Published in IJCP January-March 2023
The Paradox of Plenty: Caution against Complacence
May 01, 2023 | Sanjay Kalra, Jubbin Jacob, Nitin Kapoor
Diabetes & Endocrinology


Diabetes mellitus is a disease of paradoxes. The focus on diabetes prevention has not halted the increasing incidence of new disease. Newer and better drugs for glucose control and cardiovascular protection have neither improved glucose nor cardiovascular outcomes. This brings in focus the concept of “Quadruple of Atreya” which focuses on an educated cooperative patient in addition to the physician, the drug and the caregiver. Another current paradox is the easy availability of information which includes useful, useless and information intentionally designed to misguide. This year’s theme for world diabetes day, “education to protect tomorrow” appreciates this need for patient education today to improve outcomes tomorrow. We are not only urged to educate to improve outcomes but also urged to contest misinformation at its source leading to ‘quinary prevention”. The harvest of these measures at education and preventing misinformation will lead to better outcome tomorrow analogous to the concept of “metabolic karma” wherein today’s actions will have bearing on the future.

Keywords: Quinary prevention of diabetes, World Diabetes Day, diabetes education, metabolic karma, misinformation


Diabetes mellitus is a syndrome of paradoxes. While we invest more and more in preventing diabetes, its incidence is increasing.1 Though we have more and more drugs to manage diabetes, mean glycated hemoglobin (HbA1c) levels remain high. And despite developing multiple cardioprotective drugs, avoidable cardiovascular morbidity and mortality continue to prevail in persons living with diabetes.2

This is the paradox of plenty, mere availability of effective diagnostic, monitoring and therapeutic tools does not ensure effective management of diabetes. Just as a vehicle needs a trained qualified and experienced driver, diabetes care requires persons living with diabetes, and their care providers, to be well-versed in their work.

Education is Empowerment

The first step towards this is education. The concept of education has been present in medicine from time immemorial. The Charaka Samhita describes the Quadruple of Atreya, which includes a cooperative patient as one of the four pillars that uphold therapeutic success.3,4 The other three members of the ‘therapeutic quadriga’ are the physician, the drug, and the patient’s sattendant (caregiver).

Challenges are Plentiful

This, however, is easier said than done. The paradox of plenty comes back to haunt us, yet again. The number of stakeholders in diabetes care is rising, and rightfully so. The complexity of diabetes management has increased and so has the knowledge required to use available medication in a safe and smart manner. Proliferation of social media and other communication channels has increased the spread of information, and misinformation simultaneously.5

The Theme

The theme for World Diabetes Day, 2022, acknowledges and appreciates this need for education. “Education to protect tomorrow’s”6 underscores the need for person-centred therapeutic education, the necessity of quinary prevention, and the novelty of metabolic karma.

Person Centred Care

Modern medicine uses the phrases person centred care ‘or’ patient centred care’, along with ‘therapeutic patient education’, to describe the importance of educating and involving persons living with diabetes regarding their self-care and management.7,8 Person centred therapeutic education empowers the person living with diabetes to take optimal care of oneself, and protect oneself against avoidable complication.

Metabolic Karma

The phenomenon of glycemic legacy or metabolic memory has been documented in various long-term trials, the most recent being the 44 year long follow-up of the UKPDS (United Kingdom Prevention of Diabetes Study).9 This finds resonance with Asian philosophy, which describes the occurrence of ‘karma’ (Sanskrit/Hindi) or ‘vipaka’ (Sinhala) as past, present and future actions, all of which have a bearing on each other.10 This is true in diabetes education as well, what one learns today influences one’s tomorrow as well, hence, today’s education protects tomorrow’s health.

Quinary Prevention

The ease of communication that we enjoy, thanks to various social media and e-based messaging, has opened up another paradox of plenty. While the flow of information has certainly eased, so has the spread of misinformation. Fake news appears to fly at the velocity of light.

Inaccurate knowledge can harm health in general, and diabetes care in particular. Quinary prevention, a construct beyond primary secondary tertiary and quaternary levels of prevention, calls for preventing misinformation, and promoting the right education, as a part of health care delivery.11 There is no room for complacence: we need to keep working to ensure that we protect the today, as well as tomorrow, of our fellow citizens.

Editorial Policy

At the Asian Journal of Diabetology, we endeavor to educate, to empower, to enrich. Through insightful editorials, original research articles, interesting case series/reports, and comprehensive reviews, we share meaningful knowledge about diabetes, so that it can be disseminated to other health care professionals, through them, we hope to reach all persons living with diabetes, and protect them from the complications of diabetes.


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