Diabetes Unravelled

By Aarti Narang

This isn’t someone else’s problem: India has 41 million diabetics. It could rise to 70 million by 2025.

If you have diabetes, the problem is basically this: you have too much glucose in your blood. Glucose is our main source of energy, derived from eating carbohydrates, and is absorbed into our cells with the help of the hormone insulin. If our body has a problem with insulin, the glucose isn’t absorbed.

There’s a range of reasons for this. In some people, their pancreas fails to produce insulin. That’s Type 1. A small number of people become diabetic when their pancreas is destroyed, for example in an accident or during surgery. But for most people with diabetes, the body has problems processing the insulin the pancreas does produce: Type 2.

Actually, within the term “diabetes,” doctors are discovering dozens and dozens of conditions. “The lines are getting fuzzy,” says Dr Sreemukesh Dutta of the Hyderabad-based Research Society for the Study of Diabetes in India, “Earlier, only Type 1 diabetes was insulin-dependent but in the past decade Type 2 diabetes has become insulin-dependent too.”

Adds Dr Greg Fulcher, an Australian expert, “As we learn more, we can identify the conditions more accurately; for example if they’re caused by different genetic abnormalities.

We even talk about a Type 11⁄2, which has elements of Type 1 and Type 2. One day they may become categorized by the underlying abnormalities rather than just being bundled under one issue.”

But for now the big headache for health authorities is Type 2.

That’s where a complicated metabolic process means not enough insulin is produced, or the insulin that is produced doesn’t work effectively.

Type 2 comprises 70 to 80% of total diabetes cases in India, and its incidence is increasing rapidly—so much so that India is often described as the “Diabetes Capital of the World.”

Linked to obesity, the most worrying trend is that it’s being diagnosed in younger and younger Indians. Previously, the onset of diabetes was generally among those above 35. Since the past decade, Type 1 is getting to be increasingly seen among children, while youngsters even in their 20s are developing Type 2. That’s a major problem, since the longer you live with diabetes, the more likely you are to develop complications.

Living with Type 2

When 43-year-old Mumbai businessman Mark Lewis was detected with diabetes in June last year, it came as no surprise. He had already lost his father to complications from diabetes, and at 103 kilos, he too was a potential target for the killer disease. “It was only when I mentioned to my sister that I was forever thirsty and she suggested I get myself tested that we suspected diabetes,” says Lewis.

People most at risk are those that have the classic “apple” physique.

Carrying more fat around the abdominal organs makes insulin less efficient at controlling glucose levels. Routine blood tests in GPs’ clinics pick up most cases, as more often than not the patients have no idea they have diabetes.

When the doctor charted out a plan to control his diabetes, Lewis was determined to follow it diligently.

He was immediately put on medication and followed a 1400-calories-a-day diet set for him. When asked to exercise, Lewis alternated between walking, lifting weights and yoga. By May this year, Lewis had lost 20 kilos. As his blood sugar levels fell, he was weaned off medication. Today, Lewis is keeping his glucose levels in check through the diet and exercise regimen.

People with Type 2 diabetes don’t necessarily need to follow a special diet, but if they are overweight—which over 70% of people with Type 2 are—then it’s important they lose weight.

“Weight loss helps in controlling diabetes and preventing its onset,” says Dr B.M. Makkar, senior diabetologist and obesity specialist at the New Delhi-based Diabetes and Obesity Centre. According to Dr Makkar, a mere 7% weight loss can reduce the risk of diabetes by 58%. In fact you don’t even have to achieve your ideal body weight for it to make a discernible difference.

Most people may think it’s hard to follow a weight-loss diet and exercise regime. But people with diabetes ignore the risks at their peril: all diabetes is serious, and can lead to devastating complications that are usually irreversible and often fatal. Too much sugar in your blood damages the vascular system and organs. That means people with diabetes are much more prone to cardiovascular disease, and are three times more likely than most people to have high cholesterol, high blood pressure or obesity. Many people with diabetes end up dying as a result of a heart attack or stroke.

Blood glucose can also damage the small blood vessels, which causes problems in the eyes (a quarter of patients develop retinopathy, which can lead to blindness), kidneys, feet and nerves. That means that if the diabetes isn’t well controlled, people are looking at kidney failure or lower limb damage requiring amputation.

Exercising and losing weight can reduce the risk of all of these complications, but what many people don’t realize is that their diabetes is a progressive disease. “Only about 10% of patients are able to maintain normal glucose levels with lifestyle modifications, and that too only up to one or two years,” says Dr Makkar. “Most patients will eventually require lifelong medication, not only to control their diabetes but to prevent complications as well.”    

Type 1 Explained

The threat of serious complications weighs heavily on the mind of anyone with diabetes. But it’s particularly tragic when the diabetic is a child.

Childhood is usually when Type 1 diabetes is diagnosed. In Type 1, the body’s own immune system attacks the beta cells in the pancreas that produce insulin. It’s responsible for a majority of diabetes cases.

Type 1 diabetes cannot be prevented. Patients usually have a genetic predisposition but their disease is triggered by something in the environment, such as a virus. Traditionally called “juvenile onset diabetes,” Type 1 can strike at any age. What doctors don’t understand is why it’s increasing. Research is pointing the finger at milk or certain fats inducing diabetes in people with a genetic predisposition, but at the moment these are just theories.

Usually the descent into diabetes is swift and shocking. That’s what happened to schoolgirl Kyra Shroff, diagnosed four years ago at age 12.

Kyra appeared gaunt and would wake up several times in the night to go to the bathroom. Clinical tests revealed her blood sugar count to be 695 mg/dl (the normal fasting blood glucose level is about 100 mg/dl and post lunch blood glucose level is 140).

A controlled diet, constant monitoring of blood glucose levels and insulin injections every few hours brought Kyra’s condition under control. In fact she’s in top form: Kyra recently won the national junior tennis title, and two silvers at last month’s Commonwealth Youth Games in Pune. Unlike Type 2 diabetes, Type 1 is all about controlling the blood—by adjusting the insulin depending on how much carbohydrate is consumed.

People with this disease used to monitor their carbohydrate intake carefully around regular insulin shots. These days, patients are more likely to follow the DAFNE (Dose Adjustment for Normal Eating) plan—they eat anything, as long as it’s healthy, and adjust their insulin intake accordingly.

Though it requires great diligence, Dr Vishal Chopra, diabetes specialist at Dr L.H. Hiranandani Hospital, Mumbai, maintains “DAFNE can be practised if the patient goes to a specialist at an early stage, when the diabetes is easier to control. Unfortunately, most people first go to a GP who may refer them to a specialist only when complications develop.”

The big problem with Type 1 is it’s impossible to accurately supply insulin all the time. If the amounts are wrong, it can be life-threatening: too much insulin will cut sugar levels leading to hypoglycaemia; too little insulin to hyperglycaemia, while a build-up of organic compounds known as ketones in the blood can lead to a ketoacidotic coma.

“We understand the patient’s insulin requirement after two meetings. We determine the requirement after taking pre- and post-meal readings, and monitoring exercise levels, duration and intensity,” says Dr Chopra. “We give them a scale to follow and then it’s not hard to lead a normal life.”

And that’s just what Kyra Shroff is doing. She injects herself with insulin four times a day, after each meal, and keeps a tab on her blood count thrice. Though she cannot take sugar-rich energy boosters as other tennis players do, Kyra continues to train and travel all over for tournaments and manages her school assignments as well. “I’ve learnt that diabetes isn’t an illness,” she says. “It’s just a different way of life that you work around, and it’s no excuse to stop doing other things.”

Adds Firdaus Shroff, her proud father: “Kyra has helped us change our lifestyle too—we now eat healthy and avoid being sedentary.”

Diabetes in Pregnancy
There’s one more cause of diabetes: pregnancy. It’s called gestational diabetes, and the rate is increasing fast—up eight-fold in the last two decades.

The increase might be because women are having babies when they’re older, or because obesity, a risk factor for diabetes, is increasing. The extra stress of pregnancy on the body can cause high glucose levels, but often pregnancy highlights a woman’s predisposition for diabetes: up to 50% of women develop Type 2 within five years of having the baby, not because of the gestational diabetes, but because they were on course to get the disease anyway.

Women with a predisposition to diabetes are at particular risk while they’re pregnant because their energy needs increase, plus hormones pro-duced by the placenta can block the action of the mother’s insulin, causing insulin resistance. These factors mean insulin needs in pregnancy are two or three times greater than normal from about 24 weeks. Up to 16% of women develop gestational diabetes and it’s usually picked up with a routine glucose tolerance test between 24 and 28 weeks of pregnancy.

Alafiya Firoz, 29, a Chennai housewife, is 11 weeks pregnant and has been diagnosed with gestational diabetes. She isn’t surprised—she was diabetic during her previous pregnancy four years ago too. “The diabetes was then diagnosed in the 36th week of my pregnancy. Only one of my grandmothers was diabetic, so I wasn’t really expecting it,” Alafiya says. Immediately, Alafiya started taking a dose of insulin and walking for 30 minutes everyday. She cut sugars from her diet completely and brought her glucose levels under control within a month.

It wasn’t easy, but she had a big incentive: she learnt that babies of women with gestational diabetes could have problems, too. The mother’s glucose crosses the placenta to the baby’s bloodstream, prompting its pancreas to produce more insulin. That can result in larger babies, putting them at risk during delivery. They are also more prone to developing Type 2 later in life.

Women with gestational diabetes have to juggle their insulin resistance with eating a healthy diet for the baby. They are allowed to eat carbohydrates, but are advised to space out their intake: “If the patient is used to eating, say, two chapattis every morning, then we ask them to have one at 9am and the other at 11. This helps keep the sugar levels down,” says Dr V. Balaji, senior consultant diabetologist at Chennai’s Apollo Hospital.

It was a good-news story for Alafiya. Soon after she delivered her first baby, her blood sugar levels were found to be in the normal range: she was no longer diabetic. Doctors warned her that the diabetes could return if she became pregnant again. It has, but Alafiya isn’t too worried. “I’ve kept my weight in check and am restricting my diet,” she says. “I am determined to get rid of the diabetes this time too.”

In fact, many of the health messages that become so important for people with diabetes have relevance for us all. Regular physical activity, a healthy eating plan and keeping an optimum weight are the keys to living healthily with diabetes—and to preventing it in the first place.

THE DIABETES EPIDEMIC
• It’s the fastest-growing disease in the world, with 230 million people already affected.
• Diabetes is the world’s leading cause of heart disease, stroke, blindness, kidney disease and lower limb amputation.
• The incidence of diabetes is five times higher among Asians than it is in white populations.
• By 2025, every fifth diabetic in the world would be an Indian.

CAN DIABETES BE CURED?
A CONCERTED EFFORT IS UNDER WAY TO FIND A CURE FOR TYPE 1 DIABETES. “It’s looking exceedingly promising,” says Australian expert Dr Gary Deed, who predicts it may happen in 10-15 years.

Meanwhile the emphasis is on halting the disease in newly diagnosed cases. Doctors are trying to modulate the immune system so it doesn’t progress to the ultimate destruction of the pancreas.

The other tack is to try to recreate the body’s ability to manufacture insulin, for example by transplanting the pancreas or insulin-producing cells. Stem cell research is also offering hope that these cells may be created in the lab.

As for Type 2, public health messages promoting weight loss and exercise seem to be the best way of stopping the disease in its tracks. International studies have shown that weight loss of just 5-7% and exercising for 30 minutes five times a week lowers the risk of developing diabetes by a massive 60%.

“It may take ten years before Type 2 diabetes stops increasing every year in populations. Then we will see numbers begin to decrease,” predicts Professor Jaakko Tuomilehto, an international authority on diabetes.

THE WARNING SIGNS
Here’s what should ring alarm bells:

TYPE 1
Extreme thirst • Frequent urination
Constant hunger • Blurred vision
Sudden weight loss • Nausea
Vomiting • Infections
Extreme tiredness


TYPE 2
Excessive thirst • Frequent urination
Feeling tired and lethargic
Slow-healing wounds
Itching and skin infections
Blurred vision • Mood swings

GESTATIONAL
Pregnant and over 30 years of age
Family history of Type 2 diabetes

Overweight
Certain ethnic groups including Indian, Vietnamese, Chinese, Middle Eastern, Polynesian/Melanesian, indigenous Australians
Gestational diabetes in previous pregnancy
Previous problems carrying a pregnancy to term

COMMON MYTHS

Myth 1: Sugar causes diabetes.
Wrong. Type 1 diabetes is thought to be caused by genetic factors combined with environmental triggers. Type 2 diabetes is caused by a combination of genetic and lifestyle factors. People with diabetes do need to limit foods that are concentrated sources of sugars, but they can eat small amounts of sugar.


Myth 2: People with diabetes can’t eat chocolates or sweets.
Small quantities of chocolates and sweets are occasionally OK as part of a healthy eating and physical activity plan.


Myth 3: People with diabetes have to eat special foods.
Like everyone, people with diabetes have to eat healthily. That means a diet low in saturated fat and high in fibre and whole-grain foods.


Myth 4: You can catch diabetes.
Diabetes is not contagious.


Myth 5: People can have a “touch of diabetes.”
You can’t have mild or borderline diabetes. All diabetes is serious and, if not managed properly, can lead to serious complications.