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Being “Indian”: A risk factor for type 2 diabetes mellitus? Type 2 diabetes mellitus (“diabetes”) was traditionally considered an age-related disease predominantly affecting individuals living in developed countries. While its global prevalence has steadily increased throughout modern times; it has reached epidemic proportions in the developing world over the past 3 decades for reasons that are not fully understood. Sumit Bhagra, MBBS Bhagra.Sumit@mayo.edu Currently, India is home to the largest number of diabetic individuals in the world. People of Indian origin living outside India, regardless of when and where they migrated, have a high risk of developing diabetes. Studies from Fiji, Mauritius, Malaysia, Singapore, Kenya, United Kingdom and United States of America have reported a higher risk of diabetes in people of Indian origin living in those countries compared to local people and even other immigrant ethnic groups. Prevalence of diabetes in India: Based on projections from a recent study (phase 1 of the ICMR-INDIAB); India has 62 million diabetic individuals and 77 million people with prediabetes (Anjana, Diabetologia, 2011). Indian people develop diabetes at a younger age and lower body mass index (BMI) than their western counterparts. A study from Chandigarh in northern India showed that 11.1% people surveyed had diabetes (Ravikumar, Diabetes Metab, 2011). A study from Chennai in southern India showed that the number of diabetics had nearly doubled (72% increase) over a short span of 14 years (Ramachandran, Diabetologia, 2001). Prevalence of diabetes in Asian-Indians living in the United States: A survey conducted on randomly selected Asian-Indian people living in various cities within the United States showed that nearly 1 in 5 people had diabetes. Surprisingly, the average age of those surveyed was just 45 years and these people were not markedly overweight (Misra, J Diabetes Complications, 2010). Diabetes in Indians: Nature vs. Nurture?: How do we explain the high risk of diabetes in Indian people? What factors can explain the rapid increase in diabetes seen over the past 3 decades? Is it our genes or the environment... or both? It is reasonable to assume that Indians have a genetic predisposition for diabetes, being that Indians living in different parts of the world share that risk. However, studies from India show that city-dwellers and people with a higher income are affected with diabetes more often than lower-income rural counterparts. Moreover, healthy people from villages that migrate to an urban setting within India show adverse metabolic changes including diabetes. While genes may play a permissive role, it appears that the recent epidemic of diabetes ought to be explained by invoking environmental factors such as changes in diet, activity and other lifestyle patterns. Nutritional Imbalance: A variety of dietary factors could explain the development of diabetes (a) increased omega-6 fatty acid intake (b) increased intake of saturated fat (c) increased sugar consumption. One or more of above factors may be partly responsible for the higher prevalence of diabetes in Asian-Indians. Alternatively, Asian-Indians may be ill-suited to “western” dietary patterns due to genetic factors. Physical inactivity: Data regarding leisure activity and physical fitness in Asian-Indian children and adolescents are sparse. Asian-Indian children may have lower level of activity and fitness due to nutritional, social and cultural factors. Cross-sectional data from Asian-Indians living in the United States shows that 65% of those interviewed did not get the recommended minimum daily exercise. Prevention: The first step towards prevention is the recognition that being “Indian” is a risk factor for diabetes. Summarized below is a list of interventions that can potentially decrease the burden of diabetes on Asian-Indian populations. 38
Being “Indian”: A risk factor for type 2 diabetes mellitus? Diabetes: Prevention at the population level Catch them young! School based educational programs School based dietary interventions School based physical activity interventions Spread the word Mandatory food labels Educational programs for via mass media Educational programs for medical providers to spread awareness regarding Asian-Indian predisposition for diabetes; need for aggressive risk reduction. Screening programs Lower cutoff points for overweight and obesity to appropriately identify at-risk individuals. Develop guidelines to screen for pre-diabetes and diabetes in Asian-Indians. Development of robust healthcare infrastructure Cost-effective, value-driven primary care for all Secondary prevention Surveillance and lifestyle coaching programs for at-risk and pre-diabetic individuals Tertiary prevention Cardiovascular risk reduction (weight reduction, cardiorespiratory fitness programs, smoking cessation, optimal management of blood pressure and lipids) Diabetes: Prevention at the individual level Diet (Misra, Diabetes Technol Ther, 2011) Reduced intake of carbohydrates. Preferential intake of complex carbohydrates and low glycemic index food. Higher intake of fiber. Reduced intake of saturated fat. Optimal ratio of essential fatty acids. Reduced intake of trans- fatty acids. Lower intake of salt. Restricted intake of sugar. Activity (Misra, Diabetes Technol Ther, 2011) Children: 60 minutes of moderate-intensity physical activity daily Adults: 30 minutes of moderate-intensity physical activity + 15 minutes resistance training + 15 minutes work related activity (total 60 minutes daily) Summary: Diabetes shows many worrisome characteristics in the Asian-Indian population. First, the age of diabetes onset in Asian-Indians is at least a decade earlier than in a Western population hence threatening young people in the prime of their life. Second, the early age of onset translates to a higher lifetime risk of diabetic complications and associated costs. Third, the sheer magnitude -- 140 million people with prediabetes or diabetes live in India, totaling a little less than half the population of the United States. How to stem the tide? There is no magic bullet solution for this problem. Diabetes is a complex disease resulting from adverse interactions between genetic and environmental factors. For any solution to be effective, a comprehensive multi-pronged strategy is needed; an action plan that incorporates elements of healthcare infrastructure investment, childhood education, lifestyle counseling, early diagnosis and management to decrease complications and deaths related to diabetes. 39
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Page 10: Amb. Nirupama Rao Ambassador Of Ind
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