FEBRUARY 2014

POINT
OUT
HEALTH DIABETES
The silent killer
» DR. ANOOP MISRA &
DR. SWATI BHARDWAJ
Diabetes Mellitus (DM) is one of
the most common non-communicable
diseases (NCDs) globally.
Over the past 30 years, the status
of diabetes has changed from being a mild
disorder of the elderly to one of the major
causes of morbidity and mortality affecting
the youth and the middle-aged people.
It is the fourth or fifth leading cause
of death in most high-income countries
and there is substantial evidence that it is
epidemic in many economically developing
and newly industrialised countries.
What makes Indians more prone?
For years, we have heard that Indians
are at a greater risk for diabetes. Clearly,
Indians have a higher predisposition to
syndrome X (clustering of various risk
factors, a first step towards diabetes), type
2 diabetes and coronary artery disease, as
compared to other ethnic groups. These
phenomena cannot be ascribed to a single
factor, but to multiple factors.
Most importantly, Indians have more
accumulated fat in their bodies from the
time of birth, nearly 1.5 times more than
the white race. This can be accumulated
in many places, but when it gathers at the
abdomen, it interferes with the body’s
metabolism and becomes a health problem.
As a rule, Indians tend to have greater
waist circumference and waist-to-hip
ratio. Why Indians have higher body fat
is not clear, however it has been suggested
that during centuries of famine, body developed
a mechanism that enables it to
store energy in the form of fat (‘best storage
form of energy’) to be used at times
of food scarcity. Now that the food is in
excess, this accumulated fat has increased
rapidly. We have also researched that
this excess fat gets deposited in peculiar
places in the body; nape of neck (akin to
‘buffalo hump’) and below chin (‘double
chin’). In fact, these markers could easily
be recognized and lend increased risk for
the development of diabetes.
Secondly, there is an inherent tendency
amongst Indians for insulin to act
slowly and in an ineffective manner. This
could be dictated by the genes.
Next, our livers (‘prime site of glucose
metabolism’) are also full of fat and
the metabolism is markedly sluggish as
shown by recent data on Indians.
Besides, these risk factors are aggravated
by the social and economic outcomes
of urbanisation, industrialisation and globalisation.
In India, rapid urbanisation
and changing lifestyles are contributing to
widespread onset of diabetes. More people
are leading relatively sedentary and highly
stressful lives, combined with regular intake
of fast foods with high quantities of fats, refined
carbohydrates and sugar.
Migration increases Adiposity (fatness)
and Type 2 Diabetes (T2DM) amongst Indians.
Migration, whether inter-country, or
intra-country, appears to be a risk factor for
diabetes and other cardiovascular diseases.
Adiposity and insulin resistance in migrant
Indians tended to be higher than either
urban or rural-based dwellers in India. Indians
are metabolically dysfunctional. We
can be classified as ‘metabolically obese’ or
more appropriately dysfunctional, i.e. we
have multiple metabolic derangements but
are ‘non-obese’ by conventional body mass
index standards. These ‘non-obese’ people
usually have high body fat, abdominal adiposity
and thick truncal subcutaneous fat.
These body composition characteristics
individually, or in combination, contribute
to insulin resistance, dyslipidemia, and
hyperglycemia. According to our view, it
seems that the ‘switch” for metabolic control
slowed down several centuries ago.
This ‘switch’ continues to work in the same
mode, even when more control is needed.
A hypothesis emphasising on the fact
that fetal under-nutrition leads to altered
metabolic programming in adult life has
been proposed but lacks firm evidence. Indian
babies born small and with low birth
weight were found to have higher systolic
blood pressure and adiposity at the age of
eight years. These data have prompted the
concept that the syndrome X originates in
the mother’s womb and that at this time,
key metabolic activities may get modulated.
Lifestyle and diabetes
Presently, the Indian population is
going through a phase of dietary transition;
leaving the traditional diets, people
have now started opting for commercially
available packaged foods or quick homemade
foods. These snacks, often regarded
as ‘comfort foods’, are quickly prepared or
are easily available commercially and include
fried foods that are high in energy
and fats (saturated and trans fats) but low
in nutrients. The increase in the intake
of energy dense foods together with low
levels of physical activity are leading to
increased incidence of obesity and other
related lifestyle diseases like diabetes, hypertension,
cardiovascular disease and
the metabolic syndrome. Sedentary habits,
especially watching TV, are associated
with significantly higher risks for obesity
and type 2 diabetes.
Given the current dietary patterns
of Indians and increasing prevalence of
lifestyle diseases like diabetes, cardiovascular
diseases, etc., it is important to generate
awareness about good nutrition and
health for the prevention of obesity and
diabetes. These shall not only promote
good health, but also help in the prevention
of non-communicable diseases such
as diabetes, heart problems and other
related diseases. In the long run, such
programmes shall help in reducing the
burden on the country’s economy.
(Dr. Anoop Misra is
Chairman, Fortis-C-DOC
Centre of Excellence for
Diabetes, Metabolic Diseases
and Endocrinology
& Dr. Swati Bhardwaj
is Head, Nutrition and
Fatty Acid Research, National Diabetes,
Obesity and Cholesterol Foundation)
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FEBRUARY 2014