Vanathi, a 39-year-old single mom, who works as a maid in three homes has been diagnosed with diabetes. Her parents do not have diabetes and she is not overweight. She did however have a very traumatic relationship with her abusive husband who died of alcohol-related complications a year ago. As the only earning member of the family and two high school-going children, she finds managing her diabetes a real challenge. Her inability to afford healthy foods, medications, and self-monitoring supplies, and the added stigma of diabetes have caused her considerable distress.
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Why did Vanathi develop diabetes and what could she have done about it?
Each year, November 14 is marked as World Diabetes Day. The International Diabetes Federation selects a theme for the year and there are worldwide awareness and advocacy efforts around the theme. This is not only necessary but critically vital to help contain the rapid rise in the prevalence of diabetes and its complications.
There are currently 540 million persons living with diabetes globally and the vast majority live in middle- and low-income countries. Diabetes has long been thought of as a problem of the old, and the affluent but the ground reality is entirely different. In many metros in India, the poor have more diabetes than the rich. The urban-rural divide is blurring. If genetics and ethnicity are the only major risk factors, why are the numbers of persons with diabetes multiplying at such an alarming rate in such a short time? The reasons are many. Keeping with the theme of WDD 2023, I have listed the existing and emerging risk factors [There are likely many yet-to-be-discovered risk factors].
Genetics
A family history of diabetes (grandparents, parents, siblings) increases significantly the risk for type 2 diabetes. This is what we call a non-modifiable risk factor.
Response: every effort must be made to have family members of persons with diabetes screened periodically and begin proactive efforts to prevent or postpone the development of diabetes.
Ethnicity
Certain ethnic groups seem to be at much greater risk for developing diabetes. The Asian ethnic group [ Includes Indians, who are part of the South Asian group] has the world’s highest number of persons with diabetes, and rising tremendously due to risk factors like low birth weight, nutrition transition, genetics, urbanisation, and social determinants of health like poverty and environmental factors.
Response: Screening for diabetes at the appropriate age and regular intervals. Lifestyle changes to lower risk and policy level changes to address air pollution, built environment, and food security.
Also Read | Explained: How can India tackle its diabetes burden?
Overweight and obesity
The obesity epidemic is fuelling the rise in diabetes in a big way. The National Family Health Survey 5 has shown that obesity continues to rise especially in women. Obesity also predisposes to prediabetes, gestational diabetes and amplifies certain complications of diabetes.
Response: Healthy eating from childhood and throughout life, physically active lifestyle, policy level changes for an enabling environment. School-level education about healthy eating and physical activity and workplace wellness initiatives.
High blood pressure
Hypertension is both a driver of diabetes and a frequent companion of diabetes. Both are often dismissed Together it is double jeopardy and raise the risk for kidney and heart disease considerably.
Response: Screening for diabetes and optimizing BP control in individuals with hypertension.
Gestational diabetes
Nearly 10-15% of pregnant women in India develop gestational diabetes and 25% of women in SE Asia are reported to have high sugars during pregnancy. The big challenge is the increased risk of diabetes in the mother within 5-10 years of the pregnancy and her child at a relatively young age.
Response: Prevention of gestational diabetes with good preconception care and focusing on prevention of childhood and adolescent obesity through school and college-based awareness programs.
Breastfeeding is known to decrease the risk of diabetes after GDM [ in the mother]
Women with GDM must have their blood sugars retested 6-12 weeks after their delivery and periodically even if their initial results were normal. The next pregnancy must be planned well with preconception testing and care.
Unhealthy eating
The intake of excess calories can lead to weight gain which is a well-known driver of diabetes. The composition of the diet also matters. Increased intake of red meat, sugary foods, artificially sweetened drinks, high-calorie junk foods, white rice, deep fried and salty foods have been implicated in causing diabetes
Response: Inclusion of vegetables, fruits, nuts, seeds, millets, good quality protein [ fish, chicken, egg whites, lentils/ dhals. dairy] and portion control in addition to avoiding sugar-sweetened and diet drinks and high-calorie snacks.
Sedentary lifestyle
Lack of physical activity and prolonged sitting are well-established risk factors for type 2 diabetes. Several of the drivers of diabetes such as obesity, high blood pressure, unfavorable cholesterol profile, and insulin resistance are increased or amplified by a sedentary lifestyle.
Response: An active lifestyle from childhood and throughout life significantly lowers the risk of developing diabetes. Including brief periods of activity [ 10 mins every 1-2 hours] throughout the day or dedicating 30-60 mins of physical activity daily are recommended solutions.
Low birth weight
This paradoxical phenomenon is explained by the Barker hypothesis. Babies born small [ defined as below 2.5 kg for Indian babies’ born full term] have changes in their organs [ called programming] that predispose them to diabetes, heart disease, and hypertension. They are at greater risk if they are overfed after birth.
Response: The nutrition of pregnant women is critically important. Even more important is the health of women of reproductive age before they become pregnant. Undernutrition, nutritional deficiencies, anaemia, stress, hypertension, smoking, and air pollution can all lead to low birth weight. Good preconception care could ensure the optimisation of birth weight.
The first 9 months shape the rest of our lives.
Mental stress
There is strong evidence that links mental stress with the development of diabetes. Several mechanisms have been put forward. Stress causes a rise in serum Cortisol and Catecholamines which are counter insulin stress hormones and in inflammatory cytokines. In addition, stress may be associated with unhealthy eating, physical inactivity, poor sleep, smoking, and substance abuse.
Response: Developing coping skills through counselling, yoga, meditation, and mindfulness.
Smoking
The chemicals in cigarettes and some of the metabolites of nicotine increase the risk of inflammation, insulin resistance, and oxidative stress, all of which predispose an individual to diabetes. This includes all forms of nicotine use.
Response: The only solution is to quit smoking. It may be challenging. Many smoking cessation programs can help. Large scale public health program are needed to prevent school and college students from any form of smoking .
Caregiving
Many aspects of caregiving may increase the risk for diabetes. Mental stress, depression, lack of time for self-care, time constraints for physical activity and routine health checks, financial difficulties, and poor sleep may all independently and or collectively raise the risk for diabetes. Caregiving can be an independent risk factor especially in the elderly and especially when associated with an unfavourable support system at work and at home.
Response Sharing caregiving responsibilities, dedicating time for self-care, pursuing stress-relieving activities/ hobbies, and practicing mindfulness, yoga, and meditation. Counselling and attending support groups may also help.
Sleep
Insomnia, poor sleep habits, and obstructive sleep apnea are all associated with the risk of developing diabetes. Poor sleep may also be associated with smoking, alcohol use, obesity, and stress.
Response: Good sleep hygiene, 7-8 hours of sleep, and consulting a physician / a sleep medicine expert when appropriate. Addressing the root cause of poor sleep patterns is most important.
Gut microbiome
This is fast emerging as an important driver of many health issues including diabetes. An assortment of microbial organisms lives in our intestines playing an important role in immunity, and glucose metabolism. Dietary patterns, composition of the food, use of antibiotics, and unhealthy foods can lead to changes in intestinal flora and permeability and inflammation Gut dysbiosis has also been linked with type 1 diabetes, gestational diabetes, and obesity.
Response: Healthy eating, avoiding antibiotic overuse and abuse, avoiding unwarranted C-section deliveries[ the baby’s gut flora is influenced by mother’s normal vaginal flora] Foods rich in pre and probiotics can help.
Also Read | Can community support, social welfare policies bridge the gender gap in diabetes care?
Poverty and social determinants of health
The social determinants of health especially education level, food security, access to health care, and the built environment (crowded living spaces, lack of urban planning, air pollution) have an outsized role as drivers of noncommunicable diseases such as diabetes.
Vanathi is a striking example of this. She had financial difficulties, was resource-limited, had severe mental stress, and poor sleep. She could only afford inexpensive foods like rice and could not buy vegetables, dhals, and healthy proteins often. She also lived in a crowded small space. Her work schedule precluded her from seeking preventive health care. Her risk factors for developing diabetes are many but all are modifiable. Vanathi’s current challenges need the support of her family, the community, and the health care system.
Many additional risk factors
Age has always been considered as one. However unhealthy lifestyles and many of the risk factors listed above have made diabetes increasingly prevalent in men and women in their 20s. 30’s and 40’s.
Non-alcoholic fatty liver [ now known as Metabolic dysfunction associated steatosis liver disease MASLD] is emerging as a risk factor.Persons with TB and HIV are also at greater risk for diabetes and so are individuals who have had Covid infection.
Response : Vaccinations, safe sexual practices, and screening for diabetes are the appropriate preventive strategies.
Polycystic ovary syndrome, the most common endocrine disorder in women of reproductive age has a severalfold higher risk for diabetes and gestational diabetes
Response: Frequent screening, good nutrition, weight management, and physical activity remain the best and most effective solutions.
Be free
Diabetes is preventable in 75% or more of the cases. Education, empowerment, and engagement are key to prevention. Knowing the risks and responses is the first step in that journey.
Be aware. Be proactive. Be free of diabetes and its complications.
(Dr Usha Sriram is head of Diabetes and Endocrinology, TAG Center, Voluntary Health Services, Chennai)
Published - November 13, 2023 07:44 am IST
