Diabetes currently affects over 65 million people in India, and it is expected that by 2030 there will be over 100 million people on treatment for this condition. 77 million people are in the pre-diabetes stage, which means even more people will be affected with diabetes in the next year alone.
Let’s admit it; these numbers are staggering.
One primary reason why India seems to be the ‘world’s diabetes capital’ is our genetic make up. Unfortunately, from birth, we are genetically programmed to develop diabetes. Some of us lucky few will escape it for sure, but many of us are likely to be affected by it or at least have borderline elevated blood sugar levels.
The largest number of patients with diabetes are seen between the ages of 40 to 59 years. This number is rising as obesity seems to be affected more and more adolescents these days. This is a very disturbing trend, as what used to be the disease of the older people is now one of the younger generation.
But it is not just diabetes alone that is worrying. The recent years have seen a surge in the complication rates in diabetes, and premature coronary artery disease incidence is rising amongst Indians with diabetes compared to other races.
All the life savings put together for future generations are being spent on investigations and treatments of diabetes and heart disease. In fact, the WHO has stated that in low income families, once 1 family member is diagnosed with diabetes, around 25% of the family income will be spent on just treatments. Imagine how hard that is for them.
A lot of people develop diabetes despite their every attempt to keep their food habits healthy and perform regular exercise. Those who do develop diabetes fail to get a grip on their blood sugars, thus requiring more and more treatment with every visit to their doctor.
But why is it that people fail to control their diabetes? Here are some common reasons why.
Failure To Follow Diet and Lifestyle Advice
It is quite interesting to see why patients with diabetes fail to manage their diet and exercise.
When an individual is diagnosed with diabetes, he/she is asked to follow a specific diet and commence an exercise plan. This can be quite a drastic change to the way the person has led their life for many years prior.
For example, the individual may be asked to stop eating sugar and sweets and possibly a staple food like white bread or milk. This may be easy enough to advise, but not easy enough to carry out.
A clinical study looking at long term adherence to exercise programs to vary between 10 – 80%. Two reasons for this include a lack of motivation and the presence of injuries, aches and pains.
But it appears that healthcare providers and patients view barriers for following diet and exercise plans quite differently. For example, doctors feel their patients don’t exercise enough due to lack of motivation and pain to be reason, while patients often report being busy with work or factors like the weather interfering with their exercise routine.
Similarly, barriers in diet are also viewed a little differently. Doctors feel that patients don’t follow dietary advice due to social commitments and family reasons, while patients avoid following the recommended diet due to a lack of satisfaction with the alternatives.
Poor Adherence To Medication
100% adherence to medication is a rare thing to come across amongst patients with diabetes.
Clinical studies have found that adherence to oral medication ranges between 36% to 93% in patients who had been on treatment for up to 2 years.
More recent studies have found that only 65% of patients take more than 80% of their medication.
It is not very clear why exactly this non-adherence exists. It is likely related to the cost of medication, busy work schedules, untimely meals (thus affecting timing of medication) and the fact that medicines are viewed as an inconvenience.
Now let’s take a look at insulin.
Advanced cases of diabetes requires patients to start insulin therapy. This is because the body gradually becomes deficient in insulin.
The commencement of insulin brings with a stigma and occasional fear as well. ‘Oh dear doctor, I don’t want insulin’ is a common phrase heard in medical practice. Why we hear it is not clear – it may be related to patients feeling they failed in managing their diabetes, or their concern that insulin injections are a bad thing.
Clinical studies have found that only 62% of patients who are on long term insulin adhere to treatment.
Why Don’t Patients Stick To Their Treatment?
There are a number of reasons why patients fail to adhere to their prescribed treatments.
‘Too Many Tablets Doctor’
This is one of the most common reasons. Patients find it very hard to stick to the complex treatment regime prescribed by their doctor.
It is well known that as diabetes progressed, the number of tablets can increase. In fact, there are over 7 kinds of oral medicines and 5 different kinds of insulin that can be used to treat diabetes.
The problem is this – the more the medicines, the higher the likelihood of getting confused about them, thus leading to missed doses.
Not just that. Changing to insulin can make things worse, as the pain of daily injections is a complete put off.
‘Why Do I Need The Meds Doc?’
Adherence can increase if a patient understands why they are taking the tablets to manage their diabetes, and what each of the medicines does in protecting them.
For example, if a patient is told that they are unlikely to have any problem with diabetes, then they are less likely to stick to their medicines.
Many patients who are started on insulin believe they are doing so because they failed to control their sugars through tablets, diet and lifestyle changes. Many a times, is just these simple myths that can lead to poor adherence.
Clinical studies have listed why patients fail to adhere to insulin regimes. The most common reason include health behaviors, followed closely by fear of injections. Other reasons include concern of taking injections for many years, inconvenience of taking insulin and believing that insulin was unnecessarily prescribed.
‘What About The Side Effects?’
One concern patients have with starting treatment is the development of side effects. In fact, many of them feel that starting medicines will give them side effects, even if their doctor reassures them that it is unlikely.
Tolerating medicine is an important aspect that is considered when medicines are prescribed. Doctors have to keep in mind that too intensive a control of blood sugars is not really good for the patients, and hence dose adjustments need to be made from time to time.
Weight gain and gastric troubles are 2 of the most common side effects seen with diabetes medicines.
‘It Costs Too Much’
Yes, medicines taken to treat diabetes can burn a hole in your pocket, especially the newer medicines.
The WHO estimates that if one member of a low income group develops diabetes, then over 25% of the family’s income will be utilised in their treatments alone.
These days, there are a number of agencies such as Netmeds that offer a decent discount on medicines along with home deliveries.
A good doctor will take the time to explain their diabetes to their patients.
Doing so will increased their compliance markedly. Having a diabetes nurse seems to improve compliance remarkably.
So What Happens If Patients Fail to Stick To Their Treatments?
Firstly, by not sticking to their treatments, patients are increasing their risk of developing complications of diabetes sooner.
The increasing number of visits to the doctor or to a hospital can increase personal costs and can wipe out years of savings.
Fixing The Problem
Simple measures can help improve adherence to treatments.
Keeping treatment regimes simple is the first step. Insulin use should be encouraged if needed, and the clinical need for it explained to the patient. Economic benefit of keeping blood sugars under control must be explained.
Self monitoring of blood sugar levels using devices can help achieve better control in the long run.
Finally, education is probably the most important measure to improve adherence to diabetes treatments. You can find information on this blog, or you could find books like the one below for some useful tips to control or even reverse diabetes.