Diabetes: India’s growing epidemic

Dr Jatinder Kumar Mokta and Dr Sanjay Kalra

The parents of a four-year-old, from a remote village of Jubbal in Shimla district of Himachal Pradesh, walked into my room last summer with complaints of their child behaving abnormally. She asked for food all the time, drank excessive water and then rushed to the washroom to relieve. Despite a healthy diet, the child was losing weight and turned pale. She did not show child-like energy and had no inclination for going to school. She was diagnosed with type-I diabetes with sugar levels in the range of 400 to 500 mg/dl. She was treated with insulin injections four times a day, the child is doing well now. 
In another case, a well-educated schoolteacher came with multiple problems.  He knew, he suffered from diabetes but had been making hits and trials to beat the disease by taking non-prescribed treatments and  home remedies, which led to further deterioration of the problem. On blood examinations, his sugar level was found to be in the range of 250 to 400 mg/dl, along with other complications like damaged kidney and eyesight.  He too had to be put on insulin treatment immediately to stabilise his condition and prevent further deterioration. He had to change his lifestyle. 
Age, no bar
Diabetes can strike at any stage of life; from childhood to old age. Then, there is a general tendency in our society to avoid taking medicines as long as people consider themselves capable of managing their daily affairs conveniently. They visit physicians only when the condition deteriorates and problems get out of hand. There is an urgent need to sensitise people about the drastic impact of this dreaded disease and check its spread.
 Diabetes is a chronic disease, associated with high levels of blood glucose, giving rise to the risk of damaging tiny blood vessels, it has assumed a critical public health problem in our country. Diabetes is the major cause of kidney failure, blindness, and non-traumatic leg amputations worldwide and a leading cause of stroke and heart disease and is associated with reduced life-span.
Indian scenario   
Approximately 65.1 million Indians live with diabetes today and half of them are ignorant of their disease.  The number is expected to touch the figure of 109 million by the year 2030. Overall diabetes burden is higher in rural India, as 68.34 per cent of the population lives in villages and suffers heavily either due to ignorance or lack of specialised medical facilities.
Diabetes occurrence is a result of the interplay between genes and environmental factors. The ongoing "epidemic" of diabetes, which currently affects 9.09 per cent of Indian adults, is mostly type-2 diabetes, and largely reflects the "success of society." We eat too much, and we are inactive. The problem is not only excess food that is available, more importantly, theses foods are unhealthy (containing excess of simple sugar and bad fats). It is compounded by easy accessibility and availability of these unhealthy foods in every nook and corner of the country. Hence, spreading of diabetic epidemic is evident in rural areas and among the low socio-economic strata also, as revealed by the study in four states of the country.
Sedentary lifestyle
According to one estimate, an average Indian has been consuming more than 50 per cent of his required energy in the last decade and has reduced 30 per cent (800 Kcal/day) expenditure of non-exercise associated energy (NEAT) because of physical inactivity. Two environmental factors i.e. excess food and physical inactivity are mainly attributed to rapid urbanisation and industrialisation in our country. Being overweight and sedentary makes us resistant to insulin. Increased insulin resistance in conjunction with our genetic make-up, makes Indian more susceptible to development of diabetes at a younger age and at lower body weight as compared to Caucasians. The mean age of death was 56.5 years among the diabetics, a decade earlier, than non-diabetic population. This means that, in the next 10 - 20 years, productivity of the youth of our country could be seriously affected. Due to these sheer numbers, the economic burden due to diabetes in India is among the highest in the world.
When to suspect
Increased thirst, increased urination, increased hunger, weight loss, easy fatigability, blurred vision, dry or itchy skin (vagina/groin), slow healing of sores or cuts, erectile dysfunction are the common symptoms of diabetes. Person having any of these symptoms should measure his or her blood glucose levels for early and timely diagnosis of diabetes. However, many patients are asymptomatic, their diabetes is  detected during routine laboratory tests only.
Because of ageing population, industrialisation and rapid urbanisation, it is difficult to stop the epidemic of diabetes. Therefore, the emphasis should be on early diagnosis and effective early treatment to prevent the chronic complications. We the Indians, being genetically more susceptible for diabetes, early annual screening at the age of 30 years should begin. If any of the risk factors is present: obesity, positive family history, hypertension (>140/90), lipid abnormality (Low density lipoprotein >130 and triglyceride >250mg/dl) and women with gestational diabetes and polycystic ovary syndrome, the treatment should begin immediately.   
Prediabetes
The earliest stage of type 2 diabetes is prediabetes (impaired glucose tolerance [IGT] and/or impaired fasting glucose [IFG]), where glucose levels are higher than normal but not in the diabetes range. Prediabetes tends to progress to diabetes, (about 50 per cent will develop frank diabetes over next 8-years), and over time; this persistent increased blood glucose levels lead to the complications. Recent evidence suggests that early intervention with lifestyle changes/ or glucose-lowering medications decreased the progression from prediabetes to diabetes and suggests that natural history of diabetes can be altered through routine early screening to detect prediabetes with timely and early intervention to keep glucose levels as normal as possible. Unfortunately, we waste the first close to 10 years of the natural history —when  the disorder is easiest to treat. There are 54 million Indians with prediabetes and half of 63.1 million Indians with diabetes, who are unaware of their disease and are largely unrecognised, because we do not screen to find these states of dysglycemia. Therefore, screening to identify early diabetes and prediabetes should become a routine.
Treatment
Two-third (66 per cent) of diabetic patients die due to coronary artery disease (heart attack), mostly prematurely. In real-world setting, achieving near normal plasma glucose is considered essential to the diabetic management; both by patients and medical professionals. However, in reality glycemic control is only one facet of the multi-factorial approach in which all known risk factors for cardiovascular disease, like blood pressure and lipid abnormality, have to be controlled.  Recently, studies have shown that the benefit of control of blood pressure and cholesterol may exceed the control of blood sugar in reducing diabetes related deaths due to coronary   artery disease and stroke. In a recent diabetic survey in the rural areas of the state, only 25.54 per cent eligible diabetic hypertensive patients were taking anti-hypertensive drug and only 10.54 per cent eligible for lipid lowering therapy were taking lipid lowering drug Statin. Therefore, equal, if not greater, focus should be laid on controlling these risk factors (hypertension & cholesterol)) in addition to glycemic control.
Diet, exercise and medication are the three important components of diabetes management and need to be in perfect balance to maintain blood glucose control without risk of hyperglycemia or hypoglycemia.
Nutrition Therapy: Nutrition therapy is the cornerstone in the management of diabetes. "There is no specific diabetic diet", the meal plan should be based on taking into consideration the eating habits, food preferences, culture and religious practices/ beliefs. Blood glucose levels are also affected by timing, portion size and type of food. Diabetic patient should eat at least three balanced meals / snacks at fixed times spaced throughout the day daily and should eat the same amount at each meal each day. A diabetic diet has to be a balanced diet that is rich in fiber, whole grains, and legumes, fruits and vegetables; contain less fats and limited in calories. Diabetic patients should avoid trans-fats, fruit juices and simple sugar.
Exercise: Exercise has to be an additive effect when combined with caloric restriction. All persons should engage in at least 150 minutes/week of moderate-intensity exercise. One should select an exercise that one enjoys and is able to sustain. Practice small lifestyle changes like using stairs instead of elevator and parking at a reasonable distance from the destination with a view to compulsory walk. Leisure activities (going to market or office walking rather than in car) are as good as structured activities (going to gym) and short bouts (10-15 minutes) of exercise are as effective as long exercise schedule. Even without losing weight, exercise has beneficial cardiovascular effect and improves the quality of life.  Of course, the exercise program should be carried under the medical supervision.
Medications: Medication is a long-term process and in case blood glucose is not controlled with single drug, one should consult their physician to increase the dose/or to add another drug. All diabetic patients aged above 40 years with one more risk factor, should be on Statin therapy irrespective of cholesterol levels and, once blood pressure exceeds 140/80mm Hg, anti-hypertensive should be added to the drug list.
Long-term follow-up: Except for pregnancy, acute decomposition and patient on multiple insulin injection, follow-up at 2 to 3 month interval is the best strategy. Blood pressure, fasting and post-prandial blood glucose and off sox foot examination for callus, ulcer and discoloration should be done on every OPD visit, A1C should be done quarterly and lipid profile, kidney function tests and eye examination should be done once in a year.

Eating habits, the culprit
A dietary survey of India has revealed that 65-70 per cent of total energy is drawn from carbohydrates, which is much above the recommended levels. Recently, WHO has declared: sugar a silent killer and termed it as bad as tobacco because in every 6 seconds a person dies due to use of tobacco products as also from the effect of sugar/diabetes. There is myth about sugar consumption among people and is considered synonymous with table sugar. However, over last one decade there is considerable increase in the consumption of refined sugar 330.0gm/day (equal to 1139 Kcal) as compared to consumption of table sugar 47.9gm/day. The risk of type II diabetes increases as total consumption of refined sugar (white flour, polished white rice, suji, maida) exceeds 200mg/day and it doubles once it reaches 330gm/day, the amount an average Indian is consuming.
Fast foods should be restricted in the school canteens and parents should be advised to give healthy food containing fruits and vegetables to their children in the tiffin. Dietary advice for children is: eat less, eat in time, do not skip meals, eat right, down portion size and avoid binge eating, fast and fried food.  No fast-food shops should be there within 100-metre/yards radius of the school. Prevention of childhood obesity guideline recommends a minimum of 60 minutes of out-doors physical activity and restriction on TV time, including computer usage, to less than 2 hours.

Dr Jatinder Kumar Mokta is Associate Professor Medicine, IGMC, Shimla, &  Dr Sanjay Kalra (DM Endocrinology), Executive Editor, Indian Journal of Endocrinology & Metabolism.