Diabetes in India | A bitter sweet truth

When Rajeev Srinivas discovered he had diabetes in 2013, his first thought was, “This isn’t so bad. I can survive without sweets.” In the past 10 years, the now 52-year-old software engineer from Bengaluru says diabetes has impacted his life far beyond sweets. “I have vision problems, which means I cannot drive after nightfall. There are also early signs of kidney and heart troubles,” he says. Even though Srinivas, who has Type 2 diabetes, is on medication, there have been times when he has cheated on the ‘no added sugar’ mandate. “Even the occasional spoon of sugar in my tea is too much for my body,” he says. The inability to process sudden spikes of sugar has been slowly poisoning his system. There are millions like Srinivas in India, and their numbers are accelerating at an unprecedented pace.India has the highest number of diabetics in the world. In 2020, the International Diabetes Federation estimated around 77 million Indians to have the disease. That figure has risen by nearly 30 million in just three years. A July 2023 study by the Indian Council of Medical Research (ICMR), the Madras Diabetes Research Foundation and the Union health ministry found that 101 million people are living with diabetes; another 136 million people are in pre-diabetes stages (research suggests nearly half of them may have diabetes in the next five years). This means almost a sixth of our population is either diabetic or teetering on its brink. The 12-year-long study, the largest of its kind, used a representative sample of over 113,000 people across 31 states and Union territories. “Diabetes is a growing problem,” says Dr Sunil Kumar Mishra, who is with the endocrinology department at Medanta - The Medicity, Gurugram. “The issue should be taken very seriously.” Both Type 1 and Type 2 diabetes are diseases that affect the way the body regulates blood sugar or glucose. The agent of that crucial function is the essential hormone Insulin, which is made by beta cells in the pancreas, and which moves glucose (which comes from food) in the blood into cells in organs all over the body, where it’s used to generate life-giving energy. Type 2 diabetes is a result of insulin resistance—meaning the cells in muscles, fat, and liver don’t respond well to insulin and can’t absorb glucose from the blood. The extra glucose in the blood stays in the system, resulting in pre-diabetes and then, over time, full-blown diabetes. Too much blood sugar in the bloodstream can affect the heart, kidney and vision. Type 1 diabetes is an autoimmune disease that causes the immune system to attack and destroy beta cells, resulting in the pancreas’s inability to produce insulin. There is no definite cure for Type 1 diabetes, and patients have to take insulin regularly. Type 2 diabetes, which develops over many years and is related to lifestyle issues such obesity and inactivity, can be managed with diet and exercise, though other medication may be required. “The problem with diabetes is that the excess sugar in blood causes almost difficult-to-manage complications like heart attacks, cerebral strokes, kidney failure and infected limbs that have to be amputated. These are a huge burden to individuals and their families, to society and the country,” says Dr B. Sesikaran, former director of the ICMR-National Institute of Nutrition in Hyderabad.Even more concerning is the fact that though diabetes was once projected as a lifestyle disease among well-off urban dwellers, it has insidiously spread to our villages. The ICMR study showed that if the prevalence of diabetes stood at 16.4 per cent of the population in urban India, it was also 8.9 per cent in rural India. Another ICMR study published in the journal Diabetologia in 2011 had found this figure to be 2.7 per cent in rural India. “We are certainly seeing this trend. Cases from rural areas are rising. People come to cities and pick up the urban lifestyle—packaged, convenience food and less exercise. They then take this habit back with them,” says Dr Dheeraj Kapoor, head of endocrinology at the Kokilaben Dhirubhai Ambani Hospital in Mumbai. This is what gave 38-year-old Shibani Kapur’s younger, unemployed brother diabetes. For, every time the Noida-based customer care executive visited her village Ajnauli, near Meerut, she carried boxes of biscuits, sweets, chips and soda. Two years ago, he was diagnosed with diabetes. “Nobody in our family has ever had it,” she says. “Now he has to come to Delhi to get affordable medicine and treatment. Doctors say he has to exercise and cut out all sugar.”A weighty lifestyle problemDue to our long, primordial state as hunter-gatherers, when supply of food was uncertain, the human body evolved a mechanism to save energy from food, through fat, as a reserve during possible scarcity. In our era of mechanised agriculture and refrigeration, humans not only eat well and more, but this store of fat in their bodies is now a main reason for insulin resistance.The impact of fat on insulin resistance is well researched. A 2020 study in the journal Plos One found that an increase in BMI (body mass index) increases the risk of diabetes and pre-diabetes, overweight individuals being at a decidedly higher risk. Another 2020 study in Diabetologia found obesity increases the risk of Type 2 diabetes by at least six times. How does this happen? Abdominal fat usually releases pro-inflammatory chemicals which can make the body less sensitive to the insulin it produces. Too much fat can also cause the pancreas to oversecrete insulin, the consistently high levels becoming another cause for resistance to it. In addition, a diet loaded in simple sugars (food that lacks fibre and whole grain) is quickly digested, leading to a spike in insulin. “Inefficient insulin, an outcome of too much fat in the belly, and reduced storage of excess glucose due to loss of muscle [as a result of inactivity], means extra sugar stays in your blood and, over time, affects blood vessels, leading to multi-organ diabetic complications,” says Dr Sesikaran.“Easy access to eateries and financial well-being leads to the eating of junk food. Our sedentary lifestyle and work-from-home pattern worsens the situation. Excess energy in fat leads to excess calorie accumulation that leads to diabetes,” explains Dr Vidya Tickoo, endocrinologist and diabetologist, Yashoda Hospitals, Hyderabad.Experts feel that reasons for the alarming rise in diabetes in India lie in the growing incidence of obesity. The ICMR study found that 28.6 per cent of the population would count among the obese per the BMI measure and 39.5 per cent of the population, or 351 million people, have abdominal obesity—the most frequent trigger for diabetes. “We have a genetic predisposition towards obesity and diabetes as Asians,” explains Dr Kapoor. “Add to this a sedentary lifestyle and poor diet, and you have a health disaster on your hands.” He emphasises that it isn’t just what you eat, but also how often you eat. “If you are eating calorie-loaded food with no regulation regarding the quantity or quality of calories, you are putting pressure on your body to continuously release insulin,” he adds. Other factors also play a part in the diabetes epidemic—stress, among them. Experts say it increases cortisol levels, which causes blood sugar to spike. Lack of sleep is another contributor. In 2022, a study in the journal Cureus found short sleep duration was linked to insulin resistance. However, it’s the lack of exercise that reduces insulin sensitivity, say experts. “Decreased physical activity due to modern technology and mechanised mobility drastically reduce energy expenditure. This leads to the weakening and loss of our muscles, which are also the storehouses of our excess sugar. Our ancestors physically exerted and burnt excess energy,” explains Dr Sesikaran.Exercising the body and willIf diagnosed in time, pre-diabetics can make lifestyle changes to halt or reverse the progression of diabetes. Unfortunately, the ICMR study showed that only seven per cent of diabetics keep their BP, sugar and cholesterol in check. “Mostly, diabetes in its early stages is asymptomatic. It is picked up only if you do annual blood check-ups. It is a good practice to keep your blood sugar, cholesterol and BP in check, especially if you are overweight and have a family history of diabetes,” says Dr Kapoor. The lifestyle changes that can help prevent diabetes or reverse early signs of insulin resistance start with what we eat (see Gastronomic Shield Against Diabetes). “The answer is simple—going back to our ancient food habits, with less carbohydrates in the form of rice or wheat, more vegetables, salads and fruits,” says Dr Tickoo. Exercise and controlling one’s weight help too. Experts say these should be ingrained from childhood. “Diabetes can be reduced through awareness. People must understand that it is not just about blood sugar being high. Chronic diabetes will lead to heart problems, vision issues, reduction in quality of lifestyle. Knowing the consequences would ensure people take prevention seriously,” says Dr Swamikannu M., director, internal medicine, MGM Healthcare, Chennai. For those who have diabetes or are likely to develop it, the American Diabetes Association (ADA) recommends at least 150 minutes of moderate to vigorous intensity aerobic exercise a week, spread over three days a week, and avoiding more than two consecutive days without activity.Finally, there is consensus that health awareness is vital to reduce our country’s burden of diabetes. “Family, community, schools and educational methods, public transport, walkable roads and municipal facilities, the food and beverage industry, healthcare and insurance, catering and food delivery, workplaces—all play a role in reducing diabetes,” says Dr Sesikaran. Of course, with the unquestioned and unequivocal acceptance that diabetes is fast becoming a catastrophic health problem for India. A silent, predatory killer, it opens the door to multiple diseases, contributes to a high mortality rate, results in a reduced quality of life and causes great economic loss.Edited By: Aditya Mohan WigPublished On: Sep 7, 2023Trending Reel

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