Diabesity in India is turning into an alarming epidemic. It is estimated that in the next 20 years, the number of those afflicted will stand at more than 100 million. With 80 per cent diabetes cases pegged on obesity, any attempt to treat the disease without managing weight is futile. SHALINI SAKSENA speaks with doctors and experts to tell you that rapid urbanisation and socio-economic development have changed lifestyles, turned diets to rich food and killed physical activity to such an extent that the disease is crossing traditional borders to assail the rural populace and children too
He weighed around 100 kg when he was 38 but didn’t really worry about it because regular medical check-ups didn’t give him any alarming indications. The doctor would tell him that all was within parametres. But that was till last year, when he went for a random blood test because a friend insisted. The blood sugar level stood at 250. His family GP told him that he had diabesity, a medical condition which has afflicted more than a billion globally.
In India, about 50.9 million people suffer from diabetes, a figure likely to go up to 80 million by 2025, making it the diabetes capital of the world. According to an Indo-US study, Delhi alone has an estimated 29.8 lakh diabetics! Almost 80 per cent of diabetes is related to obesity and alarmingly diabesity has reached epidemic proportions. In the next 20 years, more than 100 million people in India will have diabesity. Studies conducted in Mumbai and Delhi show that 65 per cent to 70 per cent Indians are obese.
But what is diabesity and what causes it? Dr Neal Bernard says in his study Program for reversing diabetes that insulin resistance comes from muscle cell fat which reduces the sensitivity of insulin receptors in the body.
In a healthy person, whose insulin receptors are working optimally, insulin lodges in the receptors and signals the gates to open for glucose to enter. The body then uses the glucose for all functions. However, in an obese person, these insulin receptors become sluggish and insulin is not effective enough to signal the uptake of glucose. This increases blood glucose levels.
Dr Anoop Misra, chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology says diabesity has become a major problem in India due to lifestyles changes. “The Indian population is going through a phase of dietary transition. Leaving traditional diets, people have now started opting for packaged foods or quick home-made foods. The increase in the intake of energy dense foods, together with low levels of physical activity, are leading to increased obesity and diabetes,” Dr Misra says.
It is not only in India where diabesity is a serious health problem. Type-2 diabetes, which makes up 90 per cent of all diabetes cases, affects about six per cent of the total adult population in the world. Cases of obesity-related type-2 diabetes among children and teenagers have grown in leaps. In her book, Diabesity, Dr Kaufman explains why: “Our ancient genes and modern environment have collided. Our forefathers hunted for food and calories were hard to come by so they were stored as fat. But in the world today food is everywhere and easily accessible as fast food and junk food and added to this is our increasingly inactive lifestyle — resulting in obesity.”
A new study conducted by the Public Health Foundation of India (PHFI) with Stanford University and published in PLOS Medicine journal in January this year says that by introducing 20 per cent extra excise duty on sweetened drinks, India can prevent four lakh people from getting diabetes and another 11 million from becoming obese over the next decade.
Dr Sutapa Agrawal who is co-author of the study said that the incidence of obesity and diabetes is increasing across India especially among women and children due to easy availability of energy dense foods and low physical activity. “One factor responsible for this is the easy access to soft drinks. This may also be true for the rise in diabesity in villages where soft drinks (both local and branded) are available in the nukkad kirana shops and thus easily accessible. In villages serving a soft drink to a visitor or is a status symbol. Also energy dense diets are available in rural areas more often today,” Dr Sutapa opines.
Therefore, by increasing excise duty over and above the existing 30 per cent, it will reduce consumption of soft drinks among middle-income groups and the rural population which are emerging as the new hotspots for diabetes. “The rural population is also undergoing lifestyle changes. Improvised technology has replaced manual agricultural practices with more mechanized techniques involving much less physical labour. This coupled with high calorie diet has led to increased problem of obesity even in rural areas. Further, migration, whether inter-country, or intra-country, appears to be a risk factor for developing adiposity, insulin resistance, diabetes and other cardiovascular risk factors,” Dr Misra explains.
According to Dr Deep Goel, director, Bariatric & GI Cancer Surgery, BL Kapur Hospital, uncontrolled diabetes leads to serious complications like high BP, heart attacks, brain strokes, blindness, kidney failure and nerve damages with amputation.
“People with family history of diabetes, heart disease and obesity are predisposed to have diabesity. If a woman’s waist is greater than 35 inches and a man’s more than 40 inches and they often have craving for sugar and refined carbohydrate then they should have their check up done for diabesity. Infertility is also commonly associated with diabesity. Seventy per cent of infertility cases have diabesity problem,” Dr Goel says adding that dietary and lifestyle factors lead to diabesity.
“The entire spectrum of diabesity, including all its complications, result from dietary and lifestyle changes and environmental toxins interacting with our unique genetic susceptibilities. The reason these dietary and lifestyle factors lead to diabesity is because they create a condition known as insulin resistance,” Dr Goel tells you.
In rural areas it is about malnutrition. It doesn’t mean that they have no food to eat, it means that their nutrition is not correct. There is imbalance in their diet. Eating foods cooked in unsaturated fats is a real killer when it comes to diabesity among villagers. “Eating fried foods cooked in the same oil again and again, drinking local sweetened drinks, children having ice lollies are other major contributors. In urban cities it is a question of eating too much, in rural areas it is about eating wrong food,” Dr Goel says.
When the diet is full of empty calories and foods that absorb sugars quickly liquid calories and carbohydrates (like bread, pasta, rice, potatoes), the fat cells which has receptors, slowly become resistant to the effects of insulin and need more and more to do the same job of keeping the blood sugar even. Hence, one develops insulin resistance.
A high insulin level is the first sign of the problem. The higher the insulin levels, the worse the insulin resistance. “For example, a healthy human body produces 300 ml of insulin to to breakdown the glucose in the cells. But due to wrong diet, the body now needs 500 ml of insulin. So there is a deficit of 200 ml of insulin. This leads to accumulation of fat in the body. The more the fat, the less the insulin leading to insulin resistance,” Dr Goel explains.
As the insulin levels increase it leads to an appetite that is out of control, increasing weight gain around the belly, more inflammation and oxidative stress, and myriad downstream effects including high blood pressure, high cholesterol, low HDL, high triglycerides, weight gain around the middle, thickening of the blood and increased risk of cancer, Alzheimer’s and depression. These are all a result of insulin resistance and too much insulin.
Because insulin resistance and diabesity are a direct outcome of diet and lifestyle, the condition is 100 per cent reversible in majority of the cases. Most people just need to eliminate the things that are sending their body out of balance and include what’s needed to help the body rebalance itself. For most, the interventions required are simply and effective.
But Dr Goel opines that what may appear to be simple may be extremely difficult for another. Making changes in one’s lifestyle and diet will not work for those who are indisciplined.
“We all know that eating pizzas, samosas and other fried items is harmful yet we eat it. So to say stop eating these foods is easier said than done. Only a disciplined person can do it. Hence, I never recommend bariatric surgery for a person who wants to just sit at home and think that the surgery will work miracles, not that it doesn’t. But the chances of that person gaining weight again, because he is indisciplined, is high. So the first change that one has to make is — ‘from eating a plate full, eat spoon full’. If he can do this, the surgery is recommended, Dr Goel tells you.
Unfortunately, in our country, our culture lays too much stress on food all the time. “Right from the time a baby is born, parents force-feed him. Saying that he is a growing child and can digest anything is setting a wrong precedent. Making him eat ghee and giving him food at all times leads to unhealthy eating habits which get ingrained. When that child attains adulthood, he carries those habits and changing them becomes difficult,” Dr Goel says who sees around 70 to 80 patients who need surgery on a monthly basis.
In an extensive research by Dr Misra and his colleagues conducted in 2009 he observed that obesity in urban children in New Delhi increased from 16 per cent in 2002 to about 24 per cent in 2006-2007. Further, the prevalence of obesity alone in 14 to 17-year-old children increased significantly from 9.8 per cent in 2006 to 11.7 per cent in 2009.
“Today, right from our child to adults, nobody does any physical activity. Green belts are disappearing, children don’t have space to play. Even in schools there is only one class where children go and play. But that is not enough. Adults have stopped walking. We want to take our car every where. We take the lift instead of taking the stairs. People’s lives are becoming more and more sedentary. Then there is the diet itself. The quality of carbohydrates, oils etc is deteriorating. It is not so much about how much but the quality of food we are eating,” Dr Rekha Sharma, president of Indian Dietetic Association and director of Clinical Nutrition and Diabetes Foundation (India) tells you.
She is also quick to point out that diabesity is increasing at a fast pace — right from childhood to adults. And the rise is seen more in the migrating population. “The drastic lifestyle changes in this section of the society due to food habits (from eating wholegrain to refined) to smoking, is leading to rise in diabesity. Of course, one can’t say that the same holds true for those living in rural areas. However, diabesity is on the rise here as well. While in urban population the rise is at 12 per cent, in villages it stands at six per cent,” Dr Sharma says.
However, Dr Sharma insists that it is not so much about western influence as it is genetic. “Indians are pre-disposed to be genetically fat. Our bad lifestyle has only added to the problem. We are eating more, but not burning enough,” Dr Sharma says.
Lack of awareness about the disease is a major challenge in treating the problem. Most of the people who are obese do not consider it as a health problem. Once they develop insulin resistance they are either unaware of the symptoms or they try to manage it on their own, especially in rural areas, which worsens the condition.
Other challenges include lack of medical facilities, high cost of treatment, hectic lifestyle, increased and easy availability of high fat, high sugar containing quick foods. But a a modest weight-loss goal of 5-10 per cent can substantially reduce the risk. Increasing the physical activity and following a low carbohydrate, low fat diet daily can prevent or postpone the onset of diabesity,” Dr Misra says.
- Eat three healthy meals a day, including a nutritious breakfast. Add two-three healthy snacks per day
- Replace processed foods with wholegrain and high fibre foods
- Reduce eating red meat. One is at a 20 per cent greater risk of getting diabetes over those who don’t eat red meat. Eat nuts, seeds, daal, fish or poultry
- Eat plenty of fruit and vegetables. Drink fresh vegetable juice instead of fruit juice
- Eat low calorie foods. For example, eat low fat cheese instead of the regular one and skimmed milk instead of whole milk
- Lose weight if overweight. Losing even five to seven per cent of the body weight can make a big difference
- If one can’t go to the gym opt for a brisk half-an-hour walk daily
- Smokers increase their diabetes risk by 50 per cent, so quit smoking
- Drink alcohol in moderation. One drink a day for women and up to two a day for men is ideal
- Go for regular blood tests. So, if tests show pre-diabetes symptoms, make immediate lifestyle changes
- Use as little oil as possible while cooking vegetables
- Abnormal belly fat
- Consistent rise in blood pressure
- High blood sugar
- Tendency to form blood clots
- Sugar cravings, especially after meals
- Fatigue after meals
- Increase in thirst and appetite
- Difficulty losing weight
- Visual problems
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