Telemedicine Detects Diabetes, Complications in Rural Areas

LISBON — A telemedicine program in remote areas of India enabled screening for diabetes and its complications and could be used as a model in other parts of the world, new findings suggest.

Data from the Telemedicine Project for Screening Diabetes and Its Complications in Rural Tamil Nadu (TREND) study, conducted in 30 rural Indian villages during 2018-2021, were presented at the International Diabetes Federation (IDF) 2022 Congress by Rajendra Prabhu Guha Pradeepa, PhD.

The program identified high prevalences of undiagnosed diabetes and diabetes complications among people with known and newly diagnosed disease. The results underscore the need for systematic screening and awareness programs in remote rural areas, said Pradeepa, executive scientific officer and head of the Department of Research Operations & Diabetes Complications at Madras Diabetes Research Foundation, Chennai, India.

"Telemedicine is a promising strategy to make affordable and accessible diabetic complications screening available in remote rural areas," she said during her presentation.

The TREND model could be adapted for use in other rural parts of the world, Pradeepa told Medscape Medical News. "This is feasible in other countries, even developed countries. The cost of setting it up is less now compared to what it used to be," she said, noting that's in large part because satellite connectivity is no longer necessary in the age of global internet connectivity.

"The technology is simple — just the equipment in the van. With internet connectivity, we can connect from rural to urban centers where the specialists are available. Through telecommunication you can do that."

Asked to comment, session moderator Carlene Radix, MD, head of the Human and Social Division at the Organization of Eastern Caribbean States, Castries, Saint Lucia, agreed.

"Not only do I think it's feasible, I think it's necessary in other parts of the world. COVID-19 really exposed the fact that [telemedicine] can be done in places where there may have been the feeling that it can't be done. That's something we repeat in medicine all the time with new technology. We feel like things can't be done in low-resource settings when they can," he told Medscape Medical News.

Radix added that the rapidly growing incidence of diabetes in the developing world necessitates proactive measures. "If the systems aren't reaching out there's going to be a lot of undiagnosed diabetes. I think that's what this is reflecting."

A telemedicine program in remote areas of India enabled diabetes screening.

High Rates of Undiagnosed Diabetes and Complications Revealed

The TREND project is a collaboration between the Madras Diabetes Research Foundation in Chennai and the University of Dundee, Scotland.

Diabetes is increasing in both urban and rural areas of India, but there's an imbalance in service delivery. Currently, about 28% of the country's population lives in urban areas, where about 34 million people have diabetes. The majority, 72%, live in rural areas, where about 43 million have diabetes.

However, 75% of qualified diabetes specialists practice in urban areas, Pradeepa explained.

In addition to the lack of specialists, other challenges to rural diabetes care include poverty, low literacy, and lack of transportation to enable access to specialist facilities.

Thus, the TREND project was developed to screen for diabetes, both via in-person questionnaire and laboratory testing, and to screen for complications remotely via telemedicine. Retinopathy was assessed with retinal color photography using a "fundus on phone camera." Neuropathy screening was done using biothesiometry, coronary artery disease via electrocardiogram, and peripheral vascular disease via Doppler.

Trained village residents assisted with using the equipment, which was brought to each of the sites in vans. Venous blood samples were obtained from 14,117 adults aged 18 and older. Of those, 13.7% had diabetes, including 9.7% by self-report and 4.0% newly diagnosed.

The overall group with diabetes were a mean age of 53 years. They had a mean body mass index (BMI) of 25.3 kg/m² and blood pressure of 134/82 mmHg. Mean fasting blood glucose was 96 mg/dL, but notably, the 2-hour oral glucose tolerance test value was 293 mg/dL. Mean A1c among those with self-reported diabetes was 9.0%.

Of the 1426 participants with self-reported diabetes, only 25.3% had an A1c < 7%, 29.8% had an A1c of 7%-8.9%, and 44.9% had an A1c ≥ 9%.

Overall, 12.8% had retinopathy, 39.3% had microalbuminuria, 4.3% had macroalbuminuria, 38.0% had neuropathy, 11.4% had coronary artery disease (CAD), and 10.2% had peripheral vascular disease (PVD).

Among those with newly diagnosed diabetes, 5.8% had retinopathy, 38.7% had microalbuminuria, 1.3% had macroalbuminuria, 27.3% had neuropathy, 10.9% had CAD, and 9.7% had PVD.

"Those with newly diagnosed diabetes also have a high prevalence of complications, underscoring the need for systematic screening and awareness programs," Pradeepa said.

Comparing individuals with A1c levels ≥ 7% or < 7%, the prevalence was significantly higher for retinopathy (14.8% vs 3.2%; P < .05), microalbuminuria (41.3% vs 25.2%; P < .05), and macroalbuminuria (5.7% vs 3%; P < .05). The differences weren't significant for neuropathy, PVD, or CAD.

There was also an increasing trend for complications with diabetes duration. At 10 years or more, 56.1% had neuropathy and 26% had retinopathy, including 3.7% with proliferative retinopathy.

Van used for the TREND study.

Radix told Medscape Medical News: "We're diagnosing late because we're not reaching the population, and the numbers are going up. So, where we thought there wasn't diabetes before now there is...so that's reflected in the complications...It's really showing the need for systems to reach out."

The team has now established a diabetes center in one of the rural villages and people identified with diabetes in the study are being brought back for either low-cost or free care. A future follow-up study is planned, Pradeepa said.

TREND is funded by the UK National Institute for Health and Care Research. Pradeepa and Radix have reported no relevant financial relationships.

IDF 2022 Congress. Presented December 7, 2022.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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