July - September 2018

Vol.4 Issue 4 JULY - SEPTEMBER 2018

THE DIAGNOSTICS NEWS JOURNAL Published at Agappe Diagnostics Limited on July 01, 2018 | 62 Pages |` 20

IN GLORY OF THE NATIONAL AWARD FROM THE HON’BLE PRESIDENT OF INDIA Mr. Thomas John

DIABETES MELLITUS LABORATORY INVESTIGATIONS Dr. D. M. Vasudevan

“NEVER NEGLECT DIABETES” AN INTERVIEW Dr. V. Mohan

“PREVENTION IS BETTER THAN CURE” AN AWARENESS SESSION Dr. Anand Gokani

TYPE 1 DIABETES: CURRENT SCENARIO Dr. K.M. Prasanna Kumar

“LEADING A SEDENTARY LIFE IGNITES DIABETES” AN INTERVIEW Dr. Arvind Lal DIABETOLOGY Exploring Pathophysiology of Diabetes Mellitus - Type 1 and 2 Privilege® Don’t forget It’s not about how much you give to scan the But how much we admire! BARCODE !

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Volume 4 | Issue 4 | July-September 2018 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ CONTENTS○○○○○○○○○○○○ 7 Recapturing the sweetness of life 12-15 Laboratory investigations in Diabetes Mellitus 20-23 Never neglect diabetes! Dr. V. Mohan 24-25 Importance of Diabetic profile

26-29 “Prevention is better than cure”- An awareness session-Dr. Anand Gokani 08-11 IN GLORY OF THE NATIONAL AWARD FROM THE HON’BLE 16-19 PRESIDENT OF INDIA SHE PAINTS 52-53 Brand Reach - Customer Speaks HER LIFE 54 Engagements - Exhibitions & Conferences WITH 55 Engagements - Special Days VIBRANT 58 Moments-Awards HUES 59 AG Privilege Registration Form 60 Medical Quiz & Editorial Submissions 37-39 Beauty, Boldness and Compassion! She has it all!! 30-33 40-43 Type 1 Diabetes: DECORATING Current scenario in India THE 44-46 Steer away from diabetes A social menace! BEAUTIFUL 47-49 Glycated Hemoglobin (HbA1c) FABRIC OF LIFE New trends in testing

Views and opinions expressed in this magazine are not necessarily those of Agappe Diagnostics Limited, its publisher, or editors. We do our best to verify the information published but do not take any responsibility for the absolute accuracy of the information. We do not take responsibility for returning unsolicited material sent without due postal stamps for return postage. No part of this magazine can be reproduced without the prior written permission of the publisher. Techagappe publishers reserve the right to use the information published herein in any manner whatsoever.

Caution: After going through the techniques, procedures, theories, and materials that are presented in Techagappe, you must make your own decisions about specific treatment for patients and exercise personal/professional judgment for further clinical testing or education and your own clinical expertise before trying to implement new procedures. Contact info: The Manager-Corporate Communication, Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district , Kerala-683 562, India. www.agappe.com Contact: Ph: + 91 484 2867065, Mob: +91 9349011309. Published from Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district , Kerala-683 562, India. Contact: Ph: + 91 484 2867000, Fax: + 91 484 2867222; Printed at Five Star Offset Printers, Nettoor, Cochin-40, for Agappe Diagnostics Limited Printed and Published by Ms. Meena Thomas on behalf of Agappe Diagnostics Limited and Printed at Five Star Offset Printers, Nettoor, Cochin-40 and published from Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O, Ernakulam district, Kerala-683 562. Editor is Ms. Meena Thomas.

4 TECHAGAPPE JULY-SEPTEMBER 2018 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ From The Chief Editor’s Desk

THE DIAGNOSTICS NEWS JOURNAL

Volume 4 | Issue 4| July-September 2018 ○○○○○○○○○○ ○○○○○○○○○○○○○○○ Exploring Diabetes Mellitus... EDITORIAL BOARD I am very pleased to place before you, this 16th issue of Techagappe, the EDITOR quarterly review of health and laboratory medicine. Since its beginning, all Meena Thomas editions were based on various organs and health conditions. This magazine is now regular in publication at intervals of three months. I am also happy to CHIEF EDITOR report that the laboratory community has warmly welcomed the previous Dr. D.M.Vasudevan issues of the magazine. This issue focuses on the complications of Diabetes CONSULTING EDITOR Mellitus. We have, as usual, included three scientific articles, three life sto- Rarima N.S ries, two interviews and one technical article. EDITORIAL ADVISORY BOARD In the MD’s desk, we are highlighting the recent national award we have Rajesh M. Patel received from the honorable president of India for the innovation in Mispa I Dr. C.S. Satheesh Kumar series. Sudhir K. Nair Jofy Paul The first scientific article describes the laboratory methods for identifying Sanjaymon K.R the complications of diabetes. The second scientific article is from the pen of Vijith Kumar V. Mallya the great-grandson of Mahatma Gandhi, Dr. Anand Gokani from Mumbai on Bintu Lijo Type 2 Diabetes. His article emphasises awareness sessions and preventive measures. The third article is from Dr. K.M. Prasanna Kumar from Bangalore LEGAL ADVISORY BOARD about Type 1 Diabetes and its relevance in the current Indian scenario. Adv. Denu Joseph In the life story sessions, we have three young women who are from PUBLISHING COORDINATOR different parts of the country. We start with Ms. Pranjali Valsangkar who is an Jayesh Kumar IT specialist from Pune, suffering from Type 1 Diabetes for a long time and has been successfully managing it by an artificial pancreatic system. Her DESIGN AND LAYOUT experiences are tunefully elucidated in the poem session also. The second M.T. Gopalakrishnan story is of a professional tailor from Malappuram district of Kerala, Ms. Dezign Centre, Kochi.9947144570 Shabnam, who had undergone pancreas and kidney transplants three years WEB MANAGER back due to complications arising from Type 1 Diabetes. Now she is free from Sanjaymon K.R insulin injections. The third story is from north India, about a young patholo- gist who suffers from Type 1 Diabetes, and is now a member of the Interna- PHOTOGRAPHY tional Diabetes Federation. In this capacity, she serves the juvenile diabetic Nelson Thomas patients.

BOARD OF DIRECTORS In this issue, there are two informative interviews with two eminent doctors, Dr. V. Mohan from Chennai and Dr. Aravind Lal from Delhi. Both of them CHAIRMAN have contributed their valuable time to discuss with TechAgappe team about Prof. M.Y. Yohannan the latest trends in the treatment and laboratory tests for diabetic patients. In the technical category, we are presenting a practical article on new trends in MANAGING DIRECTOR HbA1c testing, which will help the laboratory technologists to function more Thomas John effectively. EXECUTIVE DIRECTORS I am glad to state that we have received very good feedback and great Meena Thomas appreciatory letters for the last issue along with quiz participation. I am sure Mary Baby Meleth that this issue of the TechAgappe will give useful insights to the Diabetes Sangeeta Joseph Mellitus, and different aspects of laboratory practices. I am proud to an- Dr.D.M.Vasudevan nounce that the ensuing issues of TechAgappe will cover other important topics. Your constructive criticisms to improve the contents will be greatly Subscription-For subscription queries, write to techagappe@ appreciated. agappe.in or call us at +91 484 2867065. Permissions-For permissions to copy or reuse material from Techagappe, write to techagappe With warm personal regards @agappe.in Letters to the editor-Email: [email protected] Postal address: The Manager-Corporate Communication, Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district, Kerala-683 562, India. Advertisement Queries- Email: [email protected] Dr. D.M. Vasudevan

TECHAGAPPE JULY-SEPTEMBER 2018 5 LETTERS TO THE EDITOR Pleasurable reading, Serene Power-packed with updated presentation knowledge Seasonal greetings, Team An excellent clinical presentation makes this magazine worth TechAgappe! Thank you for gift- reading from page to page. Article on advanced interventional ing me the latest issue of the cardiology, heart transplant, cardiac biomarkers, lipid pro- A cornucopia of journal. I would say, for a clear file and last but not the least, the best one is the article on mind, reading should be a habit. hardware calibration in clinical laboratory practices, which information To become it as a habit, quality will really help medical professionals in updating their knowl- Dear TechAgappe team, kindly materials should be available edge. All the articles are nicely selected and up- accept my heartiest congratula- for us. Nowadays, a lot of maga- dated. A message for organ donation is tions on publishing such a mar- zines, from different sectors, an inspiring one through your velous magazine, which is full of are available. But reading will be heart trans plant article. I sa- the most valuable information in a pleasure only when the maga- lute Dr. Jose Chacko a systematic way. I have gone zine has that kind of serene pre- Periappuram for through your latest issue of sentation. Whatever shown in his ever shining TechAgappe (April - June, 2018) the journal is information. Even services to the and was completely swayed by an advertisement is very useful mankind. its contents. I am very much im- for us. I could not read this Dr. T. N. Budhe, pressed with the presentation magazine first issue onwards. Sushroosha and selection criteria of articles. But I will read its online versions Nursing Home, All are well placed. It is my de- where all the past editions are Kurkheda sire to go through all the previ- available. Wish your team good ous issues at the earliest. I trust luck. Let your great vision and that you will understand my feel- mission to help people through Grateful for the great Commendable ings and arrange for the same as TechAgappe succeed in the fu- a special case. ture also. information source - health tips for N.K Bansal, Mr. D. Datta, ‘TechAgappe’ better life Goyal Intercity, Ahmedabad Dhanbad, Jharkhand TechAgappe is overall a well pre- I always admire and appreci- sented and edited magazine. The ate the poetry column, a liter- look and feel and the articles pre- ary-scientific mixture. Every Empowering lives sented are marvelous. Coloured issue is special and brings photographs are pleasing and cover stories of good informa- Being a regular reader of TechAgappe’s health tips, I would clear. The magazine is remark- tion in a simple manner. Fur- like to share my understanding for a peaceful and healthy life. able with ample and apt mate- ther, I would say that the health We should develop a good opinion of ourselves first of all. rial. Health tips are decently well tips are very useful and very Eating good food at the right time is very important. Doing placed, which touches the natu- relevant these days as it is writ- exercises regularly is one of the finest requirements for better ral way of living and caters to our ten in such a way that even lay- health. Stress is not avoidable but we should learn to manage healthy life solutions. The tech- man can understand. For it. After all, live in the present, enjoy it and find your work-life nical article about preanalytics is maintainingquality in labora- balance, wherever you are. Finally, after daily responsibilities, highly appreciated as it is inter- tory practices, GLP column is sound sleep is a must to nourish you very excellent. I appreciate all for the next day. I gained estingly very important for lab these tips from diagnostics and the information the officials of TechAgappe in the health tips is saved and kept with us as a continuing this effort for the sessions of Tech reference point. Thanks Agappe betterment of medical as well Agappe. Good work, for your whole-hearted efforts to as social community and for TechAgappe team! helps us better with ‘Tech their well-being. Agappe’. Vaskar Baidya, Prof. S. Prabhavathi, Girija Diagnostic Chandresh Dagha, Principal, Centre, Tripura. Anant Pathology Lab, Vellalar College of Nursing, Malad, Mumbai Erode

6 TECHAGAPPE JULY-SEPTEMBER 2018 Cover Story Poem on Diabetes

“You are so sweet!” someone complimented her. She smiled. “Of course! Sugar is in my blood” She reminded herself… She was asked a question “What do you want to be in near future? Her reply: SUGARFREE The therapist asked, “Have you forgotten anything since the last two years?” “Yes. To live” Her body wanted to give up, but her heart wanted just the opposite. She chose to be with her heart… At 23, life was full of sweet surprises! What she forgot was, too much sweetness can cause diabetes… Life was never the same for her.. But… Life was not this better She sailed in the ship of her own dreams… But she forgot, that ships may sink… but her dreams cannot… “How much it pain?” As vast as the ocean, as limitless as the sky… Only my will to be happy empowers it all… Recapturing the Sweetness of Life

Pranjali Valsangkar Graphic Designer, Pune. (To read her story, refer page no.16)

TECHAGAPPE JULY-SEPTEMBER 2018 7 Agappe MD’s Desk IN GLORY OF THE NATIONAL AWARD FROM THE HON’BLE PRESIDENT OF INDIA Thomas John, Managing Director, AGAPPE. In the recent past, the R&D initiatives have brought the most prestigious recognition to Agappe – a national award. Agappe’s Mispa-i3, the automated Cartridge based Specific protein Analyzer was selected as the winner of National Award 2018 for the ‘Indigenous Development of Technology and Commercialisation’. The award was organised by the Technology Development Board, Department of Science and Technology, Govt. of India, in connection with the 20th Technology Day at Vigyan Bhavan, New Delhi.

It was indeed a moment of overwhelming pleasure and pride Secretary, Department of Science and Technology. for the Agappe family when Agappe was selected as the winner The Technology Development Board, which is governed by of the National Awards 2018. The prestigious recognition was Department of Science and Technology, GOI, has distributed the given for the ‘Indigenous Development of Technology and National Award on the 20th National Technology Day to those in- Commercialisation’ of Mispa-i3, the Automated Cartridge dustrial concerns that have displayed excellence in commercial- Based Specific Protein Analyzer. izing the indigenous technology. This award ceremony was held The National Award was presented by the Hon’ble Presi- on 11th May 2018. dent of India, Shri. Ram Nath Kovind to Mr. Thomas John, the May 11th is commemorated as the National Technology Day Managing Director and Mrs. Meena Thomas, the Director of considering the outstanding technological feats like the success- Agappe, in the presence of Dr. Harsh Vardhan, Honourable ful carrying out of nuclear tests at Pokhran, the victorious test Union Minister for S&T and ES and Prof. Ashutosh Sharma, flight of first indigenous aircraft ‘Hansa-3’ at Bangalore and the

Mr. Thomas John, Managing Director and Mrs. Meena Thomas, Director, Agappe Diagnostics Ltd., receiving the prestigious memento from Hon’ble President of India, Shri. Ram Nath Kovind as the winner of National Awards 2018 for the “Indigenous Development of Technology and Commercialisation” of Mispa-i3, the Automated Cartridge Based Specific Protein Analyzer, in the presence of Dr. Harsh Vardhan, Union Minister for S&T and ES.

8 TECHAGAPPE JULY-SEPTEMBER 2018 Thomas John and Meena Thomas with other National Award winners shared the frame with Hon’ble President of India, Shri. Ram Nath Kovind. successful test firing of the Trishul missile – all on May 11th. of same was an indelible mark of achievement and the display of expertise of our team. Agappe participated with the peers in the realm with its revolutionary innovation, Mispa-i3 the Automated Cartridge Based Spe- In making the advanced technology reagents, Agappe’s R&D cific Protein Analyzer. Through this contribution, Agappe could to team proved their mettle by developing LEIT (Latex-Enhanced reduce the patient diagnostic cost to 1/10th in the specific protein Immuno Turbidimetry) reagents. We are proud of being the testing. only Indian company which has its own LEIT reagents. Today, Agappe is considered to be the topmost clinical chemistry re- While felicitating the innovators with the awards, the president agent manufacturer in India and has a heads-up position in emphasized on the common attributes of the technologies awarded. haematology reagents. “First, the solution should favour the Indian scenario; secondly, it should be cost-effective and finally, the technology should be of Over the time, Agappe also focused on indigenizing the topmost quality”, he stated. diagnostic equipment and thus in 2010, we started a wing for R&D equipment as well. In the year 2012, we were able to launch The Union Minister for Science & Technology and Earth Sci- our first product of R&D equipment - the compact and afford- ences, Dr. Harsh Vardhan, while complimenting the winners, high- able Specific Protein Analyzer viz. ‘Mispa-i2’. This system was lighted on a renewed pledge of empowering people with compre- developed on a platform where it can perform tests in hensive technology. nephelometry and photometry together through a technology The Innovation Generator – Agappe R&D called ‘Unique Channel Shifting (UCS)’. This analyser can perform about 25 specific protein parameters with high accuracy. Since the time of inception, Agappe has set its focus on pro- The system has a specially designed calibration card which viding top-notch products to its customers. In the initial stages, we associated with a number of European and Japanese companies to deliver the best quality products. Agappe participated with the peers Within a few years, Agappe realised the importance of estab- in the realm with its revolutionary lishing an in-house R&D wing to succeed in its motto of providing innovation, Mispa-i3, the Automated better quality products at a highly affordable pricing. As the years passed by, the demand from the IVD industry steadily increased Cartridge Based Specific Protein and our product innovation was turning remarkable in each situ- Analyzer. Through this contribution, ation. Agappe could reduce the patient Agappe started with indigenization of the chemistry reagents diagnostic cost to 1/10th in the at first and followed with the introduction of system packs as well. Subsequently, the development of immunochemistry assays was specific protein testing. also materialised by our R&D team. The successful introduction

TECHAGAPPE JULY-SEPTEMBER 2018 9 Agappe MD’s Desk

helps in reducing the errors in the calibration process. On the other hand, for HbA1c estimation, Mispa-i2 is also certified by NGSP (National Glycohemoglobin Standardization Program), which is considered as the international standard for diabetes testing. The success of Mispa-i2 has changed the pace of R&D activities in Agappe and the thirst for new products in R&D was never-ending. This has eventually led our team to develop the semi-automated chemistry analyzer – ‘Mispa VIVA’; the coagulation analyzer – ‘Mispa Clog Plus’ etc. In 2016, we were able to launch a new version of the specific protein analyser, which works on cartridge-based system viz. ‘Mispa-i3’. Mispa-i3 offers benefits like high precision and quick turnaround results for all protein assays and sup- ports the clinical management of a variety of diseases such as diabetes, cardiovascular disorders, inflammation, kidney disease and other specific protein assays. This automated analyser works with pre-filled, bar- coded, ready-to-use reagent cartridges with 30 and 10 test pack sizes offering stability for more than 6 months. The goal of using a pre-filled cartridge with a barcode was to reduce the errors in the sampling process at the diagnostic centres. The system is also equipped with Smart card calibration which eliminates the errors and reagent wastage. The analyser has a voice support mode, which guides the user at every phase of the testing and gives error free work environment, making life easier for laboratories, clinicians and patients. New projects in Agappe R&D: z Agappe join hands with Hitachi Chemical for manufacturing their most advanced fully automatic specific protein and clinical chemistry analysers in India. These in- struments provide ease of operation, fast and highly specific puram, Kerala for another project through Technology transfer results at a reduced cost - estimated at roughly one-third of agreement for developing and marketing the Vein Detection the cost per test compared to the conventional method ana- systems. The technology and system will facilitate the pre-analyzers. The equipment enables early detection of kidney mal- lytical aspects of drawing samples and also in terms of sup- functioning, cardiac problems and osteoporosis. This can porting the treatment at the clinician’s office for medicinal in- also support detection of prostate cancer through PSA test- jection processes. The highest advantage accessible is for the ing and TB detection through ADA testing. paediatric consultation centres, where the identification of vein z Agappe is associated with Sree Chitra Tirunal Institute for in infants is very difficult. Medical Science and Technology, Thiruvananthapuram, z Pre-analytical automation is one of the best ways to prevent Kerala, through technology transfer agreement for develop- pre-analytical errors due to improper sampling. This has led ing and marketing the Rapid Diagnostic Kit with antibiogram Agappe to think of developing a prompt and apt solution and for Urinary Tract Infections (UTI). The new method devel- thus, the ‘Mispa Label’ is introduced as an intelligent tube la- oped by the Sree Chitra Tirunal Institute for Medical Sciences belling system. It is a unique product with 6 channels and can and Technology will be manufactured and marketed by Agappe be connected to the LIS or HIS interface easily. This system Diagnostics Ltd. It will be a real blessing to the Indian diag- helps in reducing about 70% of the errors, which are occurred nostic scenario. By this new technique, the infective agent in the pre-analytical (mainly sampling errors) phase in any IVD could be identified within 6 hours. Above all, being affordable laboratory. and very simple, the technique requires no costly equipment. Today, Agappe invests more than 6% of its total revenue to- z We could also establish an association with Sree Chitra Tirunal wards R&D activities, which in turn helps us to be the No.1 inno- Institute for Medical Science and Technology, Thiruvanantha- vative company in the Medical Diagnostic sector.

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* Toll Free No: 1800 425 7151 Cover Story Diabetes Mellitus - An Overview LABORATORY INVESTIGATIONS IN Dr. D. M. Vasudevan, MBBS, MD (Biochem), FRCPath, Technical Director, AGAPPE. DIABETES MELLITUS Diabetes is a disease known from very ancient times. Charaka, in his treatise (circa 400 BC), gives an elaborate clinical description of madhumeha (sweet urine). He described that urine of the patient will attract ants. This is the first in vitro test described in the medical literature. Thomas Willis, in 1670, rediscovered the sweet taste of diabetic urine. In 1838, Peligot proved that the sugar of diabetic urine is the same as the one present in grape sugar. Qualitative test for urine sugar was perfected by Hermann Fehling (1848) and semi- quantitative test by Stanley Benedict (1908).

Folin-Wu method In the 1930s and 1940s, this method was popular for the quantitative estimation of glucose in the blood. The method is based on the reducing property of glucose. An alkaline copper reagent is reduced by glucose at 100 degree Celsius. The cuprous oxide formed is reacted with phosphomolybdate to produce a coloured complex, which is measured colorimetrically. The method is non-specific and many other reducing substances present in serum may give the colour leading to false higher values. The normal fasting blood glucose value by Folin-Wu method was taken as 90-130 mg/ 100 ml.

12 TECHAGAPPE JULY-SEPTEMBER 2018 Nelson-Somogyi method In the 1950s, this method replaced the Folin-Wu method for quantitative determination of reducing sugars because of the simplicity of the reaction. In this method, copper oxidises the sugar, which forms a coloured complex with arsenomolybdate. The colour is read at 520 nm. Again, this was a nonspe- cific reaction and any reducing substance in the blood may contribute to the colour reaction. The normal fasting blood glucose value by Nelson-Somogyi method was taken as 80-120 mg/100ml. Ortho-Toluidine method By 1960s, the ortho-toluidine method was described, which became very popular in 1970s. The amine reacts with the aldehyde group of glucose to give a coloured condensation product. The reaction is specific for the aldehyde residue and since glucose is the major aldehyde in the blood, the result is said to be nearer to the ‘true blood glucose value’. How- ever, by 1980s, it was known that the ortho-toluidine is mildly carcinogenic and so the method was dis- continued in 1990s. Enzymatic Method, GOD-POD method By 1990s, the glucose oxidase-peroxidase (GOD- POD) method came into use and by the end of the century, it was the lysis is inhibited. If fluoride is not added, blood cells will utilise standard procedure for blood glucose estimation. Glucose oxidase glucose and by the time the blood reaches the laboratory, some is very specific - it converts glucose to gluconic acid and hydrogen glucose is metabolised by the cells. So, false low values may be peroxide. Peroxidase converts the peroxide into water and nascent obtained. oxygen. This oxygen oxidises a colourless chromogenic substrate 3. The graph of the colour reaction will be a straight line (e.g. ortho-dianisidine) to a coloured one and the colour intensity is only up to 300 mg. After that, the graph flattens. So, higher directly proportional to the concentration of glucose. This is highly values are not recorded unless the serum sample is diluted specific, giving ‘true glucose’ values. The reference value of fasting and the test is redone. blood glucose by GOD-POD method is taken as 70–110 mg/dl. Enzymatic Method, Hexokinase Method Disadvantages of GOD-POD method From 2005 onwards, Hexokinase method came into promi- 1. Although it is stated that the method is very specific, this nence in the market. The hexokinase method is the most spe- statement is true with regard to cific method for measuring glu- the GOD reaction only. The sec- cose in serum or plasma. The en- ond reaction, ie. POD part is very The hexokinase method has more zyme hexokinase will convert glu- non-specific. The dye will be cose to glucose-6-phosphate. oxidised by any reducing sub- specificity, precision and accuracy. This is a very specific reaction and stance present in the blood. For Therefore, newer automated laborat- only glucose will give this reaction. example, if the patient has taken The glucose-6-phosphate is then vitamin C a few hours before the ories use hexokinase method. Both reacted with glucose-6-phos- test, the value will be wrong. hexokinase and glucose-6-phosphate phate dehydrogenase to form 2. For estimation of blood dehydrogenase enzymes are very NADP, which is measured spec- glucose, the blood is collected trophotometrically. using an anticoagulant (potas- specific and no other components Advantages of Hexokinase sium oxalate) and an inhibitor of the blood will interfere with the method over GOD-POD of glycolysis (sodium fluoride). method Fluoride inhibits the enzyme reaction. called enolase and hence glyco- 1. The hexokinase method has

TECHAGAPPE JULY-SEPTEMBER 2018 13 Cover Story Diabetes Mellitus - An Overview

good carbohydrate diet for 3 days prior to the test. The patient should avoid drugs likely to influence the blood glucose levels, for at least 2 days prior to the test. The patient should not take food after 8 PM the previous night and should not take breakfast. This is to ensure 12 hours fasting. At about 8 am, a sample of blood is collected in the AGAPPE’S AGGLH is based on Gold fasting state. A urine sample is also obtained. This is denoted as the Standard Hexokinase Method which ‘0’ hour sample. is 100% specific and with an Glucose Load Dose: The dose Excellent Linearity of 900 mg/dL is 75 g anhydrous glucose (82.5 g of glucose monohydrate) in 250- that helps reduce rerun of the high 300 ml of water. This dose is fixed sample, saves time & cost. for an adult, irrespective of body weight. (When the test is done in children, the glucose dose is ad- justed as 1.75 g /kg body weight). In order to prevent vomiting, the patient is asked to drink it slowly (within about 5 minutes). The flavouring of the solution will also reduce the tendency to vomit. more specificity, precision and accuracy. Therefore, newer auto- Sample Collection: As per current WHO recommendations, mated laboratories use hexokinase method. Both hexokinase and two samples are collected - one at fasting (‘0’ hour sample) and glucose-6-phosphate dehydrogenase enzymes are very specific two-hour post-glucose load. This is sufficient to get a correct and no other components of the blood will interfere with the reac- assessment of the patient. tion. (Whereas the POD part of the GOD-POD reaction is non- specific). Normal Values and Interpretations: Following the glucose 2. Blood collection does not require special precaution of adding fluoride. In fact, fluoride will inhibit the The plasma sugar levels in OGTT in normal persons and in diabetic patients hexokinase enzyme and so fluoride should NOT be used. Immediately after the blood collection, serum or Normal Criteria for Criteria for persons diagnosing diagnosing plasma is separated and tested later on. diabetes I.G.T 3. The graph of the colour reaction will be a straight Fasting < 110 mg/dl > 126 mg/dl 110 to126 mg/dl line up to 900 to 1000 mg. So, higher values could be estimated correctly. 1 hr (peak) after glucose < 160 mg/dl Not prescribed Not prescribed The parameters for diagnosis of Diabetes Mellitus load are the following: 2 hr after 1. Blood glucose level glucose load < 140 mg/dl > 200 mg/dl 140 to 199mg/dl As per WHO recommendation, in a normal person, the fasting plasma glucose level is 70–110 mg/dl. The present load, the level rises and reaches a peak within 1 hour and then day tendency is to view values above 100 mg/ml as suspicious. comes down to normal fasting levels by 2 to 2½ hours. This is due According to the recommendations of the American Diabetic to the secretion of insulin in response to the elevation in blood Association, the revised upper limit is 100mg/dl, above which a glucose. Criteria for diagnosis of diabetes are shown in Table 1. person has to be further tested periodically. Impaired Glucose Tolerance (IGT): Here blood sugar values 2. Glucose Tolerance Test are above the normal level, but below the diabetic levels (see Table 1). The fasting plasma glucose level is between 110 and 126 mg/dl Preparation of the Patient: The patient is instructed to have and two-hour post-glucose value is between 140 and 200 mg/dl.

14 TECHAGAPPE JULY-SEPTEMBER 2018 Such persons need careful followup because IGT progresses to frank diabetes at the rate of 2% patients per year. As per WHO recommendation, in a Gestational Diabetes Mellitus (GDM): This term is used when carbohydrate intolerance is noticed, for the first time, dur- normal person, the fasting plasma ing a pregnancy. A known diabetic patient, who becomes preg- glucose level is 70–110 mg/dl. The nant, is not included in this category. Women with GDM are at increased risk for subsequent development of frank diabetes. GDM present day tendency is to view values is associated with an increased incidence of neonatal mortality. above 100 mg/ml as suspicious. Maternal hyperglycemia causes the foetus to secrete more insulin, causing stimulation of foetal growth and increased birth weight. According to the recommendations of After the childbirth, the women should be re-assessed. the American Diabetic Association, the Glycated Hemoglobin or Glyco-hemoglobin or HbA1c revised upper limit is 100mg/dl. It is the best index of long-term control of blood glucose level. Enzymatic addition of any sugar to a protein is called ‘glycosyla may be done once in every month so as to analyze the effectiveness tion’, while the non-enzymatic process is termed ‘glycation’. Once of the treatment. Normally, the level of HbA1c is less than 5.5%. The attached, glucose is not removed from hemoglobin. Therefore, it value 5.5% denotes very good control of diabetes by treatment mea- remains inside the erythrocyte, throughout the lifespan of RBCs. sures; 7% means adequate control; 8% inadequate control and 9% (120 days). The value of HbA1c is expressed as the percentage of means very poor control. Any value above 5.5% is to be closely the total Hb. watched. Values between 5.6 and 6.4 are to be considered as im- Interpretation of Glyco-Hb Values: It is unaffected by recent paired glucose tolerance. The risk of retinopathy and renal compli- food intake or recent changes in blood sugar levels. The estimation cations are proportionately increased with elevated glycated hemoglobin value. Reduction in 1% of Glyco-Hb will decrease long- term complications to an extent of 30%. Any type of anemia, where RBC lifespan is reduced, will reflect in lowered HbA1c value because the time-averaged value is less. Advantages of HbA1c over fasting blood sugar estimation are (1) For HbA1c, fasting sample is not required; the test may be done at any time. (2) Low intraindividual vari- ability. (3) HbA1c sample is stable while blood sugar level is lowered unless precautions are taken. (4) HbA1c value is not altered by acute factors while many factors will affect blood sugar values. (5) HbA1c reflects long-term glucose control, while blood sugar estimation will show the result of a particular time only. (6) HbA1c is a better index for predicting complications. Because of all these reasons, HbA1c has become the preferred test nowadays. Diagnostic Criteria for Diabetes Mellitus 1. If the fasting plasma sugar is more than 126 mg /dl, on more than one occasion. 2. Or, if two-hour post-glucose load value of OGTT is more than 200 mg /dl (even on one occasion). 3. Or, if both fasting and two-hour values are above these levels, on the same occasion. 4. If the random plasma sugar level is more than 200 mg/ dl, on more than one occasion. Diagnosis should not be based on a single random test alone; it should be repeated. 5. Glycated Hemoglobin (Glyco-Hb) or HbA1c level more than 6.5 % at any occasion. As per the recommendations of American Association of Clinical Chemistry and American Diabetes Association, HbA1c level is the preferred method for initial diagnosis of diabetes mellitus.

TECHAGAPPE JULY-SEPTEMBER 2018 15 Life Story Pranjali Valsangkar (Graphic Designer) SHE PAINTS HER LIFE WITH VIBRANT HUES For Pranjali, the present health condition has now become a part of her life. She can’t just ignore the warning from her insulin pump. Late night is never an excuse for her. Tiredness or laziness will yield nothing better. If you ignore the warning signal, chances are that you might not be alive to do so tomorrow. It’s a Normal Day for Her! The last Friday was a busy day for Pranjali Sanjay Valsangkar (27) from Pune. After her work as a graphic designer at Kaleidoscope, a brand development expert agency which is a 25 year old organisation, she had gone for her daily German classes. Later that evening, she had dinner with her friends. It was while waiting for the food to be served, a small beep sound typically like a warning came from Pranjali’s insulin pump, which was attached to her body. The warning showed no delivery of insulin. She had changed her patch for the insulin pump in the morning and it was working properly for the entire day and now she understood that it was not working properly at this very moment. The patch had failed in a day, for reasons unknown. After reaching home around 10.30 pm, she tried another patch and that too failed. The third patch was however successful. Now, she could take a good night’s rest! For Pranjali, this has now become a part of her life. She can’t just ignore the warning from her insulin pump. Late night is never an excuse for her. Tiredness or laziness will yield nothing better. If you ignore the warning signal, chances are that you might not be alive to do so tomorrow. “Living with Type 1 Diabetes is Pranjali Sanjay not so hard if you Valsangkar accept the condition,” Pranjali points out.

16 TECHAGAPPE JULY-SEPTEMBER 2018 Daughter of Sanjay Valsangkar, an em- period. “Those days, just as I woke ployee at Bank of India and Mrunal up, I felt like vomiting. Thirst was an- Valsangkar, who works with LIC Premium other problem. Even after drinking Centre, Pranjali was born and brought up several litres of water, I felt thirsty in Pune. She was a very active child. For again. My normal weight was the neighbours, Pranjali was a bubbly, around 48-50 kg and it reduced to perky child who used to enjoy skating. 28-30 kg during that period,” she re- Apart from this, she was also part of many calls the panic days. extracurricular activities. She was very social and lovable child. After completing The disease was very new to the her Diploma in Applied Arts from Pune, 24-year old Pranjali. The only dis- Pranjali became a commercial artist. In- ease she remembers having in her spired by her, Pranjali’s younger sister childhood was jaundice and she had also became a graphic designer later. no other health issues at all until that time. She was also part of NCC in An Unexpected Twist! school and college apart from many The Unforgettable November 2, 2014! other activities. “I was very shocked Pranjali remembers the day when the big- and shattered with the news. The un- gest revelation about her life came upon. awareness about Diabetes Type 1 or The difficulties of disease engulfed Type 2 also made situations worse,” Pranjali for a while now. She had really she comments. She was admitted fallen very sick and getting infections along to the hospital for four days and the with fever, urinary infection and was ex- doctors started injecting insulin to periencing weight loss. She had no idea her. “I was in the hope that in three what was happening to her. She felt it was or four days, I will get discharged because of her hectic schedule. By Octo- from hospital and I will be back again ber, her condition turned really bad. She to my routine life. But on the last day, was gripped by a bad fever and a viral the doctor came to me and told me infection. The doctor suggested her to do that I will have to inject insulin all by several tests including thyroid, diabetes myself in the following days on a and so on. The sugar level recorded was regular basis. I was totally really 430 mg/dL and the doctor was really shocked,” Pranjali recalled those shocked. He wondered how she could moments with intense emotion. even stand up with this high sugar level. After some reflection on the dis- To confirm the results, the doctor sug- ease, Pranjali understood that there gested another checkup at some other was no point in crying about the con- lab and the sugar level was pretty much dition. To overcome the situation, the same. Tiredness, thirst and frequent she should think and act like she was urination were the problems she faced being cured. She realized that only during the period. She also remembers Pranjali during her diagnosis days (file pic) that would keep her ticking. Her fam- of having morning sickness during that ily was also in deep shock. “My family would have been in much more depression if I hadn’t acted bravely,” Pranjali smiles confidently. At that time, she was not After some reflection on the disease, working as she had a job change in her mind. Pranjali understood that there was no The treatment started with insulin injections. For Type 1 Dia- betes, there was no other option available. Type 1 Diabetes hap- point in crying about the condition. pens when your own immunity system is attacked by your own To overcome the situation, she should beta cells in the body. Insulin is mainly produced in the beta cells located in the pancreas. In Type 1 Diabetes, these beta cells are think and act like she was being degenerative. As a result, we become insulin insufficient. There cured. She realized that only that is no solid reason why this condition happens. It can happen to anybody at any time. It is not hereditary. The complications are would keep her ticking. same as of the diabetic patients. It may affect the kidney, eyes, heart and so on. The three major symptoms are frequent urina-

TECHAGAPPE JULY-SEPTEMBER 2018 17 Life Story Pranjali Valsangkar (Graphic Designer)

tion, major weight loss and thirst. “I had always made it a point to tell people that Type 1 Diabetes is not a disease but a disorder. If you are Vitamin D deficient, you will have to take injec- The insulin pump is now attached to her tions to get rid of the deficiency. It is also same here. Only thing body and is like an artificial pancreas. It is that this is not curable,” she says. does the work of what beta cells do in our A New Addition! pancreas. It is attached 24x7 to her and Fifteen days after being diagnosed with Type 1 Diabetes, another news came as a shock to Pranjali. “It was another con- only when she goes for a shower does she dition called Listhesis, a rare condition which happens only to remove it. Much like an organ, it has been 5% people. It is a gap between two joints in your spinal chord, a very small gap which causes intolerable pain”. It was just above with Pranjali ever since 2015. the tailbone and happened because of the weight loss. She had become so weak that the muscle support around her spine was almost nil. The bone was already weak due to weight loss and was cured miraculously of Listhesis. “My orthopaedic surgeon, Dr. added to it, the muscle support is also gone. “I couldn’t sit, Mahesh Mone played a very significant role in this recovery. He sleep or do anything. The only good thing was that I had a good gave me the confidence to go on” she adds. She now does physio- immunity power. The main factors that contributed in my re- therapy daily and can now sit, sleep and travel quite comfortably. covery were my belief in God and myself and my family and Injecting insulin was a painful process. She had to take around friends. They were my biggest support. I was also very fortunate 10 units of insulin respectively before she had her breakfast, lunch to be treated by very good and efficient doctors. It took me a or dinner. Sometimes, there would be oozing of blood and some- long time to accept all this which came quite unexpectedly,” times, bruises. Accepting it took a long time for her. It was then her Pranjali emits a smile that defeated her disease to an extent. doctor, Dr. Nandedkar suggested another doctor who was A surgery was suggested to Pranjali for Listhesis when she specialised in handling cases with Type 1 Diabetes. Dr. Abhay Mutha, was diagnosed with the condition. However, her body weight, a renowned Diabetologist (who unfortunately expired in January which was 30 kg that time, made doctors postpone the surgery 2018), was also indulged in providing children (who can’t afford to as they feared it wouldn’t give the desired results. Instead of buy) free insulin, injections and insulin pens. He monitored Pranjali’s surgery, they injected a medicine into her spine and later, she sugar levels and suggested her to use an insulin pump. He said it WHAT IS AN ARTIFICIAL PANCREAS DEVICE SYSTEM? The Artificial Pancreas Device low continuous communication System is a system of devices that between the two devices. Some- closely mimics the glucose regu- times an artificial pancreas device lating function of a healthy pan- system is referred to as a "closed- creas. loop" system, an "automated in- Most Artificial Pancreas De- sulin delivery" system, or an "au- vice Systems consists of three tonomous system for glycemic types of devices already famil- control." iar to many people with dia- An Artificial Pancreas De- betes: a continuous glucose vice System will not only monitoring system (CGM) monitors glucose levels in and an insulin infusion the body but also automati- pump. A blood glucose de- cally adjusts the delivery of vice (such as a glucose insulin to reduce high blood meter) is used to calibrate glucose levels (hyperglyce- the CGM. mia) and minimize the in- A computer-con- cidence of low blood glu- trolled algorithm con- cose (hypoglycemia) with nects the CGM and insu- little or no input from the lin infusion pump to al- patient.

18 TECHAGAPPE JULY-SEPTEMBER 2018 could be a life-changing experience for her. He also provided a free trial so that he could also monitor how it reacted to her body and also for her to experience it. By then, it had been more than a year since Pranjali started taking insulin injections. Finally, a Solution! The insulin pump is now attached to her body and is like an artificial pancreas. It does the work of what beta cells do in our pancreas. It is attached 24x7 to her and only when she goes for a shower does she remove it. Much like an organ, it has been with Pranjali ever since February 2015. “Like the Pranjali Valsangkar with her insulin pump Pranjali Valsangkar with her father doctor said it was a life- which is attached to her body and works like Sanjay, mother Mrunal and sister Siddhi changing experience for an artificial pancreas me. I gained weight. I gained muscles. In the developed countries, us.” She takes our attention to the communities in Mumbai and people who have this condition use insulin pumps as it is more con- Delhi which conduct meetings and marathons for Type 1 Diabetes venient. The cartridge needs to be filled after every four days. I will people. She is now part of a worldwide community called ‘Beyond suggest this to each and everyone who faces a similar situation. The Type 1’. Pranjali hasn’t got any diet restrictions now. Only thing is only problem is that it is quite costly. I bought it for Rs.2.5 lakhs. There that she will have to take insulin according to her diet. If she wants are other models like insulin pumps in which you can have your to enjoy a jalebi, it is acceptable provided she takes insulin to sugar readings as well, provided you have a sensor, which is also, like compensate it. Though this does not mean she eats a lot of sweet. the pump attached to your body” she states. “Avoiding sweets as much as possible must be the aim of every diabetic person. Sugar really is a killer”. She points out. Meanwhile, she also tried hypnotherapy as a part of Pranic Heal- ing which she certifies to have given her wonderful results. As she Precaution is always helpful and hence once in a year, a com- was mentally disturbed before, it provided great relief and relaxation plete health check-up is a necessity. Liver function, kidney, eye to her. It helped her a lot in winning back a normal life. tests - all are checked thoroughly. There is also an HbA1c test which needs to be done every 3 months. Regarding eyesight, it is From her childhood itself, Pranjali used to love languages and her recommended to check every 6 months. This is a standard pro- learning German sprouted from that passion. In future, she also likes tocol in similar cases. to try a job abroad preferably in Germany. It will also be a step to- The biggest inspirations for Pranjali are all the fellow diabet- wards living independently. “Now I have everyone to take care of me. ics she has met through her community ‘beyond type 1’, espe- When I fall ill, I have my parents to take care of me and support me. cially all the small children who, like her fight diabetes everyday. But I would like to see how I can manage on my own. I believe going They make her face everyday courageously and with new hope. abroad will be a good decision to experiment it,” she comments with She finds herself fortunate and grateful everyday for being alive great confidence. and experiencing this beautiful world. What are the tactics followed by Pranjali in keeping Type 1 Diabe- As said, to lead a normal life after being diagnosed with Type tes in control? Acceptance of the condition is the prime thing to 1 Diabetes is not hard if you maintain your lifestyle and however tackle the situation as she points out. “As part of your organ is not much you do Type 1 always catches you unaware so be easy on working properly and you should take care of it. You should under- yourself and in any condition DON’T STRESS OUT. “Accept the stand and accept it. Taking an injection one day is ok. But taking situation. Face it with courage and never give-up. Even now I injection four times a day needs some mental preparation. From the dream of a cure. But you can only be hopeful about it.” Pranjali society, we don’t need sympathy but we need them to understand signs off leaving a happy note of unwavering hope.

TECHAGAPPE JULY-SEPTEMBER 2018 19 Interview Dr. V. Mohan "NEVER NEGLECT DIABETES" Dr. V. Mohan

TechAgappe: Could you please tell us about your childhood? How did you get interested in diabetology? Dr. V. Mohan: My father, Prof. M. Viswanathan was techni- cally, the first diabetes specialist in India. He came from Kerala Being the Chairman and Chief of to study Medicine at Stanley Medical College & Hospital (SMC), Chennai, and when he finished his medical studies, he set up Diabetology at Dr. Mohan’s Diabetes the first diabetic clinic in India in 1948 at Stanley. He can there- Specialities Centre, Chennai, Dr. V. fore be aptly called the ‘Father of Diabetology’ in India. He was an Honorary Professor of Medicine at SMC in the morn- Mohan is a pre-eminent Indian ing and a General Physician in private practice in the evening. diabetologist who has a rich Till 1971, he continued in the Govt. set up and later, he wanted to do something of his own. I had just finished High School experience of more than 40 years then. It was he who suggested that I take up medicine as my profession. I got admission into Madras Medical College and in the field of diabetology. A recipient straightaway joined my father in his work on diabetes. My of the prestigious Padma Shri father was an eminent teacher, a researcher and a great clinician. He kept all his medical records and managed to publish award, the fourth highest civilian several research articles. Initially, I learned how to collect and award in India, Dr. V Mohan found interpret data and carry out some basic statistics. We also hired a Professor of Biochemistry to set up our Biochemistry some time to talk to TechAgappe lab. By my second year MBBS, I began doing serious diabetes team. Excerpts from the interview: research, while at the same time learning anatomy, physiol- ogy and biochemistry at the Medical College. This was a unique experience. By the time I finished my MD in 1981, I had already published 30 research papers. This is an achievement of sorts, as only very few of my teachers had this many papers. After

20 TECHAGAPPE JULY-SEPTEMBER 2018 finishing, my post-graduate studies, I joined my father as a full- of the organisation. Anjana is also the Managing Director now. time diabetes specialist. I continued till 1991 with him except for Both of them have FRCP (Fellowship of all the Royal College of the two years I spent abroad - one year at London as a Wellcome Physicians of UK) in addition to MD and Diploma in Diabetes Trust Fellow and another year at Ulm in Germany as an Alexander from abroad. They both have published more than 100 re- von Humboldt Fellow. search papers each.

My wife Dr. Rema was one of the first diabetic retinopathy special- TechAgappe: Dr. Mohan’s Diabetes Specialities Centre is a ists of India. She was my classmate and I suggested her to pursue World Health Organisation (WHO) Collaborating Centre for her career in ophthalmology, as it is directly related to diabetes. Non-Communicable Diseases Prevention and Control. Tell us We went to England basically for her to get training in diabetic more about it. retinopathy. She got trained with Dr. Eva Kohner, the world-renowned diabetic retinopathy specialist in London. In 1991, my Dr. V. Mohan: The WHO collaborating centre is a stamp of wife and I decided to start our own centre at South Madras as my approval for our services. As a part of the research, I had been father had made North Madras as his base. We started in a small working with WHO, Indian Council of Medical Research, rented clinic at Royapettah. Since we already had some 20 years of Wellcome Trust and many other foundations. The WHO Col- experience and had earned quite a good name, the centre was laborating Centre is a great honour. When you become a very successful. We introduced several new things like the first WHO Collaborating Centre, you can use their logo along with Diabetes Electronic Records full fledged diabetes check up facili- yours, WHO in return would expect us to prepare documents, ties etc. Indeed we were so successful that within a few years we posters and educational materials and if they require my ex- moved to our own building at Gopalapuram. We later started es- pert opinion in Geneva, Switzerland, I may be asked to repre- tablishing branches. Our first branch was at Anna Nagar and the sent Asia or India for this. Mostly, this is for advocacy, re- second, at Hyderabad. Over the last 27 years, we have established search and awareness creation etc. We are also an ICMR Cen- 42 branches of our centre and have over 430,000 registered dia- tre for Advanced Research on Diabetes. We are one of the few betic patients, 1300 staff. I also probably hold the world record for private institutions in the country which has got this ICMR a medical doctor who has published the most number of research recognition. The third recognition we have, is from the Inter- papers, as I have crossed 1150 research papers. My daughter Dr. national Diabetes Federation (IDF). The IDF is a conglomera- Anjana and son-in-law Dr.Ranjit Unnikrishnan are also now part tion of all the diabetes societies of the world. IDF has recognised

Dr. V. Mohan sharing his experiences with Rajesh Patel, Business Head, AGAPPE.

TECHAGAPPE JULY-SEPTEMBER 2018 21 Interview Dr. V. Mohan

us as IDF Centre of Education and IDF Centre of Excellence in Diabetes Care. TechAgappe: Dr. Mohan’s Diabetes Speciali- ties Centre is a large organisation today. What are the different institutions under it? Dr. V. Mohan: Health Care: Within our organisation, we have several institutions. For Diabetes Health Care, we have Dr. Mohan’s Dia- betes Specialities Centre. We currently have 42 centres, all over South India, Bhubaneswar, UP and Delhi. We will also be expanding to Kolkata shortly. This is already the largest chain of diabetes centres in the world. Research: Our research work comes under the Madras Diabetes Research Foundation. This is a 100% non-profit organisation. Registered under Societies Act, it has no income at all and is funded by research grants or donations. There are 20 full-time scientists here involved in research and around 25 Ph.D. students. We have a large campus at Siruseri, Kancheepuram apart from three other campuses. At our Siruseri campus, we have built one of the largest standalone diabetes research centres in the Dr. V. Mohan receiving Dr. B.C. Roy Award from world with over 30,000 sq. ft of built up facility Dr. A.P.J. Abdul Kalam, former President of India. on 6 acres of land. There, we have all the basic sciences like genomics, cell and molecular biology, tissue cul- run fellowship courses on diabetic retinopathy and also provide ture labs, advanced biochemistry labs with all the equipment training courses for dieticians, educators and lab technicians. and a huge storage area where more than half a million blood Charity: Our Charitable Trust ‘Diabetes International Research samples are stored for various research studies. Education and Charitable Trust (DIRECT)’ looks after economi- Education: We have an Education Academy – Dr. Mohan’s cally weak patients who get free treatment here including free Diabetes Education Academy. It is estimated that there are 73 medicines and checkups. We are supported by several founda- million diabetes patients in India and to treat all of them, the tions in this activity. We have also some rural projects. We run free doctors available now will not be sufficient. We started a Fel- camps with the Sri Sathya Sai Organisations and Trust as Bhagawan lowship in Diabetes Program and a Post-Doctoral Fellowship in Sathya Sai Baba is my spiritual guru and master and the true rea- Diabetes Program. In collaboration with the Public Health Foun- son for all my success. dation of India (PHFI), we run a Certificate Course in Evidence Health Care Products : Finally, we have a technology healthcare Based Diabetes Management. Through this, we have trained products unit. This is called Dr. Mohan’s Diabetes Healthcare around 15,000 doctors in diabetes from all over India. This is Products. We have brown rice, high fibre white rice etc. for diabe- the largest training program in diabetes in the world. We also tes patients, which are sold through several departmental stores in South India. Diabetes is a very good model of non- TechAgappe: Why is diabetes considered as the mother of all communicable diseases. If one has diseases? Dr. V. Mohan: I think you have put it very correctly. An article diabetes, it affects the whole system published in The Lancet in which I am also a co-author titled ‘Na- like eye, kidney, heart, feet, nose, brain tions within Nations’ compares the health of Indian people in the year 1991 and 2016. The best parameter to calculate the health of a etc. Today, one of the leading causes nation is finding the cause of mortality. In 1991, communicable of death in India is heart attacks. In many diseases were the main cause of mortality in all Indian states and union territories, except for Kerala. In 2016, however, all the states cases, it is caused by diabetes. have improved and in all states communicable diseases declined and non communicable diseases are now the major cause of death.

22 TECHAGAPPE JULY-SEPTEMBER 2018 Diabetes is a very good model of non-communicable diseases. If one has diabetes, it affects the whole system like eye, kidney, heart, feet, nose, brain etc. Today, one of the leading causes of death in Diabetes is now moving from urban India is heart attacks. In many cases, it is caused by diabetes. In to rural areas. In the urban areas, all probability, in five years time, India will be the diabetes capital of the world. What HIV did to Africa, diabetes can do to India patients at least have the facilities unless we take preventive steps. Earlier, the mean age group of for the treatment of diabetes while diabetic patients was used to be around 40-45 years while now people are beginning to get it in the age group of 20-25 years. This most rural areas, specialized is something to be to be taken seriously.. diabetes care facilities are not Three significant things happened in the epidemiology of diabe- available. tes. Firstly; it shifted from the older age group to the younger age groups. Secondly; it shifted from the rich to the middle class and now to the poor. Diabetes was called as a rich man’s disease earlier. Today, the rich are aware of the disease and eat healthy search centre later. When we started our own centres, it was in food, do exercises and take care of their health while the poor are a single room. Our research has now grown into several cam- unaware and eat cheap unhealthy food. This is a very unfortunate puses. We are not part of Government or any university and situation as most often the poor people can’t afford the treatment hence we are proud that we could achieve all this. Today, six for diabetes. Thirdly, diabetes is now moving from urban to rural universities collaborate with us for offering Ph.D. courses. We areas. In the urban areas, patients at least have the facilities for the believe as long as we are able to deliver quality, we should treatment of diabetes while in most rural areas, specialized continue to grow. However what we have achieved is only a diabetes care facilities are not available. drop in the ocean and so much more remains to be done!. TechAgappe: You are now close to celebrating 50 years in the field TechAgappe: What about the future plans? of Diabetology. Have you achieved the purpose of your life? Dr. V. Mohan: In Tamil Nadu, we want to have our centres in Dr. V. Mohan: Yes, I believe so. When I started on with my father, every district. We are also spreading out to Andhra Pradesh in our lab was a small car shed. A technician used to come once in a the coming months. In Kerala, we have already two centres at while. We never thought that we will be building a diabetes re- Thiruvananthapuram and Kochi. Currently, our focus is on expanding to the Tier II and Tier III cities in India. Eastern India is also one of our future targets for growth. TechAgappe: Finally, as a diabetologist, what is your message to the society? Dr. V. Mohan: My messages are as fol- lows: First, even if you have diabetes, don’t worry. You can still lead a long and healthy life. Never neglect diabetes. Diabetes is not a disease but a disorder. Second, if you don’t have diabetes but your parents have it, chances are high for you to develop it. Check it before it’s too late. If you identify the disorder in the pre-diabetes stage, you can prevent diabetes or even revert to normal. Unfortunately, if you don’t take care, then diabetes is progressive condition and complications may arise in the future. My advice to everyone is to exercise regularly, maintain ideal body weight, eat healthy, do Yoga or meditation, eat and sleep on time and above all - Smile. If you follow these simple Dr. V. Mohan receiving Padma Shri Award from Smt. Pratibha Patil, rules, 50-80% of non-communicable lifestyle former President of India. diseases like diabetes can be prevented!.

TECHAGAPPE JULY-SEPTEMBER 2018 23 Promotion Importance of Diabetic Profile CONSTANT MANAGEMENT CAN CANTROL DIABETIC MELLITUS Bintu Lijo, Manager - Customer Support, AGAPPE. Diabetes mellitus (DM), simply means high blood sugar level, is z Weight loss (even though you are eating more (Type 1) a silent killer and it kills you 10 years before your time as per the z Tingling/numbness/pain in hands and/or feet (Type 2) study conducted by Oxford university. There are now 382 million people worldwide living with diabetes, according to International What should be the frequency of Diabetic profile check? Diabetes Federation (IDF) and India ranks among top 3 countries. The guidelines for frequency are based on diabetes risk. Diabetes is a condition in which the body either does not pro- Screening when no risk factors present: Test in every three duce enough insulin, or does not properly respond to insulin. years Individuals with diabetes are at increased risk of heart and kidney Screening when risk factors present: Older than 45, a family disease, retinopathy, neuropathy, and nonalcoholic fatty liver dis- history of diabetes / high blood pressure / high cholesterol ease. should test once in a year. The two main types of diabetes are Type 1 and Type 2. If diag- Monitoring nosed with diabetes, regulate glucose tests can help manage or z If your blood sugar control is good – four times a year maintain conditions. Type 1, is commonly seen in children or z If your blood sugar control is poor – Every month teenagers whose bodies are not producing enough insulin. Type 2 diabetes, is typically seen in adults who are overweight. The insu- Complete Diabetic Profile can be divided to 3 and it includes lin in their bodies are either not working normally, or there is not Routine diabetic tests – Glucose, Microalbumin, Dipstick test being enough produced. Standard diabetic tests - HbA1c, C-peptide Along with blood sugar control, people with diabetes need to have an eye on their cholesterol levels because Diabetes is associ- Comprehensive Metabolic Panel (CMP) – Creatinine, lipid pro- ated with high lipids, clinically known as diabetic dyslipidemia. file, liver profile, Urea, Electrolytes Later this excess fat may build up in liver and leads to nonalcoholic fatty liver disease. Medical health experts assert that regular check-ups and timely detection plays a vital role in controlling and managing the diabetic problems. Proper Diabetic profile testing is very important for the timely detection and monitoring of Diabetes. Who needs to undergo diabetes tests? Diabetes symptoms may not show up in its early stages. If any of the following signs of diabetes, are noticed, then the person needs to undergo diabetes tests immediately. z Urinating often z Feeling very thirsty or hungry (even if you are eating or have just eaten) z Extreme fatigue/lethargy z Blurred vision z Cuts or bruises that heal slowly

24 TECHAGAPPE JULY-SEPTEMBER 2018 Diabetic Profile Test Parameters from Agappe

z No Prozone effect up to 6000 mg/L & no Glucose false negative - Safe reporting z Hexokinase Method – The reference Ultrastik method for Glucose estimation developed z 11 parameters including Microalbumin – by AACC Wide test menu z Hexokinase method is 100% specific - z 30 seconds to 2 minutes- Rapid test results Hexokinase convert glucose to glucose- 6-phosphate & only glucose will give this z Designed specifically considering Indian reaction conditions like Humidity & temperature – High accuracy z Excellent Linearity of 900 mg/dL - Reduce rerun of the high sample, saves time & z High shelf life of 2 years – Ensure complete cost usage of strips z Fast Reaction - Only 5 minutes to com- AGA1c plete reaction, fast reporting z Latex-enhanced Immunoturbidimetry Meth- z High accuracy, CV <2% - Excellent CV od - Uses ultra micron latex particle, High shows the reliability of the method Specificity, Sensitivity& Reproducibility Microalbumin z Direct Method-directly measures A1c in %- Highly Precise & Accurate result z Turbidimetric Immunoassay method - Highly sensitive, Accuracy Guaranteed z Two Reagent system with 4 level calibrators -No stability problems z Calibrator provided -Multipoint calibra- zWide measuring range of 4-395 mg/L - tion-Takes out extra cost & matrix prob- Safe reporting of lower & higher side z NGSP Standardize DCCT Reference material lems values & correlated with HPLC-Ensured Accuracy

Routine diabetic tests Glucose Fasting blood glucose test (8 or 12 or 14 hours after eating), glucose tolerance test, Postprandial glucose test (2 hours after eating) & Random blood sugar test help to diagnose diabetes, prediabetes and gestational diabetes. Microalbumin A urine microalbumin test is a test to detect very small levels of a blood protein (albumin) in urine. By this method, it can find out whether diabetes has damaged kidneys because Diabetes is the leading cause of kidney failure. Dipstick test Kidney damage can cause proteins to leak through the kidneys and exit the body via urine. This test is to evalu- ate severe hyperglycemia (severe high blood sugar) by looking for control. It shows how well your diabetes has been controlled in ketones & microalbumin in the urine. the past 2 to 3 months and whether your medicine needs to be Standard diabetic tests changed. As per the recent studies, People with diabetes who reduced their HbA1c by less than 1% can cut their risk of dying C-peptide within 5 years by 50% This test is used to differentiate between type I (low level of insulin Comprehensive Metabolic Panel (CMP) and C-peptide) and type II (normal or high level of C-peptide) diabetes. C-peptide levels are measured instead of insulin levels be- This panel evaluates liver and kidney function along with impor- cause C-peptide can assess a person’s own insulin secretion even tant cholesterol levels including HDL, LDL, VLDL and triglycer- if they receive insulin injections. ides. Diabetes tends to lower “good” cholesterol levels and raise triglyceride and “bad” cholesterol levels, which increases risk for HbA1c heart disease and stroke. An increased level of electrolyte may It is the ideal parameter which can be used to assess the diabetic indicate kidney disease, so Electrolytes also need be tested.

TECHAGAPPE JULY-SEPTEMBER 2018 25 Cover Story Type 2 Diabetes - An Overview ”PREVENTION IS BETTER THAN CURE” AN AWARENESS SESSION BY DR. ANAND GOKANI Renowned diabetologist Dr. Anand Gokani (Bombay Hospital and Medical Research Centre) stands unique among his peers through his unorthodox approach towards diabetology as a whole. He confirms that prevention is better than cure in the case of diabetes and takes sincere efforts to save the youth from falling prey to diabetes. This includes awareness sessions, preventive measures including stress management sessions and workshops. Dr. Anand also carries a proud and prestigious lineage - he is the great-grandson of Mahatma Gandhi.

Understanding Diabetes A true understanding of diabetes is quite significant. “You should know that whatever we eat, when it comes to our intestine, it digests and breaks up into its basic components. Car- bohydrates break up into sugar and enter the blood. The protein breaks up into amino acids and enters the blood. Fats break up into fatty acids and glycerol and enter the blood. Whatever the nature of the food, when it gets into your blood, it is in it’s very basic form,” he elucidates. Dr. Anand explains that sugar in the blood is not a bad thing. “The sugar travels through your blood to every cell in your body and then burns up to produce energy. In a way, sugar is the fuel of our body. But to burn this sugar you need vitamins, minerals and insulin. Imagine sugar as wood, vitamin and minerals as matchsticks and insulin as a fan. You take the matchsticks and burn the wood. When the wood catches fire, you fan the fire so that it burns brightly producing light and energy. In a similar manner, sugar burns in every cell of the body. That’s how we survive,” he gives a vivid clarification.

26 TECHAGAPPE JULY-SEPTEMBER 2018 How good is cooked food? Nature has made provisions for supply- ing all these to our body. Insulin comes from the pancreas which is an organ in close prox- imity to the intestine. The specialised cells in the pancreas produce insulin at all times. Sugar, vitamin and minerals are found in fruits, vegetables and nuts. “So, if someone eats a fair amount of fruits, vegetables and nuts, which are a source of carbohydrates, vitamins and minerals, they can lead a normal life. But when you cook food, it destroys or inactivates the vitamins and minerals. We only preserve carbohydrates, protein and fat through cooking. The vitamins and minerals are very low in cooked food,” says Dr. Anand. Whenever a child is born, the child has a full complement of nutrition taken from the mother and stored in the liver. That stock is very difficult to estimate. It is assumed that if the mother has a very good stock of nutrition, she gives around 10% of it to her child. If it is less, then also she gives around 10% of what she has to the child. So, how much nutrition a child gets depends on its mother. That could be the concept of heredity. What happens when you eat cooked food? “When you eat the cooked food, the carbohydrate enters your body and converts as glucose. When it goes into the liver, it literally ‘steals’ the vitamins sugar takes more time inside the body to burn up. This sugar, and minerals already stored there to produce energy. Even though which piles up, is referred to as diabetes,” Dr. Anand throws you feel that this food is good and provides energy, it is a miscon- light on the reason of diabetes. ception. Unfortunately, our society espoused this notion. The stock Dr. Anand also points out that the acidic food has, unfortu- in the liver reduces as you grow old. “As I said earlier, the wood is nately, become our daily food. “There are four types of food present but there is no matchstick to ignite the wood. Hence there is that are actually addictive drugs - alcohol, tobacco, tea and cof- no fire and the wood piles up. By the same analogy the glucose does fee. While the first two are extremely vicious poisons, the latter not burn and the energy drops,” he adds. The first symptom of are gentle poisons. But they are surely different versions of diabetes comes in the form of tiredness. Fatigue or tiredness will be poison. connected to every organ by the time the signs of diabetes appear. Choose your food Wisely! The first cause of diabetes is the deficiency of vitamins and minerals. In this regard, the initial treatment will be to step up the The first cause of diabetes is the intake of fruits, vegetables, salads and nuts. deficiency of vitamin and minerals. “A lot of the modern food is acidic. When you eat or drink this In this regard, the initial treatment kind of food, it falls on the organs like acid and the stomach becomes the first victim. This causes a low grade inflammation of the will be to step up the intake of fruits, stomach which will harm the digestive cells. Acidity and gas prob- vegetables, salads and nuts. A lot lems are the resultant diseases. From there, the acid goes to the pancreas owing to this the cells die early. Continuous cell death of the modern food is acidic. reduces the mass of the active pancreas. Some cells might escape and produce insulin, which will be insufficient for the body. Thus,

TECHAGAPPE JULY-SEPTEMBER 2018 27 Cover Story Type 2 Diabetes - An Overview

Milk, maida, sugar, fried and spicy food are also in this list. To a certain extent, red meat is also there if you can’t digest it. Our body, being alkaline, is allergic to acidic food and therefore, all organs suffer including liver, brain, kidney and so on,” the doctor gives a warning signal here. Say No to Stress! Another factor which fuels diabetes is stress. All the negative emotions like anger, hatred, and jealousy when locked up inside, keep on generating acids and destroy the cells. Earlier, families were the ven- ues where you can talk to each other and relieve your stress. But now, in a modern family where both husband and wife work, there is no time for them to talk to each other. This should change drastically. Exercise Regularly Lack of exercise is another vital cause of diabetes. Every joint generate insulin and hence, the sugar piles up leading to diabetes. in the body is connected by nerves to every gland in the body. Hereditary traits do not guarantee diabetes and non-hereditary The pancreas is also a gland. traits don’t mean that you won’t get the disease. “It all lies in how If you move your limbs, nerves will stimulate the pancreas to you treat your body. Even if diabetes runs in your family, if you live make insulin. The logic is very profound. conservatively, eating healthy food like more fruit and salads, working hard and having no negative emotions, you can escape the dis- To move a joint, you need to contract the muscle. To do so in ease,” he points out. a sustained manner, you need energy. For energy, you need food and insulin. So, one nerve will pass the message to another nerve Diabetes can affect Kidneys and inform the brain about the need for food and ignites hunger Talking about how diabetes affects the kidneys he said that long whilst another nerve will push the pancreas to send insulin. Now, standing, uncontrolled diabetes, the chronic use of junk foods the situation has changed as we are looking for food as a habit (acidic in nature) and the abuse of medications for every symptom rather than as a need. There is no stimulus to the pancreas to experienced leads to gradual and systematic destruction of kidney cells first leading to protein in urine and later advancing to kidney failure. Another factor which fuels Diagnosis of Diabetes diabetes is stress. All the Diagnosis of diabetes is done using three criteria. First is your negative emotions like anger, random blood sugar test. Any level more than 200 mg can be treated as a strong indication of diabetes. The Glucose tolerance test is a hatred, and jealousy when foolproof test to find out diabetes. There are criteria for doing this locked up inside, keep on test, especially for pregnant ladies. The HbA1c test is the third test generating acids and destroy for the diagnosis of diabetes. the cells. The number of diabetic patients is increasing multifold each year. “In 2000, India crossed the mark of 36 million diabetic patients. It was estimated that by 2025, the number will reach around

28 TECHAGAPPE JULY-SEPTEMBER 2018 50 million. But by 2018 itself, India has more than 60 million diabetic patients. Diabetes is a major lifestyle disease now. Automation and lack of exercise play a pivotal role in this. It is alarming to note that “It all lies in how you treat your body. many youngsters have diabetes now, which will make the nation Even if diabetes runs in your family handicapped as its main workforce suffers from this disease,” he hints at an alarming fact here. but if you live very conservatively Manage your Diabetes eating healthy food like more fruits The management of diabetes is a three pronged programme and salads, working hard and having viz. diet, exercise and medication. A good diet has no substitute in no negative emotions, you can management and prevention of diabetes. Proper exercises and medication also help to lead a positive life with energy and to stay escape the disease,” he points out. away from diabetes. He also advises the youth to stay away from sugared drinks like colas. The influence of advertisement is quite and produce energy. However, some newer drugs prevent the strong in making the youth choose colas. “While the prime time slot digestion of carbohydrates and thereby prevent the absorption in TV and the prime spot in newspapers are used for their ads, little of glucose from the intestine. They don’t allow glucose to enter do people notice the health warnings against them by any advisory the blood and thus blood sugar remains normal. I don’t feel it is bodies, which will be usually deeply buried in by the media,” he a legitimate way of treating diabetes. I may be radical in my points out. thinking but that’s how I feel,” he clarifies. In general, out of the Speaking about the various drugs which are available in the 10 medicines available, only three might be safe to use. He also market to control diabetes, Dr. Anand has got a clear-cut stand points out how several medicines were banned by regulatory about them. “There are some drugs which help to produce more bodies after they were found to be harmful to the user. insulin from the pancreas by stimulating the cells directly or indi- Lifestyle Management rectly. There are some drugs which improve the efficiency of existing insulin by doing some chemical play. These two drug groups can To youngsters of the nation, his message is very simple and be called legitimate as they help to normalise glucose metabolism straightforward. “It is very important to change your lifestyle. You can never depend on a drug to cure you in the case of diabetes. In this case, prevention is better than cure. It is better to safeguard your organs than losing them. I may quote a Yogi who has given me the best advice to prevent diabetes. “Diabetes se door rehana HbA1c Normal hein toh Uttar Pradesh ko Leval thanda rakho, Madhya 4% -5.5% Pradesh ko mulayam or Dakshin Pradesh ko garam!” Uttar Pradesh is your mind. Keep it calm and cool. Don’t get stressed. Madhya Pradesh is your abdomen. You should keep it soft. Don’t eat food that causes consti- pation. Dakshin Pradesh are your legs. Keep them hot by engaging yourself in various forms of exercise. Dr. Anand gives an excellent advice to escape the disease through this lucid example.

TECHAGAPPE JULY-SEPTEMBER 2018 29 Life Story Shabnam (Professional Tailor) DECORATING THE BEAUTIFUL FABRIC OF LIFE... Shabnam Mohammed (32) is busy doing the final touchup of a churidar with the new machine she had purchased to maintain the inflow of orders and for fast delivery of dress materials. She is the proprietor of Shabnam Ladies Tailors, Kumaranellur, 5 km away from Edappal, Malappuram district. Her three workers are also busy stitching and knitting clothes with the finesse that makes people choose her shop without much hesitation. “Despite the emerging number of readymade wares, we are never short of work. To finish the job on time, we sometimes work overtime,” says Shabnam beaming with energy and enthusiasm. Her demeanour matches exactly as any other proud, extremely healthy young entrepreneur. But Shabnam deserves a little more elaboration.

Many people know Shabnam as the high- spirited girl who roams the streets of Kumaranellur on her Honda Activa. Only a few know the real story of Shabnam and the hardships she had undergone. In the medical records, Shabnam is credited as Kerala’s first woman to undergo a combined pancreas-kidney transplant. The fact that only a few such transplants had been conducted all over In- dia makes Shabnam’s case quite significant. Born to Mohammed Ali and Subaida, Shabnam is their third child. She has four siblings including a brother. Mohammed Ali was basically into bakery business and Shabnam indulged in the sweets her father Shabnam Mohammed brought home. Life was quite good indeed. Even when Shabnam had her share of dis-

30 TECHAGAPPE JULY-SEPTEMBER 2018 eases during her childhood, nothing was much serious. Her mother remembers it was always Shabnam who had been affected by diseases. Neither her brother nor her sisters had any health problems during their childhood. It was in 2000 things took an unantici- pated, sharp turn. Shabnam was appearing for her tenth-grade exam (SSLC) that year. The first symptom Shabnam noticed was her unusual weight loss. Despite the strange hunger she felt, she kept on losing weight. She also felt very thirsty throughout day and night. Shabnam’s mother Subaida recalls how she noticed her daughter using the toilet at night several times. Feeling this to be a little uncommon, they took her to a local medical practitioner. After examining her, he asked Mohammed to take her to the hospital immediately. At the hospital, they prescribed some tests and after examining the results, they asked him to get her admitted to another hospital. The doctor asked them to hurry to the hospital at once. It was here the doctors explained the seriousness of the situation to them. The doctors informed them that Shabnam’s Shabnam and her family sugar level has reached almost 500 mg/dL while the normal is around 80-120mg/dL. Insulin was given to her busiest tailors in the locality. The job also worked as a stress and the doctors engaged nurses to instruct her on how to take reliever and maintained her mental health in perfect balance. insulin herself. The doctors said that the condition was diabetes For three years, she did all her work from home itself. But as found in children, which has led to a situation like this. Thus, at the the customers increased, she moved into a shop in the town. tender age of 15, she began to take insulin herself thrice a day. Since her father owned a few apartments in the area, finding a place for the shop wasn’t difficult. At first, Shabnam had just For a 15-year old, the disease changed her world topsy-turvy. one employee and now the number has turned to three. She states that at first, what she felt was uncontrollable anger to the people around her. Sometimes she used to skip her insulin In a hurry to find a solution to their daughter’s disease, her intake as a protest and anger towards her own condition. Neither parents went to several local medical practitioners. “That was she nor her family members had any knowledge about the dis- a foolish act. Every time the situation got worse and we had to ease. Her family had no history of diabetes. She had to get admit- seek medical attention at the hospital itself,” recalls her par- ted to the hospital often when the situation turned worse. Even ents. Their advice is to stay away from fake medical practitio- though she had reduced the intake of sweets she hadn’t completely quit it. Sometimes, without the knowledge of her parents, she used to enjoy it and finally end up in hospital. After a few days in the hospital, she would return to her normal life. For a 15-year old, the disease With her disease condition, she couldn’t attend the SSLC exam. changed her world topsy-turvy. Since she wasn’t very bright in her studies, her parents also didn’t She states that at first, what she persuade her to go about it. When she was diagnosed with the disease, Dr. Ajith, who had been treating her, suggested teaching felt was uncontrollable anger to her something with which she could support herself in the future. the people around her. Thus Shabnam turned to tailoring. Her family also had a few tailors and she mastered the skills easily. Today, she is one of the

TECHAGAPPE JULY-SEPTEMBER 2018 31 Life Story Shabnam (Professional Tailor)

Shabnam at her tailoring shop

ners. “We wasted many years going behind their advice,” they lected the bad days. Shabnam’s mother points out that there were added with much dismay. a few doctors in the same hospital who helped them in many ways. “We still keep in touch over the phone with those good Meanwhile, during regular checkups, the doctors informed doctors who gave us directions at that point of time,” she adds her parents that the function of her kidney was also getting with gratitude. affected. Shocked, they took Shabnam to a super speciality hospital in Thrissur for further treatment. However, some un- Shabnam was shifted to Amrita Institute of Medical Sciences happy incidents forced them to move to Ernakulam. Her father (AIMS), Ernakulam, on the following day itself. It was from there remembers how that doctor wouldn’t even share the details of they came to know that Shabnam’s pancreas was not functioning her disease to them – her close relatives. “The doctor behaved from her birth onwards. They wonder whether other doctors di- arrogantly and was always busy”, recalls them. “He didn’t even agnosed this correctly as no one told them about this before. Only care to tell us about the possible ways ahead if kidney failure at AIMS, did they come to know about the complexity of her case. happens. We remember how casually he said that there is noth- The child can store insulin from their mother during the time of ing to be done now as the kidney failure is in its final stage. By gestation for months and years. Till 15 years, Shabnam had no then, we had completed 13 dialyses for her. It was only then he frequent problems as the stored insulin was used. Now it is over said that there is an option of a kidney transplant and that too, and that insulin has to be pumped into her body. “For that one only if happened in two days. You can’t buy a kidney from a year (2014-2015), I mostly spend time in the bed. The dialysis con- shop! He should have informed us much earlier,” they recol- tinued for almost the whole year with three or four processes a week,” recalls Shabnam. Meanwhile, Shabnam’s brother, who was abroad, came for a Shabnam’s brother, who was abroad, holiday and noticed a piece of news about the case of Syed Yunus Shahir (39) from Palakkad, who had gone through a similar situa- came for a holiday and noticed a piece of tion. He had a pancreas-kidney transplant and was the first patient news about the case of Syed Yunus Shahir to undergo such a combined transplant in India at that time. who had gone through a similar situation. Shabnam’s family is really grateful to Dr. Ramachandran at He had a pancreas-kidney transplant and AIMS who was very caring and considerate to his patients. He inquired about their opinion on combined organ transplant after was the first patient to undergo such a explaining the risks associated with it. The doctor also pointed out combined transplant in India at that time. that in Syed’s case, there had been no dialysis till he underwent the transplant. In Shabnam’s case, it was different. The huge ex- pense related to the transplant was another issue to be addressed.

32 TECHAGAPPE JULY-SEPTEMBER 2018 Her mother recalls how the relatives and people around the Another incident which they remember is about being locality helped to pay off the expenses related to the transplant. asked to take her scan after the transplant surgery. The techni- Though it was estimated that Rs.25 lakhs will be required, the col- cians there asked her to consume water prior to the scan. Her lective efforts gathered more than Rs.50 lakhs for the surgery. parents informed that she could consume only two glasses of “God has helped us when we required the help,” she says. water a day. However, the staff insisted on taking a glass of water and just minutes after consuming a glass of water, Shabnam had waited for one year after registering for an organ Shabnam had difficulty breathing. She lost her consciousness transplant. During that time, they had gone to the hospital four in the next moment and was rushed to the ICU facility. times for a possible transplant when they were informed that an organ was available. However, those were not perfect matches for Shabnam underwent three major surgeries after the trans- her. The cadaver organ Shabnam received was from a 30-year old plant and the excess amount they collected was used for this. male from Ernakulam, who had a brain death. Recently, they had It was only after six months, she was discharged home. Prior contacted the donor’s wife and child. to that, she had also encountered ear balance problems, which resulted in vomiting and headache. As they were unaware of Shabnam’s transplant surgery took place on July 31st, 2015 at the cause of her vomiting and headache, they contacted Dr. AIMS. She was taken to the operation theatre by midnight and Ramachandran and promptly informed him of her condition. taken out the next day by 12 pm. The pancreas transplant took Dr. Ramachandran identified the problem and took great care around 8 hours while kidney transplant took around the remain- to ensure the safety of his patient. ing 4 hours. Doctors informed her parents at regular intervals on how the transplant was progressing. She regained consciousness It’s almost four years now after the transplant and Shabnam only after three days. Even though they tried shifting her to her leads a normal life now. The hospital days are long gone and room, most of the time, she used to catch a fever in not less than there have been no further complications after it. Every three 2 or 3 hours after being taken to the room and would be again months, she has to go for a regular checkup. Shabnam says shifted to ICU. For three months after the transplant, she had been that her greatest desire was to live well for a day after the in the ICU itself. surgery enjoying all the food and sweets. Now, she has got no restrictions on food or sweets and enjoys whatever she feels Post surgery, she faced a few complications. A tube which had like eating. She now jokes that she will one day enter into been inserted to pass urine went wrong once removed and rein- Guinness Book of Records as a person who had lived the long- serted so that the urine started to flow through the wounds of the est after a combined transplant. surgery. At first, the doctors failed to understand that it was urine which was coming out through the wounds of the surgery. Later, Today, Shabnam is an independent woman. She earns a they put two tubes inside her body - one to remove the urine in her decent income through her tailoring shop. Regarding her fu- stomach and another to pass urine the regular way. ture plans, she says she dreams of expanding her shop. “A married life is still far away. Al- ready, a few marriage proposals ended up no- where as we informed them about my transplant. At present, I have made up my mind to con- centrate on my shop and leave the rest to the hands of God. Af- ter all, the God has given me more than I could ask. I feel abso- lutely grateful!” she emits that radiant smile that Shabnam with Dr. Ramachandran N. Menon, Dr. George Kurian and Dr. Unnikrishnan G. at has defeated Amrita Institute of Medical Science, Kochi even fate.

TECHAGAPPE JULY-SEPTEMBER 2018 33 Interview Dr. Arvind Lal (Dr. Lal PathLabs) “LEADING A SEDENTARY LIFE IGNITES DIABETES... “ Dr. Arvind Lal, Chairman and Managing Director of Dr. Lal PathLabs

Dr. Arvind Lal, the Chairman and Managing Director of Dr. Lal PathLabs, one of the most respected pathology laboratories in India, is recognised as a pioneer in providing laboratory services in India, par excellence. The President of India has also conferred him an Honorary Brigadier’s rank in the Armed Forces Medical Services. Being the recipient of the prestigious Padma Shri award, Dr. Arvind finds some time to talk to the TechAgappe team at their head office located at New Delhi. Excerpts from the interview:

TechAgappe: Could you please tell us about your childhood? How did the idea of establishing a chain of diagnostic labs in India emerge in your mind? Dr. Arvind Lal: I never wanted to become a doctor. Even for my studies, I had not selected biology. I had made up my mind to become a fighter pilot in the Indian Navy. But when I discov- ered that I had a myopic condition on my left eye (which will never allow me to become a pilot), I thought of several other options as a profession. It was then that one of my uncles suggested me to become a doctor. So I had to give up my geometrical drawing, which was my other subject and stud- ied biology in eight months’ time. Thus I made it into my pre-medical test and then to medical college. Even before that, my father Late Dr. Major S. K. Lal had established a pathological lab in 1949 and is considered as the oldest pathological lab in India. This lab is of my age as I was born in the same year. He passed away in 1971 and I had to take up the lab. I had been a lecturer of pathology and did my post graduation during that time. I introduced several new Dr.things Dharani to the Subrahmaniam lab like Thyroid Testing, which has

34 TECHAGAPPE JULY-SEPTEMBER 2018 been never done at a private lab in India before. We also got the first Auto-analyser which gave results within one minute, first Haematology Analyser, first lab information management system back in 1986 and so on. In 1996, we opened our second lab to do molecular diagnostics. We are proud to say that we introduced vacuum based evaluation tube in 1989, which was a game changer in India. Be it the case of machinery, we were the first in India to introduce the latest equipment. We also had a tie-up with a foreign company back in 1995, which was later renamed as ‘Quest Diagnostics’ and we were their first partners in India. In the same year, we grew as a private Dr. Arvind Lal receiving Padma Shri Award from Smt. Pratibha Patil, limited company from a partner- former President of India. ship company. We got our first private equity partner in 2005 - Dr. Arvind Lal: In India, anybody can open up a lab anywhere West Bridge Capital Partners. Today, we run around 280 labs, 2000 in the country. It is estimated that India has around 1 lakh collection centres and we pick up samples from 7000 additional laboratories in the private sector. Most of these labs are run pickup points. by people who have no relation to pathology or healthcare sector. There is even a Supreme Court Judgement stating that We were also the first to bring up franchisee concept to the only a doctor can run a lab. There are many labs which claim healthcare sector in India. But we don’t franchise our labs and do as testing centres even though they are actually ‘testing shops.’ that only with the collection of samples. No quality control measures, precautionary measures or ethi- TechAgappe: What is your idea about preventive testing against cal practices are taken at such testing shops. If the Govern- disease testing? ment of India can regulate the sale of Ultra Sound Machine and restrict authority to run a blood bank, it should enforce Dr. Arvind Lal: As doctors, we are confronted with the burden of the law on who can run a laboratory also. The first and the non-communicable diseases or lifestyle diseases. I will say that foremost step is that the laboratories should become more there is no family in India that doesn’t have any member unaf- quality conscious. The second step is that you provide a time fected by any of these diseases like diabetes, high blood pressure, frame or a deadline for every laboratory to get accreditation of stroke, obesity, cardiac disease, cancer, liver problems, kidney or NABL or ISO. My opinion is that if you don’t observe good lung diseases. Almost 65% of our population dies due to these quality, the bad quality will cost you dearly. We should be qual- diseases. If we do not prevent these diseases on time, our country ity conscious and the government has also got a role in this will never become prosperous because two percent of the GDP is regard. gone treating these diseases. Any human being, who is rational and educated, will want to bring it down. And that cannot be done TechAgappe: What are the plans of Dr. Lal PathLabs to take unless we do preventive testing. So, it is good to do the test during quality disease diagnosis to the rural population of India? your wellness than during your illness. The sooner, the better! Through early diagnosis, we will be able to save millions of lives in India. Communicable diseases also have its share in India. The "AGAPPE is associated with Dr. Lal PathLabs for number one communicable disease in India is Tuberculosis. their protein analysis. They are using our Though the government is doing a good job in preventing these Innovative product Mispa-i2, specific protein diseases, it can do much better with the help of private sector. analyzer in many of their centres across the TechAgappe: As one of the leaders in providing world-class diag- Country. We are very proud to be associated with nostic services, maintaining the highest ethical standards and qual- the pioneers like Dr. Lal PathLabs”. Sudhir Nair, ity, what are your suggestions to change the present condition prevailing in the diagnostic sector in India? Head - Marketing, Agappe Diagnostics Limited.

TECHAGAPPE JULY-SEPTEMBER 2018 35 Interview Dr. Arvind Lal (Dr. Lal PathLabs)

Dr. Arvind Lal: We are only con- fingers, tips of their toes and so on. centrating on metro cities and tier They get injured often and ultimately I cities as of now. But don’t forget will have to get amputated. that more than 70% of the popula- Diabetes also leads to silent heart at- tion lives in the rural areas. The tacks. Diabetic retinopathy is another three problems we face while go- situation, which shows the gravity of ing down to rural parts are- ac- the disease. Your foot will be another cessibility, affordability and qual- area, which will be affected by diabe- ity. Even then, Dr. Lal Path Labs tes. Gestational diabetes needs to be have always tried to become more monitored carefully as the child will be accessible. We have increased the heavier than the normal child. number of our labs and collection centres to reach the patient more TechAgappe: Agappe takes pride in effectively. Considering the factor claiming that we are ‘The Best Partner of affordability, it is true that we in Diagnostics’. We strive hard to re- can’t serve people below the pov- tain it. What is your advice to Agappe erty line at this point. Last year in keeping the slot filled as ‘The Best alone, we tested around 1.5 crore Partner in Diagnostics’? patients and are able to provide Dr. Arvind Lal: You have to come up them world-class quality reports. with products that match world-class We propose that the Govt. of India quality. We are not yet par with the west- should largely be interested in tak- ern world in manufacturing analysers, ing care of primary health care of testing and IVD equipment. I wish our the patients and leave the second- companies must have their own model, ary and tertiary care to the private which must reflect that we can go one groups, who are available on a pay- Dr. Arvind Lal, with former Prime Minister of step ahead than those companies ment basis. Those private groups India Dr. Manmohan Singh abroad. (For eg: we can have a lab on a should choose good nursing chip and we can take them right to pa- houses, doctors and can guarantee the quality. We are ready to tients’ homes or a collection centre or a pickup point. In this way, serve the poor if need arises even though that means cutting we would be able to diagnose the disease with it rather than send- down the cost of our top quality services. We are already pro- ing their blood sample to 50 or 100 km away to have them diag- viding it for CGHS patients. nosed.) Quality and innovation will help Agappe to stay ahead but you should also take care of a third factor-Off the shelf products TechAgappe: As a doctor, what is your message to the diabetic and services. You should be able to execute your idea fast. patients? Dr. Arvind Lal: It is saddening to note that we do nothing to TechAgappe: As a doctor, you are now many years into this IVD stand away from diabetes. Leading a sedentary lifestyle with no Sector. What do you think? Have you achieved your vision? exercise, morning walk, eating unhealthy food especially fast Dr. Arvind Lal: No, no, I have just started it. The thing which and junk food etc ignites diabetes. On top of all, doing nothing keeps bothering me is that there are still thousands of people in to take care of oneself even when someone knows that he is India dying without getting a proper diagnosis. To reach them, our diabetic is like adding fuel to the flame. accessibility has to be increased. We should be up-to-date with quality and should make it definitely affordable for all those people. People with diabetes should take care of themselves at least10 times more than they are normal. Here I doubt whether all pa- TechAgappe: What are the current issues faced by the industry?

tients take the reports to the doctor. In the UK, under National Dr. Arvind Lal: GST is too high for the industry. At present, we are

Healthcare Service (NHS) Testing, if doctors can bring the HbA1c included in the 28% slab. We also don’t get the input credit for

level of patients down, they get incentivised or rewarded. In CGST. Though healthcare sector is exempted from GST, as there

India, leave aside the reward, but I would suggest patients keep is no input credit, even people like us have been affected badly. I

your blood sugar under a tight control. HbA1c is less than seven am pointing out the monetary aspect. So, some reforms have to

for a diabetic and less than six for a non-diabetic. Get your be incorporated into the entire healthcare sector. urine checked every now and then, especially for microalbumin (to detect kidney damage). You should note that 70% of renal TechAgappe: Do you have any plans for overseas? failure cases coming to Dr. Lal PathLabs are diabetic patients. Dr. Arvind Lal: We are already there in Nepal and Bangladesh. We Diabetic Neuropathy is another condition seen in many people are looking at the opportunities in Africa. We will not lag behind in in India. They lose their sensation in their limbs, the tips of their exploring opportunities abroad.

36 TECHAGAPPE JULY-SEPTEMBER 2018 Life Story Dr. Apoorva Gomber (Doctor) BEAUTY, BOLDNESS AND COMPASSION! SHE HAS IT ALL!! Apoorva Gomber (27) is a vibrant, enthusiastic PG student in Pathology at New Delhi. She has an ideal fighting spirit flaming in her that helps her win over her health disorder - Type 1 Diabetes. She fights not just to prove her courage and confidence but she is a strong voice for many, who face a similar situation. She doesn’t welcome sympathy. All she wants is societal acceptance for the people living with type one diabetes , particularly when Type 1 Diabetes is not a disease but an auto-immune disorder. This can happen to anyone at any age, irrespective of gender or class.

Born to doctor parents in Delhi, Apoorva’s story is pretty much similar to anyone with Type 1 Dia- betes. Apoorva was studying in her eleventh grade when the symptoms of Type I Diabetes surfaced. She suddenly began losing weight and from a 50- kg body weight, she reduced to 40 kg. “I was actually feeling happy about this weight loss as I had been eating a lot that time. Ice cream and Coco- Cola were my favourite things. I was happy that I could munch on everything and can still wear a 26 waist size jeans,” she says. But the joy turned out to melancholic notes in a few days. There appeared infections on her face and lips. Along with this, breathing problems, especially when she climbs upstairs and dozing off, all started manifesting. Her mother thought that Apoorva was anaemic which is commonly the first clinical diagnosis a doctor makes in a young female in India. They ran a blood test and found her haemoglobin levels to be normal. So other things were ignored. Later, she had a row of urinary infections. Her father became doubtful about this and randomly checked her sugar levels also. It was around 750 mg/dL while the normal was around 72-108 mg/dL. The HbA1c was 16.4%, which was more than twice the ADA (American Diabetes guidelines) of a normal level of 6.5% and the doctors were astonished how she was alive until then. “My father was shattered at this news. I was ad- Apoorva Gomber mitted to the hospital immediately and insulin

TECHAGAPPE JULY-SEPTEMBER 2018 37 Life Story Dr. Apoorva Gomber (Doctor)

shots were given to me from the next day onwards,” Apoorva recollects. She was gaining weight during those hospital days and came to 65 kg. She felt alone and kept wondering what was But what makes her unique is what she wrong with her and no longer wanted to take her insulin shots. stands for currently. Meeting people Like most diseases in India are kept under the cover be- behind the International Diabetes cause of lack societal acceptance her family too was not very open about the disease. So she had to confine her disease con- Federation (IDF) Project opened up new dition to herself. Only a few close family members knew that opportunities for her. The organisation is she had Type 1 Diabetes. Her parents were very supportive and encouraged her to go ahead with her life. She took about one- for all people who suffer from diabetes. year leave from her studies as she just couldn’t focus on her studies. Since she was from a family of doctors, she knew a little about the seriousness of her condition. She also wanted to learn sharing my experiences and going through stories from people all more about her condition and to know about her peers who over living with type one diabetes was really empowering for me suffered from this disorder in Delhi. and I gained strength from it,” Apoorva recalls how she managed the disorder at that tender age. In 2009, she joined for her MBBS studies. It was a very hard time for Apoorva as the long study hours made her weak facing She unveiled the mask of “TID Fighter’ on social media and a hard time managing her blood sugars. She remembers some revealed her name only after a year. She never posted her pictures of her friends joking about her whether she was high on drugs as she felt there was a taboo prevalent in India which prevents being unaware of Apoorva’s condition. Since she had insulin women with Type 1 Diabetes from getting married. Within a year, injections, she used to go to the washroom and administer them. she got connected with several people living in Delhi itself with This must have made them mistaken it for drugs. Sometimes, Type 1 Diabetes. Gradually, she got in touch with people abroad she even missed taking injections as she didn’t want others to also, especially in UK and USA. She once got an opportunity to know about her disorder. But gradually, she opened up her visit American Diabetes Association with her father and met sev- Instagram page called ‘T1D Fighter’ and she thought that it was eral eminent personalities there. It was there, she got introduced the only way to reveal her mind to others. “Despite following all to the movement ‘Beyond Type 1.’ Beyond Type 1 is a new brand the instructions on food and quantity and taking them on time, of philanthropy leveraging the power of social media and tech- sometimes my sugar levels would go very low with symptoms nology, changing what it means to live with a chronic disease. By of hypoglycaemia like shivering , feeling dizziness and at times educating the global community about this autoimmune disease, loss of unconsciousness. I wrote openly about my feelings dur- as well as providing resources and support for those living with ing that time on social media so I could get connected with more Type 1. Apoorva is a Global ambassador council member at Be- people living with diabetes with an aim to remove the taboo yond Type 1 and has been taking various initiatives to organize which this disease is linked with in our country. Connecting and “Live Beyond educational sessions” to spread awareness about the disease. But what makes her unique is what she stands for currently. Meeting people behind the Interna- tional Diabetes Federation (IDF) opened up new opportunities for her. The organisation is for all people who suffer from diabetes. Headquartered in Belgium, they choose people who can do advocacy projects related to diabetes and change the present scenario in their own country. Apoorva’s current Apoorva Gomber as the regional representative from SEAR-south East Asian region standing advocacy project is alongside other regional representatives at the YLD- Young leader in diabetes -IDF, Abu Dhabi 2018 organising a camp exclu-

38 TECHAGAPPE JULY-SEPTEMBER 2018 It’s DIYA- Diabetes India youth in action- an active advocacy group for people living with type one diabetes .

month for her basic insulin to survive. In other countries, un- sively for people living with Type 1 Diabetes. She got the idea from like India, it is covered under insurance. They also aim to create interacting with people from the US and the UK where they con- awareness among people on how to inject insulin. “If you don’t duct camps for such people. They will gather up in a school or a know how to use it, the chances are high that you might end up convenient place for a day – having food and spending time to- in an overdose which is disastrous,” Apoorva adds. gether just like normal people. It is also an occasion for them to share information on the newer technologies like insulin pumps/ Through DIYA, they have organised two or three picnic CGM’s. It is more of an awareness and social support project. In camps. They have also organised Carbohydrates Counting ses- India, she feels that people won’t even admit that they have diabe- sions so that people can know how they can improve on their tes. Apoorva believes that by sharing their stories, people could food and how to calculate their ‘Carbs’ with the right amount of come close to each other and get support. Her project from 2018- insulin. 2019 is to organise one such camp in her area. Insulin is a life-saving drug for people like Apoorva. Even in At present, Apoorva is a part of an NGO called Diabetes India the Government of India’s Disability Act, which aims to provide Youth in Action (DIYA), which is led by a collaborative effort of nine essential medicines free of cost, insulin is not added in the list. other people - who are also living with Type 1 Diabetes. It is a Apoorva feels that it’s high time the government accepts the patient advocacy project where people living with the condition importance of insulin and ensures accessibility & affordability stand for their own rights. It works to remove the stigma associ- for all. ated with Type 1 Diabetes. “I have seen people break their relation- ship when they find out that their partner is a Type 1 Diabetic. It is DIYA team is also working on an insurance policy aimed at shocking to know that even students face discrimination in schools patients like them. They have collaborated with ‘Medtronic In- or colleges for having this condition. A few days back, one of my dia’ help provide insulin pumps to patients who need them friend said how she was rejected by others when she wanted to most. She says ‘Mithai Project’ organised by Government of stand for Sports Captaincy in College,” she voices forth the soci- Kerala for children who suffer from Type 1 Diabetes is indeed a etal stigma towards people like her. The NGO also aims to coordi- welcome move. Insulin pumps will be provided to 400 children nate with government agencies to increase the availability of insu- who suffer from the disorder in the first phase. Children from lin. Even when it is available through government hospitals, the families, who have an annual income below Rs.2 lakhs, can ap- cost of insulin is still high. Apoorva has to spend Rs.5000/- per ply for the scheme currently. People ask Apoorva why she preferred pathology to diabetes. “I had made up my mind that I would become a doctor. But Even in the Government of India’s then, I didn’t do well in the medical exams to choose what I Disability Act, which aims to provide wanted. Besides, my father also didn’t want me to go for something which my health won’t allow. Even then, I want to pursue essential medicines free of cost, insulin diabetology and in the future, may switch from pathology to is not added in the list. Apoorva feels something related with diabetes,” she adds with a winning smile. that it’s high time the government “Every disease goes through a phase of acceptance and denial. The phase of denial is long over for me now. I won’t accepts the significance of insulin. allow diabetes to defeat me,” Apoorva is confidently moving towards the direction of her goals.

TECHAGAPPE JULY-SEPTEMBER 2018 39 Cover Story Type 1 Diabetes - An Overview TYPE 1 DIABETES: CURRENT SCENARIO IN INDIA Type 1 Diabetes Mellitus (T1DM) has a wide presence in children and has a high mortality rates. The disease, if left unmanaged, poses various challenges to the patient and healthcare providers, including development of diabetic complications and thus decreasing the life expectancy of the affected child. The challenges of T1DM include awareness of the disease that is very poor among the general public and also in parents of T1DM children along with the health care professionals. The challenge of lack of awareness of T1DM can be met by increasing public awareness programs, conducting workshops for diabetes educators regarding T1DM in children, newsletters, CMEs, online courses, and by structured teaching modules for diabetes educators. Diagnosis of T1DM was a challenge a few decades ago but the situation has improved today with diagnostic tests and facilities, made available even in villages. Dr. K.M. Prasanna Kumar Consultant Endocrinologist, Centre for Diabetes and Endocrine Care, Bangalore Diabetes Hospital, Bangalore, India. Courtesy to http://www.ijem.in/ Type 1 Diabetes Mellitus (T1DM) has a wide presence in children and has a high mortality rates. The disease, if left unmanaged, poses various challenges to the patient and health care providers, including development of diabetic complications and thus decreasing the life expectancy of the affected child. A study in USA showed that when a 10-year-old boy or girl de- velops diabetes, he/she loses almost 18.7–19 years of life compared to their nondiabetic counterparts. A researcher has also stated “focused studies show that outcomes can be improved by better management, but there is no evidence of this actually happening on a worldwide basis.” Newer treatment approaches have facilitated improved outcomes in terms of both glycemic control and reduced risks for development of complications. The major challenges remain in the development of approaches to the prevention and management of T1DM and its complications. Major Challenges The challenges of T1DM include awareness of the disease which is very poor amongst the general public and also in parents of T1DM children, and this

40 TECHAGAPPE JULY-SEPTEMBER 2018 WHAT IS TYPE 1 DIABETES AND HOW DOES IT AFFECT? Type 1 diabetes is an auto-immune condition in which the immune system is activated to destroy the cells in the pancreas which produce insulin. We do not know what causes this autoimmune reaction. Type 1 diabetes is not linked to modifiable lifestyle factors. There is no cure and it cannot be prevented. Type 1 diabetes: · Occurs when the pancreas does not produce insulin · Represents around 10% of all cases of diabetes and is one of the most common chronic childhood conditions · Onset is usually abrupt and the symptoms obvious · Symptoms can include excessive thirst and urination, unexplained weight loss, weakness and fatigue and blurred vision · Is managed with insulin injections several times a day or the use of an insulin pump. Reference: https://www.diabetesaustralia.com.au/type-1-diabetes

What happens to the pancreas? exact cause of type 1 diabetes is not yet known, but we do In type 1 diabetes, the pancreas, a large gland behind the stom- know it has a strong family link and cannot be prevented. We also ach, stops making insulin because the cells that make the insulin know that it has nothing to do with lifestyle, although maintaining have been destroyed by the body’s immune system. Without a healthy lifestyle is very important in helping to manage type 1 insulin, the body’s cells cannot turn glucose (sugar), into energy. diabetes. At this stage nothing can be done to prevent or cure type 1 diabetes. People with type 1 diabetes depend on insulin every day of their lives to replace the insulin the body cannot produce. They must Symptoms test their blood glucose levels several times throughout the day. Being excessively thirsty, Passing more urine, Feeling tired and The onset of type 1 diabetes occurs most frequently in people lethargic, Always feeling hungry, Having cuts that heal slowly, under 30 years, however new research suggests almost half of all Itching, skin infections, Blurred vision, Unexplained weight loss, people who develop the condition Mood swings, Headaches, Feeling dizzy and Leg cramps. are diagnosed over the age of 30. These symptoms may occur sud- About 10-15% of all cases of diabe- denly. If they occur, see a doctor. tes are type 1. Through a simple test, a doctor can What happens if people with type find out if they’re the result of type 1 1 diabetes don’t receive insulin? diabetes. Without insulin the body burns its Management, care and treatment own fats as a substitute which re- Type 1 diabetes is managed with in- leases chemical substances in the sulin injections several times a day or blood. Without ongoing injections of the use of an insulin pump. While your insulin, the dangerous chemical sub- lifestyle choices didn’t cause type 1 stances will accumulate and can be diabetes, the choices you make now life threatening if it is not treated. This can reduce the impact of diabetes- is a condition call ketoacidosis. related complications including kidney disease, limb amputation and When we speak about the causes, the blindness. needs to be improved to effectively counter the problem of T1DM. awareness programs, conducting workshops for diabetes edu- The general population is unaware of the existence of diabetes in cators regarding T1DM in children (giving details of symptoms, children of 2–5 years of age and believe that it affects only the diagnosis, diet, monitoring and management), newsletters, middle-aged group. Awareness among the public health care pro- CMEs, online courses, and by structured teaching modules for fessionals is also very poor, and the syllabus curriculum of medi- diabetes educators. The Changing Diabetes in Children (CDiC) cine students does not emphasize much on T1DM. The challenge program is working on all these methods to increase T1DM of lack of awareness of T1DM can be met by increasing public awareness for the past few years. Diabetes care professionals,

TECHAGAPPE JULY-SEPTEMBER 2018 41 Cover Story Type 1 Diabetes - An Overview

Insulin availability, acceptabil- ity, and affordability are also major problems, compounded by the various types of insulin that are available in the market with a varied price range: From a few rupees to a few thousand rupees. However, effective use of insulin remains a matter of Agappe’s AGA1c reagent is utmost importance, rather than the different types of insulin. the unique double reagent Furthermore, the problem per- system which is reliable, sists with insulin storage; up to 80% patients lack a good stor- convenient, accurate and age facility at home. ensures value for money. It Another major problem is has regular and system packs the lack of a T1DM registry in India and the data provided is and can be performed in an assumed number. A regis- most of the fully automated try should be developed and or semi-automated system. include every child detected with T1DM. This would help the health care providers and the including nurses, dieticians and doctors, may not possess the government for planning and delivery of diabetes management specific skills required to optimally manage T1DM, and they techniques and medicines. A statement from the American Dia- may not have the time or energy to put these skills into practice. betes Association says that every child newly diagnosed with T1DM The need for a structured diabetes education program, for pa- should be evaluated by a diabetes team (consisting of a pediatric tients and parents/healthcare providers, which focuses on T1DM endocrinologist, a nurse educator, a dietician, and a mental health management, persists. The Indian Diabetes Educators professional) qualified to provide up-to-date pediatric specific Programme in 2010–2012 in association with project Health education and support. In India, however, this type of team may Opportunities for People Everywhere and International Diabe- be difficult to set up for the general public health, but the CDiC tes Federation (IDF) have trained nearly 5000 diabetes educa- team is working toward it. tors in India. This program, however, specifically lacked educa- The CDiC team is improving the infrastructure for managing tion on T1DM but has planned for future T1DM specific training T1DM better and is reaching out pan-India through 21 CDiC cen- to such health educators. ters and 20 satellite centers. CDiC has plans to extend this to over The psycho-social aspect of diabetes in children is another 100 centers across the country. The center network should be challenge in T1DM management. The patients/children some- such that it has a terminal and supervising center at the village, times fail to understand the severity of blood sugar levels and district and state levels. The present condition forces a child to only focus on the incentives provided by the social workers/ travel 150–300 km in 4–12 h time for reaching a CDiC center, which health care workers of the CDiC program. This would need regu- is at a much higher cost than the medications given to the child. lar interaction between parents, nurses, doctors, teachers, and the school authorities, which must be assured for close monitoring. The child must be encouraged to participate in the school The psycho-social aspect of diabetes in and family activities. Proper education of self-care must be given to the child so that the child can cope with his/her existing children is another challenge in T1DM disease, maintain self-confidence, ensure self-management and management. The patients/children adapt with life at large. sometimes fail to understand the severity The disease has many challenges, and these are not global but specific to developing countries. Diagnosis of T1DM was a of blood sugar levels and only focus on challenge a few decades back, but the situation has improved the incentives provided by the social / today with diagnostic tests and facilities, made available even in health care workers of the CDiC program. villages. Investigation facilities and infrastructure, however, are very poor at the primary care level, especially in rural areas.

42 TECHAGAPPE JULY-SEPTEMBER 2018 made the same available to a very large number of children who could not afford the same; subsequently achieving in con- There are approximately 70,000–75,000 trolling and bringing down HbA1c levels. The key impact on children with T1DM in the country and deliverables by CDiC is reduction of the number of children developing diabetic ketoacidosis, decrease in mortality, reduc- CDiC is only able to cater to about 4000 tion in the number and duration of admissions in hospitals, of these children. It, however, has been reduction in the number of school days lost, growth of child to their adequate growth potential, and a significant increase in able to successfully produce a model for body weight of children with T1DM.

delivery of standard of care for children. At the patient level, the disease poses challenges in terms of difficulties in education, marriage, and job opportunities. CDiC is also looking into the motivation of children for con- There are approximately 70,000–75,000 children with T1DM in tinuing their school education which is essential and would the country and CDiC is only able to cater to about 4000 of these help them sustain themselves in the future. In this regard, CDiC children. CDiC, however, has been able to successfully produce a is planning for introduction of scholarship to children enrolled model for delivery of standard of care for these children. in this program, for admission into schools. The program is Steps toward the further enhancement of the program would also providing school books and other necessary materials to involve establishment of infrastructure, providing insulin (even small children for helping them continue their education. amounts of insulin would be able to prevent ketosis and subsequent death in children), tackling the barri- ers and challenges as discuss ed above (lack of awareness, monitoring, etc.) and making expensive insulin available to all T1DM patients, with government removing the tax levied on insulin. This could be possible if both the state and central governments are actively involved in this program. A public-private partner- ship initiative is needed involving the ministry of health in the central government, civil society, World Diabe- tes Foundation/IDF/Juvenile Diabetes Foundation, State Governments, City Corporations and the Local Nongov- ernmental Organization (NGOs). NGOs and public-private partner- ships, without support from the government, would not be able to do much about the cause. CDiC looks forward for support from the government and would be able to give the data collected so far, share the roadmap of achievements till now, and the roadmap for the next 3 Summary years. This would lead to increased participation from children. The wide disparities in socioeconomic levels, educational Changing Diabetes in Children is working with some agencies background, and availability of diabetes care pose major hurdles to supply diabetes strips at about 2 rupees/strip, which usually in the management of this disease in India. Parents and the costs around 25 rupees. The CDiC aims to give 60 strips to each family tend to view T1DM as a stigma. child along with the contact details of a social worker/diabetes educator who can be contacted telephonically in case of any varia- People need to take the lead to ensure comprehensive clini- tions in daily blood sugar levels, following which he/she can sug- cal and psychological care for all children with T1DM by gest remedies or increase insulin dose. The diagnostic tests avail- preconceptional planning program. The final aim of all such able are fairly expensive in the country and the CDiC program has programs should be that no child should die of diabetes.

TECHAGAPPE JULY-SEPTEMBER 2018 43 Health Tips STEER AWAY FROM DIABETES

ADr. C.S. SatheeshSOCIAL Kumar, Sr. Vice President-Supply Chain Management,MENACE AGAPPE., (Retd. Drugs Controller, Kerala) The number of people with Type 2 Diabetes is increasing in every country but more than 80% of them live in low and middle-income countries such as India, Bangladesh, Bhutan, Pakistan, Sri Lanka, Philippines and Indonesia. India stands second with 69.2 million people with diabetes and another 36.5 million with prediabetes, which is a high-risk condition for diabetes and cardio-vascular disease.

Diabetes is a major global, social menace in the modern era bally there are 415 million people with diabetes in 2015 and is pre- which needs personal attention as a matter of fact. In diabetes, dicted to increase in umber, around 642 million by 2040. It is quite otherwise called Diabetes Mellitus, one can’t properly use or alarming to note that more than 47% of the world’s population is store glucose in the body. Over time, glucose builds up in the still undiagnosed for diabetes with the prevalence still bound to bloodstream, which can lead to serious health complications increase further. Furthermore, 318 million people are estimated to unless people take steps to manage their blood sugar. Almost have impaired glucose tolerance and 20.9 million live births are 90% of the occurrence is Type 2 Diabetes compared to Type affected by some form of hyperglycemia during pregnancy, of which 1.The International Diabetes Federation has estimated that glo- 85.1% are due to gestational diabetes. The number of people with Type 2 Dia- betes is increasing in every country but more than 80% of them live in low and middle-income countries such as India, Bangladesh, Bhutan, Pa- kistan, Sri Lanka, Philip- pines and Indonesia. In- dia stands second with 69.2 million people with diabetes and another 36.5 million with prediabetes, which is a high- risk condition for diabetes and cardio-vascular disease. This increasing incidence is mainly at- tributed to lifestyle changes, eating unhealthy food and being physically inactive. Long-term diabetes can

44 TECHAGAPPE JULY-SEPTEMBER 2018 cause cardiovascular disease, nerve damage (neuropathy), kidney damage (nephropathy), “An ounce of prevention is worth“An ounce ofa pre- eye damage (retinopa- vention is worth a thy), foot damage, hear- pound of cure.” pound of cure.” ing impairment, Alzhei- mer’s disease etc. Type 1 Diabetes is an autoimmune disease in which the body does not produce insulin and the immune system destroys insulin-producing beta cells in the pancreas. Type 1 Diabetes is usually diagnosed in children, teenagers and young adults, who need life-long insulin therapy. Globally, there are approximately 78000 new cases diagnosed in young people every year, with many additional meat, broccoli, mushrooms, green beans, brewer’s yeast, beer, cases diagnosed in adults. Beta cells in the pancreas are wrongfully chicken, cereals, eggs, sea food, corn, potatoes, fresh vegetables targeted and killed off by specific antibodies created by the body’s etc. Food rich in Zinc are cashew, pumpkin seeds, immune system. mushrooms, spinach, pomegranate, avocado, banana etc. So, our food habits shall be so matched to accommodate the A1 beta-casein is identified as a major contributor in triggering essential micro-nutrients to prevent the onset of diabetes, as Type 1 Diabetes, as per some studies. Cows of European origin are per one school of thought. the only global source of A1 beta-casein may be as a result of mutation caused some thousands of years ago. A1 beta-casein, on Excessive urination, increased thirst, increased hunger, digestion, releases a peptide (protein fragment) which has opioid blurred vision, unexplained weight loss, excessive urination, fa- and inflammatory characteristics. The protein fragment is called tigue, frequent infections, slow-healing wounds, dry & itchy skin beta-casomorphin-7, causing multiple health issues including Type etc. are the common symptoms of diabetes.

1 Diabetes. Goats, sheep, Asian cattle, buffalo, camels and indeed According to a study done by the University College Dublin in humans produce milk only of the A2 casein, which is not harmful. Ireland, resistant starch, which occurs naturally in foods such as

As per this theory, cow’s milk and dairy products, along with early bananas, potatoes, grains and legumes, may benefit your health cessation of breast feeding, turn to be one of the major reasons for by aiding blood sugar control, supporting gut health and enhanc- onset of juvenile diabetes. Exclusive breastfeeding is widely re- ing satiety. This is a form of starch that is not digested in the small garded as being protective against Type 1 Diabetes in early infancy intestine and is therefore considered a type of dietary fiber. but its benefits may be lost if the mother supplements breast milk with cows’ milk or if the duration of breastfeeding is too short. It is FOOD THAT CAN INDUCE DIABETES also conceivable that some dietary triggers might cross into breast Fatty Foods - Foods high in saturated or trans fats like fatty milk. These factors might contribute to the inconsistencies in the meats, such as organ meats, bacon, pepperoni and salami, greasy reported association between breastfeeding and Type 1 Diabetes. Type 2 Diabetes primarily occurs owing to many reasons in general. Hereditary influences, malnutrition due to Chromium, Magnesium and Zinc in diet, lack of exercise, sedentary life style, It is always advisable to stop usage of stressful life, excess consumption of maida, sugar etc. play pivotal cow milk & dairy products, especially role in the onset of diabetes. So, our life should be modified so as to in infancy. In India too, 90-95% of prevent the disease condition as far as possible. cows are of European genesis. Principal source for Magnesium are whole wheat grains, spinach, dark, leafy greens, almonds, cashews, black beans, whole peanuts etc. Chromium is available in whole grains, brown rice,

TECHAGAPPE JULY-SEPTEMBER 2018 45 Health Tips

foods such as French fries, cheeseburgers, full-fat milk, cheese, “Drink your food eat your water”. This is one of the famous schools packaged and baked foods, fast food and frozen pizza are to be of thought in terms of healthy eating habits, though it is difficult to avoided. follow. This indicates to chew your food in mouth till it becomes liquid so that we can incorporate as much of our saliva with our Refined Grains - Maida containing foods like bread, break- food to mix the amylase present in saliva for better digestion. Foods fast cereals or pasta made with refined white flour need to be that are difficult to digest are particularly in need of extra chewing, eliminated from the diet. White rice should be avoided. Opt for if the food isn’t broken down sufficiently, the stomach acids have to whole-wheat bread and brown rice to reduce your risk of diabe- work harder to break down large chunks of food. If the food hangs tes. around in the hot climate of the gut, food can ferment because of Sugar - Prolonged use of foods that contain added sugar the delay in digestion, which can then become toxic. We should such as soda, cakes, cookies and candy contain a significant hold water in our mouths for a few moments before swallowing. amount of added sugar and increase your trig- Green tea is proposed to be good drink, but without added sugar. lyceride levels. Processed foods, such as Too little sleep or poor condiments, jams and frozen sleep can disrupt your snacks contain large hormones, leading amounts of sugar to increased ap- even if they petite, higher don’t taste par- blood sugar and ticularly sweet. a thicker waist- Besides, if you line. In fact, re- are diabetic, searchers from Netherlands better abstain found that a single night of sleep from alcohol. deprivation can decrease insulin In short, for sensitivity by almost 25 percent. the best outcome, According to a study done by best food choices are the University of Sweden, ginger fruits, vegetables, has potential power to control whole grains, legumes, blood glucose by using muscle and lean cuts of meat. Healthy fats such as avocado, olive oil, fatty cells. The study found that ginger fish, nuts and seeds, may be consumed with careful portion con- extracts could increase the uptake trol. Brown rice is rich in fiber and rich in manganese. Replacing of glucose into muscle cells inde- white rice with brown rice can lower your risk for Type 2 Diabetes pendently of insulin. by 16 percent. This gluten-free grain is relatively high in calories, so sticking with a single serving size is recommended. It is also Being overweight causes in- essential that you follow a diet high in antioxidants, in other words, sulin resistance and makes it difficult for the body to maintain ap- have plenty of fruits like oranges, kiwi, mangoes, strawberries, propriate blood glucose levels. Stress and diabetes don’t mix. A which will help detoxify your pancreas. We should take vegetable minimum of 30 minutes of physical activity is a must for diabetics. juices containing cabbage, carrot, and lettuce on an empty stom- Regular exercise is required for keeping your glucose levels under ach and you should not drink anything for half an hour. Most control. Muscle movement results in the utilization of insulin. Thirty important is that never add sugar to any of these juices. minutes of walk every day will cut your risk of diabetes by one- third. Stress can elevate blood sugar. But you can find relief by Lifestyle modification is the major tool to combat this sitting quietly for 15 minutes, meditating or practicing Yoga. dreaded disease. An important theory propagated globally is, Yoga is again a very effective tool for diabetes. Yoga postures like Ardha Matsyendrasana (half-twist pose) combined with Dhanurasana Regular exercise like walking and swi- (bow pose), Vakrasana (twisted pose), Matsyendrasana (half-spinal twist), Halasana (plough pose), Mayoorasana and Vajrasana squeeze mming can help prevent heart disease, and compress the abdomen and help stimulate the pancreatic secre- lower blood pressure and improve your tions or hormonal secretions. As a result, more insulin is pushed into the system. This rejuvenates the insulin producing beta cells in the cholesterol levels. Break up long periods of pancreas of diabetics suffering from both type 1 and 2. Practicing the sitting and stand or walk while doing things postures in a relaxed manner, without exertion, meditation and breathing techniques help most patients control the triggers or causes like talking on the phone or watching TV. of diabetes. In short, believe and follow the dictum by Benjamin Franklin “An ounce of prevention is worth a pound of cure.”

46 TECHAGAPPE JULY-SEPTEMBER 2018 Cover Story Good Laboratory Practices

GLYCATED HEMOGLOBIN(HbA1c) NEW TRENDS IN TESTING Glucose estimation still has the highest share in the IVD testing. One of the reasons for the high prevalence of uncontrolled diabetes is due to the improper monitoring of blood glucose levels. The recent years have shown a drastic change in the diabetes testing facilities with the introduction of highly affordable POCT systems, especially for the blood glucose.

Sanjaymon K.R., General Manager, AGAPPE.

A study conducted estimates 285 million people worldwide (6.6%) according to time and is highly dependent on any recent food in the age group of 20–79 with diabetes in 2013. India is on the top intake. of the list with 50.8 million adults being prediabetic. Type 2 Diabe- To get a better diagnosis, HbA1c testing is introduced. tes is more prevalent than Type 1 Diabetes due to the lifestyle and Studies show that a reduction in 1% in the HbA1c will reduce dietary habits. The overall prevalence of diabetes was 12% of the the complications by 30 %. Since it is not affected by the re- population aged above 20 years. It is estimated that by the year cent food intake, it is the most preferred tests for diabetes 2030, approximately 80 million people in India will have diabetes. Glucose estimation still has the highest share in the IVD testing. One of the reasons for the high prevalence of uncontrolled diabetes is due to the improper monitoring of blood glucose levels. The recent years have shown a drastic change in the diabetes testing facilities with the introduction of highly affordable POCT systems, especially for the blood glucose. One of the limiting factors for such testing is the fact that the test is specific to the amount of glucose present in blood only at the time of drawing the blood and glucose levels in blood varies widely

TECHAGAPPE JULY-SEPTEMBER 2018 47 Cover Story Good Laboratory Practices

AGAPPE's AGA1c: The HbA1c with a difference

What is the principle used in AGA1c. z AGA1c using monoclonal antibody Latex Enhanced Immunoturbidimetry which is highly specific to A1c method, which measures the ratio of he- Accuracy Guaranteed moglobin A1c that occupy in a total he- z AGA1c highly correlated with moglobin in the whole blood. HPLC method The sample is added to the unsensitiz- Reliable and accurate result ed latex particles, and the surfaces of Guaranteed the latex adsorb total hemoglobin in the z sample. Anti-human HbA1c mouse AGA1c has NGSP Certified Standard- monoclonal antibody complex aggluti- ization using DCCT Reference nates by Anti-mouse IgG goat antibody, Ensured accuracy is measured as a turbidity. z AGA1c has less than 2% CV What makes AGA1c different. Accuracy Guaranteed z AGA1c comes with LEIT method z AGA1c, 4 levels calibrators are For highly sensitive & specific assay provided along with the kit z AGA1c, is a double reagent system Assured result accuracy at no No stability problems extra cost z AGA1c is a Direct measurement of z AGA1c can be done on Semi Auto HbA1c in % & Fully auto analyzers Highly precise & accurate results Can be adapted easily

monitoring. The major methods in Glycohaemoglobin are : skilled technical staff for performing the test. The HbA1c is calculated from the different elutes obtained after the chromatogra- Column Chromatography phy by measuring the absorbance photometrically. Since mul- This method is one of the earlier methods based on the tiple steps are involved, the chances of technical error were high. chromatographic separation of the HbA1c fraction from the Affinity chromatography based POCT systems total Hb. The test is performed manually using chromatography columns and requires more than one hour for performing These systems are cartridge-based analyzers based on the a test. This method requires constant monitoring of the col- affinity chromatography. The total Hb and the glycated Hb frac- umn and has to adhere to multiple steps and also needs highly tions are measured individually and the HbA1c % is calculated

48 TECHAGAPPE JULY-SEPTEMBER 2018 based on a factor. Since the tests are performed based on the cartridge, the cost of testing is very high as compared to the other methods. The control measurement is performed using a specific control cartridge and it is always recommended to run the control cartridge before testing. Some systems have a multistep procedure with the addition of buffer solutions at specific intervals and hence care should be taken to add the buffers exactly on time to have a better result. HPLC systems More than 40% of the HbA1c testing is performed using HPLC platforms. The systems are known for the quality of results and commercial controls are available for quality assurance. There are multiple systems available in this segment - from single platforms to modular systems. These are bigger systems which require more space and also are costly. One of the advantages of these systems systems where the laboratory needs to prepare working re- is primary tube sampling. These systems have bi-directional con- agents for testing and the reagent stability was a concern. To nectivity and can be connected to the LIS/HIS platforms. One of address this issue, two part ready-to-use reagents are intro- the limitations for these of platforms is that, due to its working duced around ten years back. Since the reagents are coming principle, it requires huge workload to have better feasibility. Since up with calibrators and controls, it was very easy to program the cost of the hardware and the recurring costs are quite high, it the tests in chemistry platforms. This segment was revolu- is not affordable for rural laboratories. tionized when highly affordable nephelometry-based semiautomated HbA1c systems are introduced at the begin- IT-based systems ning of this decade. This made the testing popular in the rural Introduction of the immunoturbidimetry reagents altogether segment. Today, cartridge-based nephelometry systems are changed the way HbA1c testing is performed in the laboratory. available in the realm. The test is based on the principle of latex-based agglutination. Except for HPLC platforms, all other HbA1c testing plat- This can be performed in most of the fully-automated and new forms required a manual step for making the haemolysate generation semiautomated systems, which gives it a wide popu- from the whole blood and this increased the TAT when the larity. In the beginning, the reagents are presented in three reagent workload is high. With an increase in the prevalence of diabetes population and increased awareness, the HbA1c testing has increased exponentially. There is a high demand for platforms with primary tube sampling. This coined the idea of automatic haemolysing on board. Today, the new generation fully-automated clinical chemistry systems are available with an automated onboard lysing function where the systems au- URINE DIPSTICK tomatically make the haemolysate from the primary AGAPPE’s Reagent Strips whole blood samples. This helps in sample traceabil- ity, reduces the preanalytical error and also decreases For Urinalysis the TAT of testing. There are systems available with a z Easy To Use - Just dip special function to perform both HbA1c and Glucose from the same primary tube which gives better result and read correlation and also reduces multitube sampling. The z Rapid Results - 60 sec. systems come up with continuous sample loading function to take care of the high workload which the z High Quality - Color Chart laboratories take for the HbA1c testing. These sys- z Designed specifically tems are having inbuilt Quality Control statistics to considering Indian assure the quality of the tests. It is always recommended that the laboratories conditions should upgrade the hardware periodically with new gen- z Shelf Life - 2 years eration combination systems with better algorithms to assure uncompromising accuracy and TAT.

TECHAGAPPE JULY-SEPTEMBER 2018 49 For Accurate And Precise AGA1c -INDIA’S NO. 1 SELLING HbA1c REAGENT Blood Glucose Measurement

HEALTHY LIVING with AGA1c testing once in a month

First double reagent system | LEIT Methodology | Highly correlates with HPLC NGSP certiﬁed reagents | Accurate results | Easy procedure The Gold Standard In Glucose Estimation With HEXOKINASE METHOD

7 Excellent Linearity of 900 mg/dL 7 Fast Reaction, 5 Min incubation 7 One month on board stability 7 High accuracy, CV <2% 7 Provided 2mL Calibrator for along with kit

The hexokinase method developed by the American Association of Clinical Chemistry has been accepted as the reference method for glucose determination.

The Hexokinase method is a two-step reaction. This method has advantages over glucose oxidase method, primarily because fewer substances interference and it uses safer reagents. In the ﬁrst step, hexokinase in the presence of ATP, adds a phosphate to glucose to form Glucose – 6 – Phosphate (G6P).

In the second step, G6P in the presence of NAD and the enzyme Glucose-6- phosphate-dehydrogenase is converted to D-Gluconate-6-phosphate with the production of reduced nicotinamide adenine dinucleotide (NADH).

EXCELLENT SENSITIVITY & SPECIFICITY HIGH LINEARITY

Packs Liquichek - 4 x 125 mL | Mispa Nano/ Mispa Ace - 4 x 35/2 x 18 mL Mispa Clinia - 4 x 50/2 x 30 mL | TBA-25FR - 4 x 35/2 x 19 mL TBA-120FR/ 2000FR - 4 x 100/4 x 28 mL For more details, contact our * Toll Free No: 1800 425 7151 Brand Reach Customer Speaks

100% Satisfaction with Agappe Productoductoduct 1

Ms. Rachana, We are using Mispa i3 of Agappe for the past several years and we are 100% satisfied with the accurate and Lab-in-Charge, Malabar Multispecialty precise results in protein parameters. Agappe’s service, Hospital, support and turnaround time is also quite appreciable. Calicut.

2 Highly RRHighly ecommendable Productsoductsoducts I have been using Agappe AGA1c for the last one year. I run AGA1c in the semi-automated analyzer and I am 100% happy Dr. Semsing Signar about the results. The after-sales support we are experi- MD, Hills Diagnostic encing from them is also appreciable. I do recommend AGA1c Centre, brand to my friends and colleagues in the IVD industry. All Karbi Anglong, the best to the Agappe team. Assam

Accurate Results, Always 3 I have been using Agappe AGA1c for the last 3 years and run AGA1c in both the semi-automated & fully- automated ana- Dr. Akbar Lirani lyzers. The results I get are always accurate. I’m also using MD, C3, C4, Ceruloplasmin in the semi automatic. Agappe offers Medipath appreciable after-sales support also. I would delightfully rec- Pathology, Raipur ommend Agappe products to my peers in the IVD segment.

4 Excellent Quality Product & RRoduct eagentseagentseagents We are using Agappe’s Mispa Nano – Fully automated Ana- lyzer. We also use Agappe’s reagents, which give accurate & Dr. Anjali Mahindru, precise results. We are satisfied with the equipment as well as Sigma reagents, specially AGA1c. I would say quality is excellent. Diagnostic Lab, Jalandhar

52 TECHAGAPPE JULY-SEPTEMBER 2018 LLLong-term and Cordial RRdial elation with Agappe 5 We are proud to say that we are using Agappe reagents for the Sr. Jyothsana, last 20 years. We are very much satisfied with the results. Lourdes Hospital, Agappe’s AGA1c is the best HbA1c available in the market. We Ernakulam are expecting more & more innovative products from Agappe.

6 VVVery TTery rustworrustworrustworthy PrPrthy oductoductoduct Few months back, I have purchased Agappe Mispa Count (Hematology Analyzer) and the equipment is very compact & user-friendly. The results were accurate and I Dr. Renjith Thomas, have no complaints till date. I trust Agappe & Mispa Thomas Clinic, Paravur, Count. Ernakulam

7 PPPerfect and Precise RRecise esultsesultsesults We are using Mispa i3 of Agappe, a much needed ana- Dr. Nayyar Khan lyzer for labs and hospitals focusing on result accu- MD, racy of proteins at all measuring ranges, especially Wellcare Diagnostic the parameters like CRP & RF. Clinic, Thane 8 Commendable Product, PPoduct, erformanceerformanceerformance and PrPrand ompt Service I am using Mispa Ace, the fully automated biochemistry Afsana Hakim, analyser from Agappe Diagnostics Ltd. since one year. The Lab-in-Charge, Glow Vision performance of the machine is excellent for all parameters Diagnostic Center, and also the service is excellent. Pune

TECHAGAPPE JULY-SEPTEMBER 2018 53 Engagements Exhibitions & Conferences MORE PLACES TO KNOW ABOUT US

2018 70th Annual Scientific Meeting & Clinical Lab Expo BETTER HEALTH THROUGH LABORATORY Team Agappe in attendance at MEDLAB ASIA PACIFIC 2018-THE LEADING HEALTHCARE EVENT IN ASIA on 2 - 4 April 2018, Stall No. M31, Singapore. MEDICINE July 29 - August 2, 2018, Agappe’s Booth No: 653 Venue: McCormick Place, Chicago, Illinois. AACC is a global scientific and medical professional organization dedi- cated to clinical laboratory science and its application to healthcare. Their leader- ship in education, advocacy and collaboration helps lab professionals adapt to change and do what they do best: provide vital insight Team Agappe in attendance at MEDICONEX 2018-THE LARGEST MEDICAL EXIBITION and guidance so patients IN NORTH AFRICA on 14 - 16 April 2018, Stall No. J30A, Cairo, Egypt. get the care they need. AACC’s strategic plan set goals for innovation, growth, and influence in five areas: value of mem- bership; best practices; science and innovation; fi- nancial resources; and global influence. As the leading event for laboratory medicine worldwide, the 2018 AACC Annual Meeting & Clinical Lab Expo is the place where breakthrough innovations in clinical testing and patient care are introduced to the healthcare Team Agappe in attendance at EGYMEDICA 2018-THE BIGGEST EXIBITION IN EGYPT world. on 03 - 05 May 2018, Booth No. B4/5, Cairo, Egypt.

54 TECHAGAPPE JULY-SEPTEMBER 2018 Engagements Special Days

JULY 2018 SPECIAL DAYS Jul 01 : Doctor's Day S M T W T F S Jul 05 : World Environment Day 01 02 03 04 05 06 07 Jul 06 : World Zoonoses Day Jul 11 : 08 09 10 11 12 13 14 World Population Day Jul 15 : 15 16 17 18 19 20 21 Plastic Surgery Day Jul 28 : 22 23 24 25 26 27 28 World Hepatitis Day Jul 29 : 29 30 31 International Tiger Day

AUGUST 2018 SPECIAL DAYS

Aug 03 : World Friendship Day S M T W T F S Aug 06 : Hiroshima Day 01 02 03 04 Aug 09 : Nagasaki Day 05 06 07 08 09 10 11 Aug 10 : Organ Donation Day Aug 12 : 12 13 14 15 16 17 18 World Youth Day Aug 13 : 19 20 21 22 23 24 25 World Lefthanders Day Aug 19 : 26 27 28 29 30 31 World Humanitarian Day

SEPTEMBER 2018 SPECIAL DAYS

Sept 08 : World Literacy Day S M T W T F S Sept 10 : Suicide Prevention Day Sept 12 : 30 01 World First Aid Day Sept 16 : 02 03 04 05 06 07 08 World Ozone Day Sept 18 : 09 10 11 12 13 14 15 World Alzheimer's Day Sept 25 : 16 17 18 19 20 21 22 World Maritime Day Sept 28 : World Rabies Day 23 24 25 26 27 28 29 Sept 29 : World Heart Day Promotion New Product RELIABLE RESULT GUARANTEED Moments Awards NATIONAL AWARDS 2018 FOR MISPA-i3

It gives us immense pleasure and pride to inform you that rector & COO of AGAPPE. AGAPPE has been selected as the winner of National Awards The award was delivered in the presence of Dr. Harsh Vardhan, 2018 for the “Indigenous Development of Technology and Honourable Union Minister for S&T and ES and Prof. Ashutosh Commercialisation” of Mispa-i3, the Automated Cartridge Based Sharma, Secretary, Department of Science and Technology. The Specific Protein Analyzer. ceremony was attended by a number of well-known dignitaries The award was organised by the Technology Development from different industry and Higher Government officials. Board, Department of Science and Technology, Govt. of India, in This is really the proudest moment for all AGAPPEANS that connection with the 20th Technology Day on 11th May 2018 at followed to the recognition which we received for Mispa-i2 at Vigyan Bhavan, New Delhi. the Rashtrapati Bhavan in 2015. Our Mispa-i3 has created the The prestigious memento of National Award was presented Historic Landmark in the Indian IVD with its outstanding tech- by Honourable President of India, Shri. Ram Nath Kovind to Mr. nology advantage of testing Specific Protein parameters. Even- Thomas John, Managing Director and Mrs. Meena Thomas, Di- tually, bringing the brand AGAPPE to the heights of IVD Segment.

KERALA STATE POLLUTION CONTROL BOARD AWARDS 2018 Agappe has been awarded by Kerala State Control Board for substantial and sustaining efforts in pollution control and for initiatives in environment protection in 2018. On behalf of Agappe, Mr. Babu Daniel, Vice Presi- dent-System Automation has received award from Sri A.C. Moideen, Co-operation and Tourism Minister, Government of Kerala.

58 TECHAGAPPE JULY-SEPTEMBER 2018 Reward Programme

By signing this form, I confirm that the information provided above is true and that I am fully familiar with and accept the General Business Terms for Privilege Account. I agree that the authorized personnel of Agappe Company may collect and process my personal information, the information about received privileges, collected points, information regarding the privileges used and other Information acquired during my visit to AG privilge website and ACEP mobile application. Also in absence of me I authorize my staff Mr / Mrs. / Miss / …………………………...... to avail benefits of AG Privilege and redeem Reward point's benefits using the registered mobile……………………………..... Number, through AG Privilege Website / AG Privilege mobile application. Also Agappe Diagnostics Ltd undertakes to handle the information in line with the requirements of the Personal Data Protection Act and that it will use them only for marketing reasons. Proprietor Name:...... CONSENT Address...... Scan QR code to download AG Date: Sign & Seal of the owner / proprietor / director Privilege app

Disclaimer submitting the signed copy of the disclaimer. • AG Privilege points are subjected to offer made to Agappe Loyal customers who are either • Agappe diagnostics/Agappe employee will not be in any manner responsible for any claim on purchasing or using existing Agappe reagent as products.AG Privilege offers are not valid on account of claim/Point redeemed or point burnt by lab technicians/distributors, distributor instrument purchase. staff or any other personnel who is not a part of lab or hold any organizational position. Any • Lab must claim points accrued through the program through the redemption process to such act, if it comes to the notice, will be considered as malpractice and the concern exchange the points for reagents. laboratory owner/director or any other official will be informed. • Lab must claim points or rewards only after reaching the redemption level. • Delivery of reagents will be done after conducting and possible due diligence. • Points can be claimed and used for rewards available in the then current program only and by • Agappe require verification of lab identity and account prior to processing your order. authorized personnel of Laboratory. • Government/Semi Government undertakings will not be covered under this program. • Point requirements assigned to any reward are subject to change from time to time without • The Privilege program is not meant for any Agappe staff. notice, and rewards may be substituted at any time. • Jurisdiction: Any dispute arising out of this program shall be subject to the exclusive • The loyalty points can be claimed by the Legal owner of the program and will be done only after jurisdiction of the Courts at Ernakulam, Kerala, India. Kindly fill the form carefully and hand over to Agappe’s staff or post to The Manager-Corporate Communication, Agappe Diagnostics Limited, Agappe Hills, Pattimattom PO, Ernakulam district, Kerala-683562. For more details, contact +91 9349011309.

TECHAGAPPE JULY-SEPTEMBER 2018 59 Editorial Quiz & Feedback

1. Which is not a symptom of diabetes? A. Itchy skin B. Thirst C. Frequent urination D. Muscle pain

2. Type 2 diabetes can cause long-term damage in the functions of...... A. Kidneys B. Eyes C. Nerves D. All of the above

3...... is a condition in which the kidneys are unable to conserve water. Scan QR code A. Diabetes mellitus B. Diabetes insipidus C. Gestational diabetes D. Diabetic coma and participate in the lucky draw 4. Which of these make it more likely for you to get type 2 diabetes? Quiz Answers of A. Obesity B. Race C. Gender D. Age April-June contest. Amazing 2018 Edition. prizes are waiting 5. Diabetes can only be managed with medicine. 1-A, 2-A, 3-D, for the winners. A. True B. False 4-A, 5-B Conditions apply*

Answers of this quiz contest will be published in the next edition along with details of the winner and the prize. Participants can either hand over the answers to Agappe’s staff or send in their responses directly to TechAgappe at techagappe@ agappe.in or post a mail to The Manager-Corporate Communication, Agappe Diagnostics Limited, Agappe Hills, Pattimattom PO, Ernakulam district, Kerala-683562.

What do you think of this edition of Techagappe? Are you happy with the overall look and feel of the magazine? Do you recommend any change of style with regard to presentation of articles? You can share your views with us in the space given below. All you have to do is to post this sheet of paper to the address given below. The best letter shall be featured in the next edition’s letters to the editor section.

......

Name...... Address......

PIN...... Mob...... Mail ID...... Postal address: The Manager - Corporate Communication, Agappe Diagnostics Limited, Agappe Hills, Pattimattom PO, Ernakulam district, Kerala-683562. Email: [email protected] Mob: +91 9349011309 Kindly let us know which section of the magazine you like more... Poem Life Stories Health Tips Cover Stories Good Laboratory Practices Interviews

60 TECHAGAPPE JULY-SEPTEMBER 2018 Why Manual Tube Labeling when you have MISPA LABEL ?

Simple Reliable Label Fast Intelligent Tube Labeling System Accurate Simplied Pre-Analytics Efﬁcient

CORPORATE OFFICE REGISTERED OFFICE GLOBAL ACCESS POINT Agappe Hills, Pattimattom P.O, Dist. Ernakulam, Office No : 401 & 402, 4th Floor, Jaisingh Business AGAPPE DIAGNOSTICS SWITZERLAND GmbH, Kerala - 683 562, India. Tel: +91 484 2867000. Centre, 119, Sahar Road, Parsiwada, Andheri (East), Knonauerstrasse 54 - 6330, Cham - Switzerland Fax: +91 484 2867222; [email protected] Mumbai - 400099, India. Tel : 022-4300 8000, Tel: +41 41 780 60 10 | Fax: +41 41 780 60 11, Branches: Delhi | Bangalore | Kolkatta Fax no: 022 - 4300 8050 | [email protected] [email protected] RNI No.: KERENG/2015/62113 www.agappe.com Toll Free 1800 425 7151

Our Motto Quality Healthcare Worldwide...

Printed and Published by Ms. Meena Thomas on behalf of Agappe Diagnostics Limited and Printed at Five Star Offset Printers, Nettoor, Cochin-40 and published from Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O, Ernakulam district, Kerala-683 562. Editor is Ms. Meena Thomas.

Sharp for accuracy and smooth in procedure open to all and no closed loops bright as future and simple as present