Just a spoonful of sugar, after all. That is how casually diabetes has been perceived by most people. Many people diagnosed with the condition were nonchalant and continued with the lifestyle choices they were comfortable and familiar with, shrugging off elevated blood sugar levels as nothing to really worry about. As a result, spooning a couple of heaps of sugar into one’s tea was done without a care in the world, simply because that is how it tasted best. But in just a few decades, diabetes became the infamous ‘silent epidemic’, and is today one of our most serious health concerns, world over.
Globally, one out of every five people older than 65 is a diabetic. By 2045, there could be 700 million diabetics in the world between the ages of 20 and 79. In 2019, this number stood at 463 million, and 79 per cent of these people were in the low- and middle-income countries. According to the International Diabetes Federation, in 2019, there were 77 million diabetics in India—a staggering burden for the country. Diabetes prevalence among adults in India currently stands at 12 per cent of the population. These are people who, to some extent or the other, suffer from a very fundamental dysfunction—that of not being able to regulate their blood sugar levels. This dysfunction arises because the body can no longer effectively use whatever insulin—the body’s natural hormone that can regulate blood sugar—is being produced. This is Type 2 diabetes, or adult-onset diabetes. Type 1 diabetes, far more rare and showing up in children and the young, is a condition where the body does not produce enough or any insulin because the cells necessary to do this are impaired or destroyed.
And in 2021, as 100 years to the discovery of insulin is commemorated, coinciding with the unprecedented global pandemic that Covid-19 is, India as a country would do well to reflect as to how diabetes—as a multi-dimensional, lifestyle disorder—is currently being managed. For one of the world’s fastest growing health crises, every move we make is critical and significant.
“Chalta hai is the attitude that lets us down,” says Dr Sathish Bhat, consultant diabetologist at the Diabetic Care India, in Kochi. And it summarises exactly how people view diabetes, and how it is managed, whether it is policy-makers or patients. “This is why it is such a problem. Till a stroke or two, till vision starts to get affected, or till the amputation of a foot starts to loom ahead, or a cardiac event, most people don’t bother,” is how Dr Bhat understands the diabetes conundrum.
Dr V. Mohan, chairman and chief of diabetology at Dr. Mohan’s Diabetes Specialities Centre in Chennai, underscores the importance of early diabetes care and management, saying that “a third of all the people who have diabetes in India will have at least one serious complication as a result of the condition, whether it is involving the eyes, heart, or kidneys”. He says the most impactful response to controlling diabetes and its complications comes from understanding the ‘ABCD’ approach of controlling key parameters of the body, where A stands for the HbA1C (a test that tells you how your average blood sugars have been over the last three months) and should be below 7, B stands for blood pressure and should be below 140/90, C stands for cholesterol where LDL cholesterol should not be more than 100, and D is for discipline and includes dietary control, exercise and no smoking etc. Only 7 per cent diabetics in India achieved all these, according to a study by Dr Mohan and collaborators.
In another study, Dr Mohan’s group found how great the lifetime risk of developing diabetes is for young people living in a big Indian city like Mumbai, Delhi or Chennai. “If you are 20 years and live in one of these cities and you are overweight/obese, your risk of developing diabetes in your lifetime is 90 per cent.” This, if anything, establishes the enormous significance of choosing health, fitness and a conscious lifestyle.
The Covid pandemic, among the several lessons it has taught the world, has highlighted the challenge of mismanaged diabetes in India like never before. As per guesstimates, 70-80 per cent mortality related to Covid infection was among those who were already diabetic. “In some sense, this has been an eye-opener, and that too in relation to a disorder that is imminently preventable,” says Bhat.
Meanwhile, the health system must find a better way to cope with this burden of diabetes. It is critical for the population to have all the support possible to control their blood sugar, but also keep a check on blood pressure and cholesterol levels—two key parameters in the management of diabetes.
India has a National Programme for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS), which was launched in 2010 with the mandate to prevent and control all these major non-communicable diseases. To several experts, the clubbing together of so many major diseases and disorders under one programme is in itself a challenge, and this is clearly evident in the way diabetes has been managed in India. NPCDCS was launched with an aim to reduce the risk for the prevention of non-communicable disease (NCD) and the early diagnosis and appropriate management of common NCDs. As of March 2020, there were 665 district NCD cells, 637 district NCD clinics, 4,472 CHC NCD clinics, 181 cardiac care units and 218 day care units functional in the country.
It is a bit hard to figure out as to why an earlier national programme called the National Diabetes Control Programme, begun in 1987 as a pilot initiative in Tamil Nadu, Karnataka and Jammu & Kashmir, was wound up for lack of funding. This programme had as its key objective, the screening and prevention of diabetes among the Indian population—something that could potentially have stemmed the tide to some extent. According to experts, this programme was hinged on a strategy of prevention among high-risk subjects using health education, and early diagnosis and treatment. In fact, even the rehabilitation of those seriously handicapped because of diabetes, was a part of this programme. Like several decisions that are taken at top policy leadership levels, this programme winding up because of lack of financial resources is a paradox, especially when the country was already sliding into a massive diabetes epidemic and infinite resources are now spent on the treatment of the disease.
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Treating diabetes with a whole array of drugs and medication is one of big pharma’s biggest businesses, globally. Interestingly, there is no real cure for diabetes across this spectrum of medicines, but it is a field of treatment medicine that has advanced enormously in the last few decades (See It’s Getting Better). Experts across the world have felt that if this drug cocktail to manage diabetes can be perfected, there might actually be a real cure. As of today, treatment often begins with metformin as an oral drug, and over the years, a patient may be required to consume other drugs alongside, and even end up with injectable insulin.
Make That Choice Today
But it doesn’t have to be this way. Diabetes is a condition that can be managed really well, and as the World Health Organization says, regular blood sugar screening, checking blood pressure, screening for any damage to the eye, kidneys or feet are extremely cost-effective interventions that can improve patient outcomes. Diabetes can also be prevented from precipitating as a condition, as long as the right steps are taken.
Today, trends of stringent lifestyle modification, even transformation, are rapidly setting in and building up. Grounded in the basic knowledge that you are what you eat, there are many people who are working to address their diabetes, or pre-diabetic condition through dietary changes and exercise. As it is with all such disorders, there is little doubt that preventing diabetes is a far better option than becoming diabetic and then managing it with drugs and external insulin.
In fact, there are several experts who are today pushing for radical behaviour and lifestyle change, backed by the knowledge that diabetes can actually be reversed. Dr Pramod Tripathi launched Freedom from Diabetes, a Pune-based organisation that works with diabetes patients to help them radically modify their lifestyles so that they can actually stop medication and live healthy lives with normal blood sugar levels and other related parameters. “I had a fulcrum moment after having read two eye-opening books and understanding how reversal actually happens,” says Dr Tripathi, who started his efforts between 2013 and 2015, and today is very proud of his 9,900 “free” patients—people who have successfully reversed their diabetes.
“Measure, measure, measure,” is Dr Tripathi’s mantra, which is built into a programme that is constantly evolving and is based on the fundamentals of agility, innovation and deep work. Right from the early days of the programme, Dr Tripathi would encourage his patients to measure their blood sugar, blood pressure, weight and cholesterol, get them to send him the readings by conventional text messaging, and he would stay in touch with each of them. Through a uniquely-designed programme (see column), Dr Tripathi has seen it all and is today happy that “diabetes reversal, as a word, is a possibility for many”.
All those who work in the domains of health education, behaviour change and health communication to support healthier life choices among people know how tough it is to shift behaviours and choices that make people unhealthy, or even seriously ill. “The toughest part of the entire spectrum of diabetes management is how to change some fundamentals in the way a person is used to living. You can change their medication quickly, but changing food choices is very challenging,” says Bhat, who treats large numbers of patients from his clinic in Kochi, Kerala, a state known for its high burden of diabetes. He has chosen to use pictures of his own patients and the conditions they are affected by, to help people understand the depth of suffering that can occur. These pictures, or video clips, have a huge impact on patients who need that extra push to work on their lifestyle choices. “A doctor has to be beyond empathetic, communicating a serious message with all the seriousness it deserves,” explains Bhat. And this made him so concerned that he decided to invest himself into wide communication efforts, through a YouTube channel, to reach out to as many people as possible so that he could spread the right kind of information, create awareness about diet and lifestyle modification, and ensure people have a credible go-to source of information and medical knowledge available to them in an easy-to-use format.
Working with young people to make sure they understand the importance of picking healthy options early in life, and act on it, can make a big difference. To be able to intelligently comprehend exactly what damage certain food choices can cause is a high-level activity, and those who are able to achieve this nuanced ability to choose right can stay healthy, in all probability. “The mind and the will to stick to discipline are key,” says Dr Mohan, because at the end of the day, the concern is—how do you live long and well?
With the critical role that communication and awareness plays in a person’s ability to manage her or his diabetes well, it is evident that social media platforms and digital sources of communication are shaking things up. Across multiple platforms, and in diverse formats, communicators and experts are reaching more and more users to talk about diabetes prevention, healthy lifestyle choices and ways to prevent chronic disease. Of course, here the greatest challenge is the need to discern between accurate and credible information versus what is fake.
But individuals would need to make the choice. Between the foods that have comforted them for years and those that would help keep their blood sugar in check; between reaching points of no return and living as well as possible with an efficiently-managed condition; and most of all, addressing the vulnerability that comes from carrying a co-morbidity like diabetes. And with diabetes, change is possible, imminent and achievable.
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Diabetic Nation
The Union health ministry and its research bodies have conducted several sample surveys from the 1970s onwards to estimate the total number of diabetic patients in India.
1 The most recent is the National Diabetes and Diabetic Retinopathy Survey from 2015 to 2019. Out of the enumerated population of 63,000 aged 50 years and above in 21 districts, 56,771 (90.1%) were assessed for diabetes. The prevalence was found to be 11.8% (known diabetes: 8%; new diabetes: 3.8%)
2 The survey says there are an estimated 72.96 million cases of diabetes in the adult population of India. Urban prevalence ranges between 10.9% and 14.2% and rural prevalence between 3.0% and 7.8% among the population aged 20 years and above, with a much higher prevalence among individuals older than 50.
3 The India Diabetes [INDIAB] Study by the Indian Council of Medical Research, New Delhi, and the Department of Health Research, Government of India, conducted from November 2008 to April 2010, found that the overall weighted prevalence of diabetes in four regions were 10.4% (Tamil Nadu: urban 13.7%; rural 7.8%), 8.4% (Maharashtra: urban 10.9%; rural 6.5%), 5.3% (Jharkhand: urban 13.5%; rural 3.0%) and 13.6% (Chandigarh: urban 14.2%; rural 8.3%).
4 The Prevalence of Diabetes in India Study, conducted in 49 urban and 59 rural areas and published in 2004, reported diabetes prevalence of 5.9% and 2.7% in small towns and rural areas respectively. This shows the extent to which the disease burden has grown over the years.
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Saving The Type 1
Harsh Kohli, President, Diabetes India Youth in Action
Diabetes India Youth in Action (DIYA) was founded in 2017 with the aim of spreading awareness regarding Type 1 diabetes in India. The NGO has conducting workshops and diabetes camps to educate people of all age groups, especially youngsters, about Type 1 diabetes and how to prepare oneself to live with it.
“In the past, we have held diabetes camps, carb counting workshops, Type 1 awareness runs, online counselling sessions, butterfly effect programmes and many more such initiatives for people who suffer from this type of illness,” says Harsh Kohli, president, DIYA. According to Kohli, “The key challenges faced by the Type 1 diabetes community in India are lack of government support in accessing insulin, which is a lifeline for such patients; inadequate testing for Type 1 diabetes, no insurance facilities, denial of many government jobs, among others.”
“The moment a person declares himself as a type 1 diabetic, he becomes ineligible for several government jobs. Not only that, as this mostly impacts kids, many times they are denied school admission also,” he said. Expressing anguish on the unavailability of insulin in rural areas, Kohli says that even after 100 years of the invention of insulin, the govt hasn’t included the medicine in the category of life-saving drugs.
(This appeared in the print edition as "Spoonful of Sweet Positivity")
With inputs from Jeevan Prakash Sharma
