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 Table of Contents  
Year : 2017  |  Volume : 8  |  Issue : 2  |  Page : 58-59

Insulin use on the top of the world

1 Department of Internal Medicine, IGMC, Shimla, Himachal Pradesh, India
2 Bharti Hospital, Karnal, Haryana, India
3 Department of Microbiology, IGMC, Shimla, Himachal Pradesh, India
4 Department of Pharmacology, IGMC, Shimla, Himachal Pradesh, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Jatinder Kumar Mokta
Department of Internal Medicine, IGMC, Shimla - 171 001, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jod.jod_9_17

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How to cite this article:
Mokta JK, Kalra S, Mokta KK, Gulepa R. Insulin use on the top of the world. J Diabetol 2017;8:58-9

How to cite this URL:
Mokta JK, Kalra S, Mokta KK, Gulepa R. Insulin use on the top of the world. J Diabetol [serial online] 2017 [cited 2023 Feb 4];8:58-9. Available from: https://www.journalofdiabetology.org/text.asp?2017/8/2/58/216462

The diabetes pandemic knows no geographical boundaries. Along with modernisation, diabetes has reached the remote Himalayan areas of Lahaul-Spiti (cold desert) and Kinnaur, in the Indian state of Himachal Pradesh, located in the upper region of the Western Himalayas. Inhabited predominantly by the tribal population, this district is located at an altitude of 8000–16,000 feet above sea level. The unique geographic conditions and far and scarce medical service impose great challenges for the management of diabetes in this part of the world. Dietary patterns, which include drinking of copious amounts of liquor, locally distilled from barley, dependence on local non-vegetarian foods and scarce availability of fruits and vegetables, go against routine diabetes diet prescriptions. These tribal areas remain cut-off from rest of the country at least for 3–4 months in the winters with interrupted supply of electricity. People living with diabetes usually seek specialised diabetic care from the state capital, located 250–500 km away (16–24 h drive through one of the most treacherous roads in the world).[1] The challenges posed by diabetes on the top of the world have been addressed innovatively.

Three patients from tribal areas living at an 'altitude' of 9500, 12,000 and 14,500 feet at a distance of 250 and 450 km from the state capital were prescribed insulin for uncontrolled blood glucose.[2] The unique geographic condition of these areas, and peculiar social habits and dietary patterns of the inhabitants, imposes unique challenges for the use of insulin in this part of the world. Besides having the danger of hypoglycaemia, however, the biggest challenge remains how to store insulin in the winter when outside temperature dips to −30°C mostly during midnight and inside temperature of the living room goes up to 40°C–70°C due to constant burning of 'Bukhari' made up of iron. Difficulty in access and storage of insulin creates a need for crafting a locally relevant, improvised solution for the same.[3] In winters, people of these areas wear warm clothes made up of sheep and yolk wool to protect from severe cold. One such unique cloth people wear in the winter is an abdominal binder, which measures 2–3 feet in width and 5–15 feet in length [Figure 1]. Seeing a woman wearing the traditional attire in a hospital, an innovative idea of insulin storage that was 'locally' relevant [4] and easily acceptable struck in mind: 'It was thought to store insulin in multiple layers of abdominal binder, which prevents it from freezing in winter' and was discussed with patients on their follow-up visit. They were advised to wrap the insulin vials and/or pens in 'multiple layers' in the abdominal binder (where the temperature recorded was between 5°C and 10°C) [Figure 1]. The success of this practice was evident from the normal HbA1c values, and the smiles on their faces, when they visit state capital for routine medical consultation. Normally, we think of people living with diabetes at normal altitude, not for those living in the extreme conditions of the world; one like those living 'in the Himalayas' and this improvised method of insulin storage may be of great value for those diabetic patients living at the top of the world.
Figure 1: Multiple layers of abdominal binders (woollen attire) used for storage of insulin

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As the recent cold waves in North America and Europe show, no part of the world is immune to extremes of temperature. Best practice sharing is required between people living with, and caring for, diabetes, in other, similarly inhospitable regions of the world, to help improve the quality of care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Mokta JK, Kalra S. Insulin storage in the upper Himalayas. Rural Remote Health 2014;14:2983.  Back to cited text no. 1
Kalra S, Kalra B. Storage of insulin in rural areas. J Acad Med Sci 2012;2:88-9.  Back to cited text no. 2
Kalra S, Gupta Y. Insulin technique. Sri Lanka J Diabetes Endocrinol Metab 2015;5:85-90.  Back to cited text no. 3
Tandon N, Kalra S, Balhara YP, Baruah MP, Chadha M, Chandalia HB, et al. Forum for injection technique (FIT), India: The Indian recommendations 2.0, for best practice in insulin injection technique, 2015. Indian J Endocrinol Metab 2015;19:317-31.  Back to cited text no. 4


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