 343 4. Soyabean 432 5. 1 cup cooked dal of medium consistency 276 C. SUGARS   1. 1 tbsf Jam 60 2. 1 Ts Sugar 16 D. FATS & OILS   1. Butter 755 2. Margarine 755 E. MTLK & MILK PRODUCTS   1. 1 cup cows milk 100 2. 1 cup buffalo milk 115 3. 1 cup skimmed milk 45 4. 1 glass skimmed lassi 25 5. 100 gms curd 60 6. 100 gms Kheer 48 F. FLESH   1. Chicken 151 2. Mutton 194 3. 1egg 65 4. Rahu Fish 97 5. Katla Fish 111 6. Lobster 90 G. NUTS   1. 10 cashew nuts 90 2. Ground nuts 560 H. VEGETABLES   1. Cabbage 45 2. Methi 49 3. Palak (spinach) 26 4. Ghana ki Saag 66 5. Carrot 48 6. Potatoes 97 7. Brinjal 24 8. Cauliflower 30 9. Mushroom 42 10. Tin da 21 1- FRUITS   1. Apple 56 2. Banana 153 3. Dates 283 4. Raisins 315 5. Guava 66 6. Grapes 32 7. Jamum 47 8. Litchis 61 9. Mangoes 50-80 10. Melon 16 11. Oranges 53 12. Papaya 32 13. Pear 51 14. Pineapple 46 J- DRINKS   1. Coca-Cola 80 2. 1 cup coffee (cont. 1 oz. milk-sugar) 25 3. 1 cup tea (cont. 1 oz milk-sugar) 22 4. 240 ml beer 112 5. 1 tbsf Horlicks 41 6. 3 tbsf BNournvita 38 K. BISCUITS   1. Cream Craker 24 2. Nice, Marie 24 3. 1 Chocolate Cake 165   The next most important consideration is the Cost of Therapy     The cost of therapy among diabetics need proper evaluations especially in our country where financial resources are limited, If the obese diabetic is not controlled by diet restriction OHA are called for. For the non obese NIDDM initial control by OHAs (single or later on combination OHAs). Finally for those still not controlled and for the      IDDM's insulin is chosen. The approximate relative costs of such therapy are dealt below:      a. Cost of single OHA therapy (on per annum basis) Chlorpropamide (OD dosing ) -          about Rs. 175/-Glibenclamide (BD) - Rs. 430/-Glipizide (BD) - Rs. 650/-Metformin (BD)          - Rs. 450/-Gliclazide (BD) - Rs. 3250/-      b. Insulin therapy costs may depend on the type of insulin (porcine/human) used. Based          on requirements the costs can come as follows :   Starting Daily Dose ID DM Body Weight (Kg) Mild in Units Moderate in Units Severe in Units 15 6 8 9 20 8 10 12 25 10 13 15 30 12 15 18 35 14 18 21 40 16 20 24 45 18 23 27 50 20 25 30 55 22 28 33 60 24 30 36     When the daily dose exceeds 30 U split into 2 doses and for stabilization Rapid + Isophane combination given   Starting Daily Dose NIDDM Body Weight (Kg) Dose Units Body Weight (Kg) Dose Units 40 8 75 15 45 9 80 16 50 10 86 17 55 11 90 18 60 12 95 19 65 13 100 or more 20 70 14         Dosing to be started with isophane insulin at 0.2 U/Kg either before breakfast or before dinner and on 30 U/day requirement split into 2 doses. If PP sugar is high rapid acting may be added increase.    Reduction percentage of Porcine/Human from Bovine is Calculated As :     Dose of conventional (Bovine) insulin Porcine Human Less than 0.6 lU/Kg body weight nil or 10% 10% Above 0.6 lU/Kg body weight 20-30% 20-30% More than 1 lU/Kg body weight 30% 30%     Hence based on these outlines the cost of therapy with insulin can be estimated from the following price list.     1. Porcine                a) 30% soluble insulin + 70% amorphous                                     b) 70% soluble insulin + 30% amorphous                                         contents 10 ml vials (400 I.U.) costing                                         approx. Rs. 100-105/-     2. Human insulin for above combinations, costing approx. Rs.160-165/-     3. Soluble insulins 400 I.U. (10 ml vials) Bovine - Rs. 30- 32/-Porcine Rs. 100-105/-Human         Rs. 160-170/-     4. Long acting (mainly insulin in shop) bovine - Rs. 30- 32/-Porcine - 100-105/-Human -         Rs. 160-170/-       Diabetes mellitus initially a problem of mainly developed countries is now posing a tremendous burden on Indian Health care system. An estimated 28 million diabetics will be present by the turn of the century (2.07% in rural and 5.72% in urban population). This increasing trend is mainly due to urbanization of the society and added problems of malnutrition. 2% are IDDM and 98% NIDDM of which a small percentage is of tropical diabetes. In developing countries added to the burden of infectious diseases DM is an active problem now. In this respect the position of the physician is very important in respect to taking adequate cost effective preventive management.     As diabetes mellitus has potentially treatable complications today, the well planned programmes of early diagnosis and follow up studies to prevent hard end points (ESRD, Retinopathy, AMI) should be concentrated upon. This will reduce the economic burden of therapy of such complications once they develop. In our country this is important because the cost of management has to be borne by the individual unlike European and American countries where health care is nationalised and insured. Regarding the cost of diabetic care there are 2 types of cost.      A) Direct-which the individual bears (cost of consultations/therapy and investigations) and    B) Indirect - including social security problems, marital problems, income tax rebate, loss of        mandays, disability payments and such costs are a major brunt to the society.       Thus considering the fact that diabetes mellitus is a tremendous economic burden on the society it is imperative that the health care approach be an integrated public and private sector approach.     In India, the health care approach is a 3 tier one -Primary/Secondary and Tertiary. On primary levels PHC/ subcentres and community health centres are doing at village/tribal areas of which PHC's are 21, 024 subcentres 1,30,336 and CHC 2293 in number. Then at district hospital levels/ ESI hospital, the secondary care is taken and finally the tertiary level includes Medical Colleges and Hospitals. At the CHC's physicians/surgeons & obstetricians are available (those below CHC are mainly consisted of paramedical staff). So at CHCs essential diagnostic and therapeutic interventions for diabetes mellitus patients can be done and the catchement area being 1,00,000 population this is an effective stratum to carry out the preventive approach.     Unfortunately, however in India only 2% of the budget is for health and thus adequate care cannot be done only by the Government Hospitals/ Health Centres even at tertiary levels. Thus, private or other Govt aided bodies are important like Diabetes Control Programme (Delhi/Calcutta), Diabetes foundation (Delhi), Diabetic Research Centre (Madras), Research Society for study of Diabetes in India (Delhi, Hyderabad) which are rendering continuous service. The several private institutions ( hospitals/nursing homes) are also catering services in this aspect at special endocrine OPD's. Social problems related to diabetes were more important upto the middle of this century but the later part saw improved diagnostic and therapeutic interventions and less social restrictions for diabetes.     Insurance benefits were previously out of reach for diabetic patients. Any person having a positive urine sugar testing (be it by other reducing substances) was prevented from getting life Insurance claims which however have seen lots of relaxations as normal life expectancy may be secured in diabetics today.     Automobile licenses which were refused previously for diabetics, have now been relaxed though pilots in several parts of the World are refused charters in commercial flights if under OHA's or insulin therapy.     Employment for diabetics are no major problem these days. This is due to the fact that better health education, stringent diabetes control and early detection and treatment of complications have reduced the number of mandays loss and acute complications (eg. Hypoglycaemic shock) at the place of work.     In conclusion it may be said that diabetes mellitus is a well known medical problem for its morbidity and mortality and is on the rise in India. However, an upliftment of health care services including private and public sector integrated approach have been of help in improving preventive and therapeutic aspects of this disease.     Presently it can be said that more and more stress should be given on early detection and control of complications to avoid loss of mandays and lives. REFERENCES         1. Joseph J. Beardwood. The Socio-economic Problems Associated with Diabetes             Mellitus'. Diabetes Mellitus Diagnosis & Treatment - Vol HI, George J. Hamwi, T.S             Danoski (Edit) Pg. 215-219.         2. Hemraj B. Chandalia, 'Health Care Delivery in Diabetes - The Indian Scene', Novo             Nordisk Diabetes Update, 1996, Pg.65-71.         3. J.K.Joshi. 'Economic Implications of Diabetes Care, Novo Nordisk Diabetes Update             Pg.79-83.         4. Elliot P. Joslin. 'The Treatment of Diabetes Mellitus.' in the treatment of diabetes             Mellitus. 10th Ed. Joslin Pg. 243- 281.         5. Insulin Manuals from Hoechst India. Torrent India.