Diabetes with Delight: A Joyful Guide to Managing Diabetes in India

By Anoop Misra

Can we prevent diabetes? Once it develops, can we reverse it? What needs to be done when a patient with diabetes has coronavirus or influenza infection? Is there a drug that can protect the heart and other essential organs? How to avoid a heart attack in a diabetic patient? How to manage diabetes in pregnancy? What to do if one has cancer and diabetes? What happens to the liver with obesity and diabetes? Could keto diets or intermittent fasting be tried by patients with diabetes? Are alternative medicines effective? How to energise muscles with long-standing diabetes? What are frauds and fads related to diet and diabetes? What are the exercises to improve fitness? Which tests show early damage due to diabetes-related complications? Should vitamins be mandatory for patients? What could be done to improve sexual functions and fertility? Are drugs better or insulin? How to protect kidneys from drugs and chemicals? How to get continuous monitoring of blood sugar done?

Diabetes with Delight answers these questions and more. Keeping pace with rapidly increasing advances in diabetes, newer therapies and ever-evolving research, it attempts to demystify the myths and conundrums surrounding this chronic disease while presenting you with the latest in the field. This edition includes seven new chapters, giving readers up-to-date knowledge of the current medical issues and controversies. Written in a simple manner, backed up by India-specific data and charting out specific diets and exercises, it is eminently suitable for all Indians.

• Language: English
• Publisher: Bloomsbury Publishing
• Release date: Feb 10, 2018
• ISBN: 9789386606471

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CHAPTER 1: HISTORICAL PERSPECTIVE AND LANDMARK DISCOVERIES

Diabetes was recognised in ancient times, and even finds reference in the Indian ancient treatise, Vedas, more than 4,500 years ago. The term ‘diabetes’ originated from the Greek word for ‘siphon’, because of marked urination in pateints. The term ‘mellitus’ is derived from a Greek word, meaning ‘sweet’, in context of presence of sugar in the urine. In second century AD, Aretaeus, a Greek physician, described diabetes accurately in the following manner:

‘…a dreadful affliction…a melting down of the flesh and limbs into urine. The patients never stop making water and the flow is incessant…Life is short, unpleasant and painful, thirst unquenchable, drinking excessive, and disproportionate to the large quantity of urine, for yet more urine is passed….If for a while they abstain from drinking, their mouths become parched and their bodies dry; the viscera seem scorched up, the patients are affected by nausea, restlessness and a burning thirst, and within a short time, they expire.’¹

Figure 1: Sushruta, an Indian Physician Examining a Patient.

Sushruta, an Indian physician during the sixth century AD observed that ants were attracted to the urine that was sweet in taste (Hindi name

of diabetes was derived ‘Madhumeha’), and used that as a test for

diabetes. The primary test of identifying diabetes until medieval times was by touching, smelling or tasting the urine of the patient!

Figure 2: First Description of Diabetes Mellitus in ‘Ebers Papyrus’ (Egypt, 1500 B.C.)

Key Landmarks in History of Understanding of Diabetes:

John Rollo first coined the adjective ‘mellitus’ in the nineteenth century;

Claude Bernard, a French physiologist researched many aspects of diabetes in the nineteenth century. Importantly, he described that the sugar was stored in the liver as glycogen;

In 1889, Minkowski and Mering from Russia observed that removing the pancreas from a dog resulted in typical signs of diabetes increased thirst (‘polydipsia’), increased urination

(‘polyuria’), and wasting associated with markedly high sugar;

Paul Langerhans of Berlin, Germany, during the same period, described small clusters of cells in the pancreas;

Laguesse of France later named these cells as ‘Islets of Langerhans’ after him, and suggested that these cells produced a glucose lowering hormone, insulin. The latter, perhaps, was a key discovery which led to life saving treatment of diabetes with insulin. In the early twentieth century, role of pancreas and insulin in pathogenesis of diabetes was proven;

In 1922, Drs Banting, Best, Collip and Mcleod of Canada made extract of dog’s pancreas and injected it into a diabetic dog whose pancreas was surgically resected, and showed decrease in blood glucose concentrations. Dr Banting treated the first patient of diabetes with an injection of insulin. They were bestowed with the Nobel Prize in year 1923 in the field of Physiology;

In 1936, Sir Harold Percival Himsworth suggested that type 1 diabetes was different from type 2 diabetes;

First personal glucose monitor was invented in 1970, allowing patients to monitor blood sugar at home;

Until the 1980s, insulin was derived only from animal pancreata.Subsequently, most human insulins are produced with help of genetic engineering;

During the last decade, new drugs, insulins and insulin delivery systems have been made available, making last two decades the most exciting era in diabetes;

Since year 2000, investigation of role of stem cells in treatment of diabetes is continuing;

First artificial pancreas was approved by Food and Drug Administration, USA, in 2016.

1. Adapted from Papyrospyrus S. The History of Diabetes Mellitus, 2nd edn. Stuttgart: Thieme 1964

CHAPTER 2: DIABETES IN INDIANS

Economic growth and affluence in India during the last two decades has brought forth a vast variety of changes in lifestyle, which are primarily reflected in a nutritional transition, globalisation of diets, and physical inactivity. All these changes have resulted in increase in diabetes and heart disease. The prevalence of diabetes has doubled during this period. It is also predicted that the prevalence of diabetes would rise by a whopping 170-200% over the next two decades. Diabetes is increasing in people belonging to middle and low socio-economic strata in urban and semi-urban areas.

Diabetes Facts at a Glance (All figures given below are approximations from various studies and subject to change with time):

More than 65 million people in India suffer from diabetes, and nearly 8% of population above 18 years has diabetes. This figure is expected to rise to 100 million by year 2030, second only to China. Every fifth diabetic patient in the world is an Indian. A study showed that 37% of Delhi’s population suffers from diabetes or pre-diabetes;

Indians have a genetic predisposition to diabetes and nearly 75% of patients with type 2 diabetes have a first degree family history of diabetes;

About 90% patients of type 2 diabetes are either overweight or obese;

Obesity is increasing in Indians. More than 60% women living in urban cities of India are overweight or obese. Women are at equal or sometimes higher risk for developing pre-diabetes, diabetes and diabetes-related complications than men. Overall, an estimated one-third of school children are overweight or obese and 40-50% of school children in most metropolitan cities are overweight or obese;

Diabetes - related complications are more common among Indians as compared with the other populations;

About one-fifth patients of diabetes develop retinal disorders leading to vision loss;

More than 50% of long-term diabetics were affected by diabetic neuropathy (nerve disorders) leading to sensory loss, non-healing foot ulcers and impotence among men. India tops in maximum leg amputations due to diabetic foot in the world;

About 20–30% patients of diabetic nephropathy need dialysis or kidney transplant to survive. Diabetes and hypertension are the most common causes of kidney failure in India;

Silent heart attacks are high in diabetics. Heart disease in diabetic patients is more complicated, and leads to more deaths. Similarly strokes are also common in diabetic patients;

The highest number of deaths in India occurs due to diabetes-related heart disease, more than HIV/AIDS, malaria and tuberculosis combined. Every ten seconds, one person dies from diabetes-related causes in India;

Net losses in India’s national income from diabetes and cardiovascular disease have been $ 336.6 billion between 2005 and 2015.

Why Indians are More Prone to Diabetes?

Greater Affinity to Develop ‘Syndrome X’ (Metabolic Syndrome): Indians are more prone to ‘Syndrome X’ (a clustering of increased abdominal girth, high blood pressure, high blood sugar and deranged blood lipids), the first step towards diabetes.

Indians are more prone to excess body fat from birth: Indians have more clustered fat in their bodies (as much as 1.5 times more than white people) from birth onwards. Most Indian children are born small, underweight and have a higher blood pressure and adiposity, which increases the chances of them developing into diabetic adults at a later stage in their lives.

Resistance to action of hormone insulin: A combination of genetic factors and excess fat over body, abdomen and liver (see below) lends an inherent tendency for insulin to act slowly and in a way that is only partially effective.

Fatty liver (fat accumulation in liver, not due to alcohol): Liver is a site of excessive fat deposition that leads to sluggish metabolism in Indians. This leads to overproduction of sugar, especially during night. Such fat laden livers may also become dysfunctional and cirrhotic, and may even turn cancerous.

Fatty pancreas (fat accumulation in pancreas): Our studies have shown that though a person may not be fat, pancreas accumulates fat easily, and which may cause dysfunction of insulin producing cells.

Sudden switch to a lifestyle that is alien to traditional Indian way of life: Switching to a more modern lifestyle is aggravating the problem and driving Indians even closer to diabetes. Most people today believe in eating ready-to-eat stuff and leading a sedentary lifestyle. Such habits are far from the traditional frugal Indian way of life and rapidly increases the risk of diabetes.

Genetic Factors: A number of genes have been identified in Indians which could predispose this race more to diabetes as compared to other races. In addition, there could be genetic tendency to accumulate excess body fat, abdominal fat and have large fat cells which decrease the action of insulin. For example, we have identified a gene ‘Myostatin’ which may cause excess fat and low muscle mass in Indians. There are other genes which may combine with each other or with bad diet or inactivity to produce diabetes.

Indians have one of the highest tendency to develop diabetes among all races. For combating this we must fight harder

than others to control it, and not suffer from it.

CHAPTER 3: DIABETES : CHARACTERISTICS AND TYPES

What are Diabetes and Pre-diabetes?

Diabetes Mellitus is a metabolic disorder. Most of what we eat is broken down into small molecules of glucose, a form of sugar in the blood. Insulin, a hormone secreted from pancreas (endocrine gland located in upper part of abdomen), helps glucose to enter the blood cells and controls its blood levels. This delicately controlled metabolic equilibrium is powered by a number of proteins and enzymes. Blood sugar increases when the secretion or action of insulin decreases.

In Indians, action of insulin is less due to resistance to the action of insulin, a phenomenon often initiated by excess abdominal fat. There are other organs (e.g. liver, kidneys, muscle) and hormones (glucagon, glucagon like peptide-1) dysfunctions of which contributes to high blood sugar levels. When sugar is unable to enter cells due to inaction of insulin, these cells are deprived of energy, which causes fatigue and weakness. Excess sugar takes up water, which causes ‘polydipsia’ and ‘polyuria’ (see chapter 1 for definitions).

Pre-diabetes:

A vast majority of patients with type 2 diabetes (see below) initially go through a phase of pre-diabetes, when the blood glucose levels are between normal and diabetes. Pre-diabetes is not an innocuous condition. Persons with pre-diabetes are at about 50% higher risk of cardiovascular disease, stroke and damage to other parts of circulatory system. Indians convert from prediabetes to diabetes faster than other races. However, prediabetes does not necessarily progress to diabetes, and many indivduals, with correct diet, physical activity, and sometimes drugs, could revert to normal glucose status. Intensive diet and lifestyle modifications could reverse the blood sugar levels to normal levels.

Diagnosis of prediabetes gives an opportunity to get this state back to non-diabetic state by correct lifestyle and sometimes, with the use of drugs.

Types of Diabetes:

Type 1 Diabetes Mellitus (T1DM or ‘Juvenile Diabetes’ or Insulin Dependent Diabetes):

Type 1 diabetes is an auto-immune disorder in which the pancreas fails to produce insulin due to the destruction of the insulin producing β cells (insulin producing cells in specialised area ‘Islet of Langerhans’ in pancreas). It’s cause is unclear, but in background of appropriate genetic predisposition, viruses, pollution, and other yet unknown factors cause the formation of antibodies against pancreatic β cells, thus, destroying them. This causes blood glucose levels to rise to dangerously high levels. Insulin therapy is essential for survival of the patient.

Type 1 diabetes is a comparatively rare form of diabetes (approximately 5–10% patients have it) in India, and occurs predominantly in younger people, from childhood to young adults (upto 20 years).

The key characteristics of patients with type 1 diabetes are:

Young age of onset (mostly in childhood);

Sudden and very ‘explosive’ onset, generally accompanied by ketoacidosis (accumulation of dangerous acids in body in the absence of insulin) and sometimes coma (unconsciousness);

Dependence on insulin for life;

Most often, there is absence of obesity. Indeed, many patients at presentation are underweight;

Positive blood tests for auto-antibodies (e.g. ‘Anti-GAD antibodies’).

In some patients, slower destruction of pancreatic β cells occurs, hence, onset is slow, often over several years. This type is called Latent Auto-immune Diabetes in Adults (LADA), since it manifests in adulthood, and onset is insidious.

Type 2 Diabetes Mellitus (or T2DM or Adult-onset Diabetes):

Unlike type 1 diabetic patients, people with type 2 diabetes are able to produce insulin in their pancreas. Many of these patients have resistance to action of insulin due to excess body fat. Body tries to overproduce insulin to counter rising glucose. Later, insulin secretion falls as pancreatic β cells get exhausted. Type 2 diabetes usually occurs among people of 30 years or more. However, it is increasingly being seen in the younger age group. It is strongly linked to overweight/obesity. Approximately 90% of diabetes cases worldwide are of this type.

Type 2 diabetes is typically characterized by:

Gradual onset over a period of time, sometimes without symptoms;

Adult onset, now also seen in age 20s and 30s;

Strongly linked to obesity (which causes insulin action to be low; insulin resistance);

Usually responds to lifestyle alterations, weight loss and oral medications.

Gestational Diabetes (Pregnancy-related Diabetes):

Many physiological and hormonal changes during pregnancy produce stress and resistance to the action of insulin, resulting in high blood glucose levels. Gestational diabetes is a term used for high blood glucose levels which occur only during pregnancy. Factors causing gestational diabetes include obesity, late pregnancy, family history of diabetes, previously delivering a child weighing 4 kg or more and in certain ethnic groups, including Indians. A woman with gestational diabetes may have hypertension, increased risk of miscarriages, caesarean section delivery, and diabetes later in life. Complications for the baby includes; large in size, jaundice, birth defects, lung problems and low sugar levels immediately after birth. Such type of diabetes is best treated with insulin (see chapter 13 for management of diabetes in pregnancy).

Maturity-onset Diabetes of the Young (MODY):

About 1–2% of diabetics suffer from a rare form of diabetes labelled as MODY. It is strongly related to genetic alterations and its main characteristics are:

Onset among young people of below 25 years of age;

Strong family history: First - degree relatives have a 50% probability of inheriting the same gene mutation, which confers a greater than 95% lifetime risk of developing diabetes;

Obesity need not a be a determining factor;

The patient may not need insulin.

Other Types of Diabetes:

Diabetes could occur secondary to pancreatic inflammation (‘pancreatitis’); calcium deposition in pancreas (‘calcific pancreatitis’), drugs (e.g. steroids, drugs used after transplanst to prevent kidney rejection); and rare genetic mutations.

Frequently Asked Questions about Diabetes (The answers may overlap with some information given elsewhere in the book)

Q.I am fit and fine; can my blood sugar be elevated?

A.Nearly 50% of patients do not have symptoms of diabetes, hence regular blood sugar check up is warranted after 30 years of age, even if a person feels ‘fit’.

Q.I am