Bitter sweet

India, the diabetic capital of the world, is struggling with the effects of a Western-influenced lifestyle, as rural and urban areas continue to overlap.
Image used for representational purpose.
Image used for representational purpose.

It came as a shock. There she was, a keen sportsperson throughout her childhood and teenage years, with a body that could absorb all kinds of junk food and the juice to party late into the night; any time she gained a few kilos, she could melt them away with a week at the gym. This was in her 20s. In the second trimester of her first pregnancy, at age 31, Aanchal Gupta was told by her doctor that she had severe gestational diabetes—a kind of high blood sugar affecting pregnant women.

As with most women with the condition, Gupta had no symptoms. Currently in the ninth month, mere days away from delivery, she is being strictly monitored by doctors. She has to check her blood sugar levels by pricking herself four or more times a day (in the mornings and after every meal) and medicate to keep her levels within the healthy range. She realised the severity of her condition only after she was rushed to the hospital, with complaints of a persistent stomach ache.

The doctors worried that the baby would come early a common occurrence in cases of patients with gestational diabetes. “It’s been overwhelming,” says Gupta, adding, “I have always considered myself fit and never imagined such a thing would happen to me.” India is having a blood sugar crisis; between 2019 and 2021, 31 million Indians became diabetic. A recent study, ‘Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17)’, conducted by the Madras Diabetes Research Foundation in collaboration with the Health Ministry and the Indian Council of Medical Research (ICMR), and published in the journal Lancet, showed that over 101 million Indians suffer from diabetes (11.4 per cent of the population), and another 136 million from prediabetes. Lifestyle problems are also on the rise, as evident from the fact that 35.5 per cent of the population suffers from hypertension, and 28.6 per cent from generalised obesity. 

The sad truth is that a large number of people don’t even know they have diabetes till it’s quite advanced. Srimoy Talukdar, a 65-year-old professor who lives in a leafy enclave in Hauz Khas, Delhi, had a moderate lifestyle till his 40s—a weekend drink or two, eating out twice a month, and an evening walk after dinner. But after his 43rd birthday party, he woke up more tired than usual. His wife too had been complaining that he had become moody and irritable. His mother worried he was becoming too thin. When shaving cuts took longer to heal, a worried Talukdar consulted their family physician who advised a health check-up. The blood work showed he had Type 1 diabetes. By the time he was 50, one of his toes had to be amputated.

In Gupta’s case, she was shocked, but not surprised. “My mother has been suffering from Type 2 diabetes for the last 25 years. It affected her kidneys and required a transplant about 10 years ago. I’ve always known that the disease might come for me too. Now I’m concerned that it may also affect my child,” she says. Type 1 happens when the pancreas of the patient stops producing insulin. With Type 2, the insulin production capacity of the pancreas reduces, and the body becomes resistant to insulin. Of the two, Type 1 is more dangerous since it has no other treatment than insulin doses. Medication, diet, weight management and, after middle age, calibrated insulin shots can keep Type 2 under control. Scientists believe that hormonal changes in pregnancy, genetics and lifestyle are the factors behind gestational diabetes.

In recent decades, diabetes has become the most prevalent lifestyle disease in South Asia, and in particular India where Type 2 is most common: some 77 million people have it. “Indians have a different body composition with higher fat content and a greater genetic predisposition for the disease, compared to the Western population,” says Dr. Aasim Maldar, consultant, Department of Endocrinology at the PD Hinduja Hospital and Medical Research Centre in Mumbai. “So, we tend to develop diabetes at a lower body mass index (BMI) at a younger age vis-a-vis the rest of the global population.” In 2022, a National Non-Communicable Disease Monitoring Survey noted that the diabetes rate was over two times higher in urban India, and affects women more than men. 

An Epidemic in Making

The diabetes epidemic is one of the unwelcome changes in India after liberalisation when the markets opened up. New employment opportunities created a number of radial jobs, and youth began to migrate from rural India to the cities, making them bloat at the seams. Infrastructure expansion also created more types of employment, and support systems to feed the urban beast. Indians travelled abroad in large numbers as wealth increased—the average wealth per adult in India was at $14,252 in 2020 compared to $2,600 over 20 years ago. The health industry and alternative healing boomed, and every place, from the smallest hick town in the hinterland to a glittering cosmopolis, began to sprout gyms. But Indians are eating, drinking and lounging more than they are exercising: statistics show that only about 50 lakh or 0.3 per cent of the population works out regularly, while 93 per cent of children dig into packaged food more than once a week.

Dr Sweta Budyal, consultant, diabetology and endocrinology, at Fortis Hospital in Mulund, Mumbai, says, “Indians are genetically prone to develop diabetes, but the problem has been exacerbated over the last three decades with lifestyle changes from factors like urbanisation, globalisation of the food market, increased consumption of calorie-dense food and the tendency to eat out.” But it is not just overweight people who are at risk. Tejpal Singh, a 55-year-old legal clerk from Delhi, whose thin, wiry frame hardly fits the profile of a diabetic, was diagnosed with it five years ago. “I don’t eat out except the court canteen food once in a while, and I don’t drink or smoke. My doctor tells me I got the disease because I don’t exercise, but how do I find the time for it? I’m on my feet all day and too tired to do anything else,” he says.

Experts agree that increased intake of processed foods fast-tracks diabetes in people. Nestle, the largest food company in the world, which makes chocolates, dairy, coffee and instant noodles Maggi, admitted recently that more than 60 per cent of its products are unhealthy. Then there is the couch potato syndrome that has become synonymous with evening leisure: have Netflix, will watch. “The demographic changes caused as India’s population ages may be behind the diabetes expansion; the risk increases with age. Stress plays a major role,” says Dr Anusha Nadig, associate consultant, of endocrinology, at Fortis Hospital in Bengaluru. But what changed the scenario in India, and even across the world, was the pandemic. Lifestyles changed: Zomato became a buzzword and how many times can you shake your butt on Tiffany Roth’s instructions on YouTube? Dr Budyal says, “As a result of spending more time at home, the percentage of overweight and obese individuals increased not only in adults but also in children.

We call this the ‘seed and soil theory’. The presence of predisposed genes (soil) and unhealthy lifestyle (seed) have led to Type 2 diabetes reaching epidemic proportions in India.” Scientists have found nutritional deficiencies to be one of the underlying causes of lifestyle diseases. Amarpreet Singh Anand, founder and CEO of Superfoods Valley, a nutrition and food-tech company based in Bengaluru, explains, “The modern health issues afflicting our society are entwined with nutritional deficiencies such as the shortage of Vitamin D. We must give priority to awareness and access to nutrient-rich foods if we are to close the gap between nutrition and disease.”

Genetics gets the worst press. The condition runs in the family of Delhi-based writer and blogger Prerna Wahi. Her father was diagnosed with it 23 years ago when he was in his 40s. Her mother, who followed a healthier regime with a balanced diet and exercise, was also diagnosed with high blood sugar 10 years ago. Her mother-in-law has it too. Now the writer and her husband, both in their 40s, have discovered they are pre-diabetic. Wahi shares, “I’m aware that I’m at high risk. I go for regular check-ups and monitor my diet.  I walk daily. I have reduced my sugar intake.” She is, however, concerned about her 11-year-old son’s health. “We try to give him a balanced diet and encourage lots of exercise. Restricting sugar or specific food items can be tricky at his age, but he leads an active lifestyle,” she says.

Unfortunately, sugar substitutes have side effects. World Health Organization recently cautioned that artificial sweeteners could cause cancer. Sugar alcohols are the new sugar: manufacturers use it to sweeten foods and beverages. Research says the approved sugar alcohols in the US in foods and beverages are generally safe, and can even be healthy alternatives. Dr Tushar Tayal, consultant, of internal medicine at CK Birla Hospital in Gurugram, calls for a major overhaul in lifestyle. Apart from cardio activity for at least 30 minutes daily, he recommends practising pranayama and yoga to reduce stress, sticking to proper meal timings and eating three balanced meals a day, along with daily consumption of fruits. “Lastly, ensure that you get seven-eight hours of sleep every day,” he says.

Sheetal Ruparel Somaiya, a certified diabetes educator and FODMAP dietician based in Bengaluru, highlights that diabetics require dedication and a proactive approach in managing their health. “The first thing to do is to ‘Cut the CRAP’—C- carbonated beverages, R- refined sugar, A- artificial sweeteners and colours, and P- processed foods,” she says, adding that it is important to feel nourished from within to aid digestion. A focus on improving gut health with probiotics and prebiotics allows maximum absorption of nutrients. In this regard, clean, plant-based foods should be included along with whole grains, millet, pulses, sprouts, nuts, fruits and vegetables. “The trick is in how you eat. Start with fibre, followed by protein and then carbohydrates,” she advises.

The impact of diabetes has bizarre consequences in some cases. Seema Goswami, a 42-year-old entrepreneur, was keen on trying dermal fillers to combat the effects of middle age like fine lines and wrinkles on her face. Since she was a severe diabetic, Dr Ishan Sardesai, an aesthetic surgeon at Delhi-based The Face Centre, advised her against it. He says, “Among diabetics, wounds don’t heal so fast and immunity levels are lower. Therefore, there is a greater chance of infection. It is important to ensure that their sugar levels are controlled prior to any treatment.” 

A Rural-Urban Divide?

Migration has played its part in India’s diabetes growth. Satya Kumari, who was already suffering from Type 2 diabetes, moved to Kolkata from her village to work as a domestic help. Her condition was discovered a few months into her job when she fainted while shopping for groceries. She was put on strict medication and told to follow a healthy diet. “The doctor has told me to stop eating rice, but that’s impossible. What will I eat then?” she laments.

Surprisingly, rural India has a serious diabetes problem with a 0.4 per cent share of the population in 1972 growing to 19 per cent in 2015-2019. Being unaware of the disease, and consequently negligent, is common. Among states, Goa leads the sugar rush with 26.4 per cent of its population being diabetic, followed by Kerala, Tamil Nadu, Puducherry and Punjab. The ICMR-INDIAB study notes, “The diabetes epidemic is in transition in India, with some states having already peaked while others are still in the early take-off stage.” South India is Diabetes Central compared to North India because its citizens mostly eat white rice, which has a high glycemic index. Kanji, a rice porridge, is believed to have strengthening properties and spikes blood sugar levels because of the starch.

The Lancet indicates that all metabolic non-communicable diseases except prediabetes are more frequent in urban than rural areas. Based on their study of 1,13,043 individuals (79,506 from rural areas and 33,537 from urban areas) between 2008 and 2020, experts worry that this will change if things continue as they are at present. Maybe the change has begun, since countryside populations have a 16 per cent higher prevalence of T2 diabetes, with 20 per cent higher diabetes-related hospital mortality. 
The condition is largely associated with wealthy urbanites, but surprisingly, rural Indians have higher rates of obesity, making them more vulnerable. Research on rural obesity, however, is thin compared to people in cities. 

A paper in World Development, a multi-disciplinary international journal, recorded that rural obesity has risen in proportion to an increase in rural per capita income driven by the growth of small towns. Good roads and transportation have improved access to markets for farmers; the downside is the influx of targeted consumer products. The authors write, “Overall, we find that an increase in rural obesity is linked to the nature of rural transformation. As the distance to nearby towns from the villages has reduced, urban proximity not only leads to improved livelihoods, but also a change in dietary practices and access to processed food.” In another paper in the Science Direct journal, researchers juxtaposed the rural sample of India’s latest National Family Health Survey (2015-16) with estimates for town distance from the village clusters. 

A reduction of just an additional kilometre increased the risk of obesity among women by 0.06 per cent; for every such kilometre, 3,000 rural women are at risk for obesity and the risk has gone up disproportionately among the lower socio-economic classes. “Rapid urbanisation leads to a shift from traditional diets to westernised diets which are high in processed food, added sugars and unhealthy fats. Also, Indians tend to consume higher calorie diets that include rice and sweets,” says Dr Nadig. In rural India, there hardly exists any nutrition education programme or obesity prevention and weight management services. As rural spaces shrink, children become less physically active in school sports or events. As of 2021, only 33 per cent of the total health workers and 27 per cent of doctors work in rural areas where about two-thirds of the country’s population resides. Only 30 per cent of hospitals are in rural India, and those too are poorly equipped while the private ones are too expensive. Moreover, the majority of the 1,00,000 diagnostic laboratories in India are based in towns or Tier-I cities.

Battling the Pandemic

The war on diabetes must be waged across many parameters. According to Dr. Sardesai, “If a person is diagnosed, a detailed systemic evaluation is essential. Diabetic retinopathy and neuropathy should be ruled out. Regular follow-ups are important.” Dr Tayal, meanwhile, is for catching them early. Dr Maldar also deplores the habit of ‘yo-yo dieting’ or seeking quick weight loss, since these short-cut methods make treating diabetes difficult in the long run. “State governments should make provisions to provide diabetes education to patients and children and make provisions for updated diabetes training of doctors and healthcare providers,” says Dr Maldar.

Meanwhile, researchers at the RIKEN Center for Integrative Medical Sciences in Japan have discovered a type of gut bacteria named Alistipes indistinctus that could help protect against Type 2 diabetes by improving insulin resistance. The gut is a miraculous organ; a proof-of-concept study by medical researchers at the University of California San Diego School of Medicine reports that transgenes—a gene that is artificially introduced into the genome of another organism—found in the gut can reverse Type 2 diabetes. New research, which will be presented in October at the Annual Meeting of the European Association for the Study of Diabetes (EASD) in Hamburg, reveals that taking a daily low dose (100 mg) of aspirin gives adults, aged 65 years and older, a 15 per cent chance of lowering the risk of developing T2 diabetes. Then there are risks. The World Journal of Diabetes speaks about ongoing research to understand the relationship between diabetes and vitamin B12. It has been found that people with Type 2 diabetes who take metformin can get vitamin B12 deficiency—the longer the duration of treatment, the lower the B12 levels. The American Diabetes Association has recommended B12 supplements while taking metformin.

Diabetes, which affects around 463 million people worldwide, goes by the deadly moniker: The Silent Killer. This is because most patients show no symptoms in the beginning or fail to recognise the early signs. The solution to keep sugar levels in control is constant monitoring. This is the year of wearable wellness devices, and companies are incorporating glucose monitoring in their software. Abbott Laboratories, which manufactures Freestyle Libre CGMs (continuous glucose monitors), introduced a new consumer interface device last year called Lingo for those without diabetes to track their glucose, ketones, lactate and alcohol levels on their smartphone. It is currently available only in the UK. Abbott’s competitor in the CGM space, Dexcom, is developing a new CGM for T2 diabetics, who don’t take insulin. CGMs work by monitoring glucose levels in real-time using a round white sensor attached to the skin of the upper arm, five millimetres deep. The microfilament in it accesses the wearer’s interstitial fluid to measure glucose. The collected data is then delivered to an app, with daily, weekly and monthly trends that are interpreted so that the doctor/dietician can make changes in diet, exercise, lifestyle and sleep.

Preliminary research conducted at Amsterdam University Medical Center has found that controlled electrical charges administered to the duodenum, the initial segment of the small intestine, could be a one-time outpatient endoscopic procedure to treat Type 2 patients, potentially enabling them to get off insulin. Indian medical startups too are using AI in diabetic treatment. Aarca Research uses infrared thermal imaging of a patient’s face to identify diabetes biomarkers using Intelligent Health Risk Assessment technology. Artelus claims to prevent diabetic retinopathy, which causes gradual blindness.

Shot in the Arm

With patents and approvals taking too long, caregivers and patients have created an international Do-It-Yourself (DIY) community that shares tips, and advice, offers help and even identifies software bugs. When they first started, they identified limitations in sophisticated technology such as insulin pumps and CGMs because the data had to be read personally, and diet and exercise managed accordingly to calculate the appropriate insulin dose. What was needed was an algorithm to analyse glucose information and programme the pump. In February 2015, they found one—Nightscout, a piece of open-source DIY hardware and software to ‘hack’ CGMs, which sends data over the internet rather than to a device close by. It was created by Milas Kozak, the father of a girl with Type 1 diabetes so that he and other such parents can keep track of their children’s sugar levels remotely and in real-time: DIYers call this ‘looping’.

Since then, the DIY movement has picked up. More sophisticated tools that allow them to take control of their treatment are being created by DIY users under the motto #WeAreNotWaiting. Kozak developed Android APS, an algorithm that automatically adjusts the amount of insulin the user needs to maintain optimal blood sugar levels. It runs on any Android smartphone, with the sensor and pump connected through Bluetooth. Imagine an artificial pancreas that can react to blood sugar levels like a healthy pancreas does, and you get the idea. DIYers are an open and connected society, ready to give helpful advice. There are online forums and developers are prompt to examine complaints about a bug in a software. In 2016, Pete Schwamb, developer of DIY diabetes systems, reverse-engineered a sensor and pump system called Omnipod. He wanted his daughter to use an insulin pump during her gymnastics classes.

Currently, Kozak is developing the next version of the Android APS software, which will incorporate a new feature that automatically reads the patient’s location and takes action. When the system detects the child at school, it sets the school profile. When he or she is back home, the home profile automatically activates. Intarcia Therapeutics Inc. developed ITCA 650, an implantable matchstick-sized device for treating Type 2 diabetes. It delivers its drug payload over a long period of time after it is implanted in the body—twice a year. There is no dearth of diabetes research: a University of Octagon study found that the dahlia flower is useful to combat the disease—its petal extracts can help the body stabilise blood sugar levels through an anti-inflammatory plant molecule that uses the brain to boost the body’s power to regulate blood sugar levels. 

The plant itself has two other molecules that can supercharge the original molecule to stop brain inflammation and boost blood sugar regulation. Recently, new research published in 
The Journal of Clinical Investigation zeroed in on adenine, a metabolite produced by the kidney to predict kidney disease in diabetics. The Lancet’s report seems to have evoked a response from the Health Ministry. It recently promised to screen and provide standard care for 75 million people with hypertension and diabetes by 2025 through primary health centres, under its ‘75/25’ initiative; training 40,000 primary healthcare medical officers through the Sashakt Portal is also on the drawing board. The operational guidelines of the ‘National Programme for Prevention and Control of Non-Communicable Diseases’ are being reversed. Nutritionist Somaiya summarises the disease by saying, “Beating diabetes is like balancing on a chair. The four legs you need to stand on to beat diabetes are nutrition, lifestyle, medication and regular follow-ups with your doctor and dietitian. Each leg is equally important.” There are no sweet dreams in diabetes. 

Causes of Concern

● Genetic predisposition among Indians for diabetes
● Lifestyle changes due to urbanisation, increase in per capita income and increased consumption of calorie-dense food
● Rise in sedentary lifestyles
● Work-from-home culture that doesn’t encourage exercise
● Excessive indulgence in smoking and alcohol
● Exposure to environmental pollution
● Change in demographics with a greater ageing population
● Increasing reliance on machines and technology for basic tasks
● Stress
● Nutritional deficiencies such as low vitamin D levels

How to Counter the Effects and Live a Healthy Life

● You are not what you eat, but what you digest. Focus 
on your gut health with probiotics and prebiotics every day to ensure maximum absorption of nutrients from the food you eat.
● Choose clean, wholesome, plant-based foods for every meal with whole grains, millet, pulses, sprouts, nuts, fruits and vegetables
● The trick is how you eat. Start with fibre, followed by protein and then carbohydrates in a meal. This is the key to balance your blood sugars.
● Always eat in a calm environment away from gadgets
● Exercise daily for 30 to 60 minutes
● Regularly monitor your blood sugar along with taking regular medication
● Rule out diabetic neuropathy and retinopathy
● Learn ways to manage stress, and maintain regular sleep timings 

What is Diabetes  

Diabetes is a chronic (long-lasting) health condition that affects how your body turns food into energy. Your body breaks down most of the food you eat into sugar (glucose) and releases it into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body’s cells for use as energy. With diabetes, your body doesn’t make enough insulin or can’t use it as well. When there isn’t enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. It can cause problems, such as heart disease, vision loss 
and kidney disease.

(According to Centers for Disease Control and Prevention USA)

  • Urban regions had higher rates of all metabolic NCDs than rural areas, with the exception of pre-diabetes.
  • In 2021, 315 million people had high blood pressure, 254 million had generalised obesity, and 351 million had abdominal obesity. Additionally, 213 million people had hypercholesterolaemia and 185 million had high LDL cholesterol.
  • Goa, Sikkim, Punjab, Puducherry and Kerala had the highest prevalence of non-communicable diseases (NCDs) like generalised and abdominal obesity.
  • Urban regions had higher rates of all metabolic NCDs than rural areas, with the exception of pre-diabetes.
  • The proportion of deaths due to NCDs (cardiovascular diseases, cancers, chronic respiratory diseases and diabetes) has increased from 37.9 per cent in 1990 to 61.8 per cent in 2016 in India.

From the doctors

“Indians have a different body composition with higher fat content for similar weight and a greater genetic predisposition for diabetes, compared to the Western population.”

Dr Aasim Maldar, consultant, Department of Endocrinology, PD Hinduja Hospital and Medical Research Centre, Mumbai

“We call this the ‘seed and soil theory’. The presence of predisposed genes (soil) and unhealthy lifestyle (seed) have led to T2 diabetes reaching epidemic proportions.” 

Dr Sweta Budyal, consultant, diabetology and endocrinology, Fortis Hospital, Mulund, Mumbai

“Rapid urbanisation leads to a shift to westernised diets, which are high in processed food, added sugars and unhealthy fats. Also, Indians tend to consume higher calorie diets.” 

Dr Anusha Nadig, associate consultant, endocrinology, Fortis Hospital, Bengaluru

“The issues afflicting our society are entwined with nutritional deficiencies such as the shortage of vitamin D. These conditions can be significantly influenced by our dietary choices.”

Amarpreet Singh Anand, founder and CEO, of Superfoods Valley

 “The first thing to do is to cut the CRAP’—C- carbonated beverages, R- refined sugar, A- artificial sweeteners and colours, and P- unhealthy processed foods.”

Sheetal Ruparel Somaiya, certified diabetes educator and FODMAP dietician

“Among diabetics, wounds don’t heal so fast and immunity levels are lower. There is a greater chance of infection after an aesthetic procedure. 

Dr Ishan Sardesai, aesthetic surgeon

(Some names have been changed on request)

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