"Who will marry my daughter who has diabetes?" asks Ram Anuj, a native of Ganga Jamuni village, situated in the Bahraich district of the Nothern Indian State of Uttar Pradesh in India. Ram Anuj's 14 years old daughter Munni (name changed) has type 1 diabetes and needs daily insulin injections.

The family members stopped sending Munni to school when other children began making fun of Munni when she took her insulin. In a village-setting, giving insulin injections to Munni, is a public knowledge. Munni often gets scorned for being a burden on the family. Munni's family doesn't have enough money to take adequate care of her and provide the treatment she needs.

Stigma-related to diabetes, is particularly more pronounced for girls. Stigma, in response to illness, is not a new issue in some parts of the world. It has long been associated with mental illness, physical disability, leprosy, cancer and tuberculosis. However, diabetes-related stigma is particularly severe as diabetes is a life-threatening chronic condition. Stigma is particularly complex as it operates at many different levels and has both social and psychological aspects. Diabetes-related stigma at the workplace or in the community and self-stigma has adverse impact on the mental health and feeling of wellness of people with diabetes.

Primary definitions of stigma usually refer to Irving Goffman (1963) whose text provides seminal critique: "Stigma can be seen as an attribute that discredits the individual, denying full social acceptance, and where notions of social inclusion and exclusion are firmly brought to the fore."

There are many factors surrounding stigma including denial, shame, blame, fear, rejection and discrimination. For any child or adolescent living with diabetes, learning to cope with it is often a daunting task.

Dealing with a chronic illness such as diabetes may cause emotional and behavioral challenges, at times, leading to depression. The need for high-quality counseling sessions, for people with diabetes and their family members, is paramount at the diabetes care and treatment centres, which may eventually help combat stigma. It may also help them to adjust to the lifestyle changes needed to stay healthy.

"Counseling and emphasizing that diabetes is not a disease but a metabolic condition and every person with diabetes should be referred to as a 'person with diabetes' and not a 'diabetic patient' will go a long way in reducing the diabetes-related stigma" stresses Dr Sharad Pendsey, a noted expert on diabetes, who runs a charitable trust - Diabetes Research Education And Management Trust (DREAM Trust, www.dreamtrust.org) in New Delhi. This trust provides free insulin, syringes, blood glucose monitoring strips and complete healthcare to the poor children with Type-1 diabetes. "Our centre has an education wing where diabetes educators regularly conduct educational classes, one to one counseling with patient and the family members. We have counselors at our centre and we have noticed a remarkable change in reducing diabetes related stigma" shares Dr Pendsey.

In addition, lack of skilled healthcare staff, apart from the treating diabetes physician, exacerbates the situation. There are not enough nurse educators, diabetes counselors, nutritionists, podiatrists (foot experts) and other health educators to help raise awareness and understanding of unique care and treatment needs of people with diabetes in society. This not only fuels the diabetes-related stigma (read burden) but also reduces the quality of healthcare for people with diabetes. The treating physician is usually single-handedly dealing with all the different responsibilities of being a counselor, educator, doctor, nutritionist, podiatrist, to name a few. "The patients' inability/ unwillingness to pay for this additional support also hinders the treatment" says Dr Surendra Khanna, a Physician at Diabetes Centre in Kanpur.