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| COMMENTARY |
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| Year : 2014 | Volume
: 60
| Issue : 3 | Page : 235-236 |
Diabetic peripheral neuropathy in India: Underestimated and overlooked?
R Patell1, S Prakash2
1 Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, United States
2 Department of Neurology, SBKS Medical College and Research Center, Waghodia, Gujarat, India
| Date of Web Publication | 14-Aug-2014 |
Correspondence Address:
Dr. R Patell
Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
United States
 Source of Support: None, Conflict of Interest: None  | Check |
How to cite this article:
Patell R, Prakash S. Diabetic peripheral neuropathy in India: Underestimated and overlooked?. J Postgrad Med 2014;60:235-6 |
Diabetes Mellitus (DM) has an undeniable significance in India. Not only does the country top the charts in terms of sheer numbers (including projected estimates), but relative to developed nations, a larger chunk of the disease appears to affect the younger generation. [1],[2] In addition, various distinctive characteristics in our affected populations have led to a now well-recognized 'Asian Indian Phenotype'; which appears to place Indians at a much higher risk for complications, especially premature coronary disease. [3] Limited resources decreased awareness and inadequate access to specialized medical care are a reality for a large segment of the population in developing countries and have implications on designing management strategies at both the level of the community and the individual.
Chronic microvascular complications such as diabetic neuropathy, nephropathy, and retinopathy are common at the time of diagnosis in type 2 DM, as the disease can remain asymptomatic for years. Although advances in managing these eventually, often disabling complications, continue to be made, early diagnosis of T2DM and strict glycemic control can prevent them and is preferred. [4] Diabetic Peripheral neuropathy (DPN) is one of the most important etiopathogenic factors in the development of diabetic foot, often leading to amputation, which takes a heavy toll on the individual, community, and the health system. [5] Perceiving the pattern and load of DPN with reference to the Indian population is a step toward the increased understanding of this important problem that can then be used to shed light on the way ahead.
This question has only recently being given the attention it deserves. [6],[7] In this issue of the journal, Gill HK et al.[8] screened 195 recently diagnosed patients with type 2 DM, using various clinical tools for DPN, to determine its prevalence and correlate it with the clinical and biochemical parameters. Their findings are noteworthy both for detection of the prevalence and also for their use of several different modalities to pick up neuropathy. The latter revealed significant disparities; especially the difference in the estimates by monofilament testing (6.1%) versus the Neuropathy Symptom Score and Neuropathy Disability Score (29.2%), which was striking. Considering the established fact that microvascular complications are the result of a prolonged hyperglycemic insult and that type 2 DM usually remains asymptomatic, and thus undetected for years, it is not surprising that the age and duration of the symptoms are statistically and significantly associated with the presence of DPN. More important is the fact that they have found that glycosylated hemoglobin (HBA1C) and albuminuria do not have a significant association with the presence of DPN, and the authors have attempted to explain this interesting finding.
In a clinical setting, assessing a patient for DPN includes a variety of quantitative and qualitative modalities, as well as ruling out other possible etiologies. [9] The authors have emphasized that systematically utilizing (clinical) tools that are financially less intensive as well as can be more widely and routinely available, especially at the primary care level, is the way forward. Another standout feature is the use of age- and sex-matched controls to compare the presence of peripheral neuropathy in the apparently healthy population, a careful reminder that diabetes is not the only cause of PN, particularly in the elderly.
It must be remembered that this study was conducted in a clinical setting, and its findings may only be pertinent to a limited subgroup of diabetics. The absence of electrophysiological testing may seem to make the study more relevant to the practicing physician than the researcher, and this must be borne in mind when comparing it with the prevalence studies, especially in different regions; however, this is also a reflection of the recommendations in everyday clinical practice. Lastly India is a large country with several demographic and geographic variations; the single center design limits its applicability to a wider population.
Diabetic Peripheral Neuropathy can certainly be a crippling problem not only for the patients and their families, but with increasing numbers of T2DM, it takes a significant toll on the strained resources of the economy and already strained healthcare system. Comprehending the size of this problem and appreciating the utility of bedside techniques to assess this important complication, can go a long way in caring for a patient, as well as planning strategies to improve detection and management on a larger scale.
| :: References | |  |
| 1. | Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, et al.; ICMR-INDIAB Collaborative Study Group. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study. Diabetologia 2011;54:3022-7. 
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| 2. | IDF Diabetes Atlas. 4 th ed. International Diabetes Federation, 2009.
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| 3. | Mohan V, Deepa R. Adipocytokines and the expanding 'Asian Indian Phenotype'. J Assoc Physicians India 2006;54:685-6.
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| 4. | Singh R, Kishore L, Kaur N. Diabetic peripheral neuropathy: Current perspective and future directions. Pharmacol Res 2014;80:21-35.
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| 5. | Gupta SK, Singh SK. Diabetic foot: A continuing challenge. Adv Exp Med Biol 2012;771:123-38.
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| 6. | Sosale A, Kumar KM, Sadikot SM, Nigam A, Bajaj S, Zargar AH, et al. Chronic complications in newly diagnosed patients with Type 2 diabetes mellitus in India. Indian J Endocr Metab 2014;18:355-60.
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| 7. | Karmakar RN, Khandakar MR, Gangopadhyay PK, Ghosh K,Babu AS. Albuminuria and neuropathy in newly detected diabetics: Profile and correlation. J Indian Med Assoc 2011;109:396-9.
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| 8. | Gill HK, Yadav SB, Ramesh V, Bhatia E. A prospective study of prevalence and association of peripheral neuropathy in Indian patients with newly diagnosed type 2 diabetes mellitus. J Postgrad Med 2014;60:270-5.
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| 9. | Dixit S, Maiya A. Diabetic peripheral neuropathy and its evaluation in a clinical scenario: A review. J Postgrad Med 2014;60:33-40.
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