The Hindu Business Line : Put up a vigorous fight

So, you have been diagnosed with diabetes - put aside the `doom and gloom' predictions and get on with the task of smart management of the disorder.

If you have been diagnosed a diabetic and have landed up with the condition either due to genetic factors or a lifestyle that is all wrong in terms of diet, lack of exercise and high levels of stress, there is no need to plunge into a `doom and gloom' scenario.

Medical specialists insist that through lifestyle modification — right diet, averting a sedentary lifestyle and coping better with stress levels — regular monitoring, and the right medicines you can lead an "absolutely normal, healthy and long life."

But the crucial factor in achieving this objective is avoiding the complications of diabetes such as coronary artery disease leading to heart attacks, hypertension, and kidney, eye and nerve problems.

Chennai-based Dr A. Ramachandran, Director of the Diabetes Research Centre and M.V. Hospital for Diabetes and World Health Organisation, says that over the years diabetes specialists have changed their strategy in managing this disease. "Earlier we had very conservative targets in controlling diabetes as far as blood sugar, BP and cholesterol were concerned. But we learnt the lesson that even if you control sugar to the extent of 180 mg and BP to 140/90, and cholesterol above 200, diabetics still ended up with coronary artery disease and other complications. The trials we've conducted have proved that we have to be more aggressive in treating blood sugar, hypertension, cholesterol etc."

He says that an important trial at the Steno Hospital in Copenhagen, where 180 patients were divided into two groups, had thrown up interesting results. One group was managed aggressively, keeping patients' sugar as low as possible, BP at 120/80 and cholesterol below 200, while the other was managed more conservatively. It was found that within seven years there was a big difference in the complications the two groups developed. "This was an eye-opener that we have to take an intensive, multi-targeted approach; if you're aggressive in total management, and not treat a diabetic only for blood sugar, you'll get good results," he says.

The best approach is of course prevention, says Dr Ramachandran, explaining that diabetes is caused by genetic and environmental factors, including stress. The biological factors are obesity and sedentary lifestyle and these surface in a society as it progresses; "in India we're seeing more diabetes than there was 10 or 20 years ago... we seem to be adopting a nutrition and lifestyle pattern that is not healthy. India in a way is still a poor country that is undergoing rapid globalisation and economic progress. For rural people or even the urban uneducated, obesity is still a sign of prosperity and therefore middle and lower middle-class people feel if you're thin, you're not healthy. That is why people want chubby babies."

High prevalence

Health experts are concerned over the danger India's public health network faces from the increasing incidence of diabetes. Its prevalence in urban population is 12 to 15 per cent; in small towns the percentage comes down to 6 and in villages, 2. The average, points out the diabetologist, is 6 per cent. "But a major problem is that the poor in urban areas have an increased onslaught of diabetes complications because of limited access to healthcare, undetected diabetes over long periods, and high rates of smoking and alcoholism. We've found higher prevalence of heart disease in poor people in urban areas compared to the rich. That was an eye-opener," he says.

Experts rue that our health planning does not place enough importance on the preventive aspect of diabetes. "Because of our national programmes on tuberculosis, malaria and leprosy we are at least controlling if not eradicating infectious diseases. But then you are also seeing the speedy emergence of diseases associated with affluent societies and this has to be researched," says Dr Ramachandran.

But some clues are available. Even though obesity among urban Indians is not as bad as that in the US, the higher prevalence of diabetes and coronary artery disease in the Indian urban population compared to western populations points to ethnic susceptibility.

"We call it ethnic susceptibility because we're not sure of the genetic basis for Indians being more prone to diabetes," he says, giving an example from Singapore, where there is even distribution of the Chinese, Malay and Indian population with similar nutrition habits and comparable affluence levels. And yet ethnic Indians have a 50 per cent higher prevalence of diabetes compared to the Chinese.

Another interesting example, which links diabetes with stress and uncertainty, comes from the Indian workers in Gulf countries. "When people go to the Gulf countries for better prospects, there is an element of stress and uncertainty on how long they will work there, how and where they will invest their extra income. With stringent investment norms in these countries they are at a loss, and we've found a high prevalence of diabetes among these people."

IT workers more susceptible

Compared to Americans whose average age for the onset of diabetes is around 59, in India it is much less at 43. But recently, increased prevalence of diabetes has been noted in the young people working in the IT industry. "I suspect this is only the tip of the iceberg; the average age is only 25 to 35. Even though they might have family history, their counterparts with similar history don't get it so young in other professions. We know IT employees have tight deadlines, work night hours and have irregular eating habits. They have very high work pressure and they get not only diabetes and hypertension but also baldness. People think that just sitting in front of the computer is bad; but it is the lack of exercise that is killing."

With phenomenally high costs in treating diabetes and its complications, those in diabetes control and management, including the WHO, are shifting their focus to prevention. Unfortunately, the medical system in any part of the world is tuned to looking after ill people rather than caring for the health of people. And lacking glamour, preventive medicine has been ignored; it is not the favourite subject among young doctors or medicos who find no challenge in it. "They think it is routine or boring to talk of sanitation, modification of lifestyle, etc. They'd like to deal with acute or chronic diseases; become a surgeon or cardiologist. The truth is we don't have young brains getting into preventive medicine and hence it is suffering. When you do a difficult heart operation you hit the headlines. But when you prevent diabetes nobody will write about you."

Dr Ramachandran thinks the prevention message is being ignored at a huge risk. "We are producing doctors who like to sit in consultation rooms and wait for people to fall ill. There is nothing wrong in that; we need doctors to look after the ill, but if you can prevent illness, isn't that even better?"

On the possibility of remission, he says that if a very obese person developing diabetes at 23 can reduce weight, he can reverse diabetes because he is young and his pancreas works much better. Such remission can be achieved by reducing weight, bringing down cholesterol and BP, but prevention programmes were more important. "If we can think of preventing leprosy or tuberculosis, why not diabetes, he asks.

Genetic mapping and cure

Of course, all eyes are on research to find a cure for diabetes. The mapping of the human genome has raised hopes of finding the gene responsible for diabetes. "We've already found the gene for diabetes in 5 per cent of patients, who have MODY (maturity onset diabetes in the young).

If a person below 25 years, whose father and grandfather also had diabetes, gets it (it's called dominant inheritance or 3 generation inheritance), we now know it is through the transmission of a gene. This is the first type of diabetes that stands to get cured through gene therapy," says Dr Ramachandran.

But he cautions that initial costs of such treatment, which might be five years away, will be prohibitive as thousand of dollars have been poured into research over long years. For the remaining 90 to 95 per cent, such treatment is far away in the future, because the current thinking is that diabetes is multigenic or polygenic, and it's possible that even though one large gene might be responsible for diabetes, it might be modulated by surrounding genes. But the cutting edge of research is transplantation of beta cells and the Edmonton trial in Canada showed that beta cells from a cadaver pancreas infused into diabetic children with Type I diabetes (insulin dependent) resulted in insulin production in the child.

Trials are afoot at centres in the US and Canada where about 1,000 diabetic children will be infused with beta cells from cadaver pancreas. "It's not a complicated procedure but the important thing is to get the beta cells, culture them in a medium to keep them as clean as possible. Earlier they were taking beta cells from aborted foetuses which is now banned on ethical considerations."

In India, says Dr Ramachandran, "we do not have the funds for this kind of research. But we are training 3,000 doctors and 1,000 paramedics from seven Indian states, as part of a $1.3-million grant from World Diabetes Foundation, on the prevention and awareness aspects of diabetes."

On the kind of patients who comply with treatment, are very careful about their diet, and exercise regularly, he says that the educated tend to be more compliant as also those who have seen loved ones suffer from the complications of diabetes. "That is a motivating factor. But women tend to be less careful, particularly the less educated or illiterate women. So it has to be a combination of self-empowerment along with the doctor taking charge as an authoritative being who tells the patient that he/she has to follow a particular diet, keep blood sugar and cholesterol levels low. A combination of the two approaches is the best."

But then however careful you might be, there are factors beyond your control. Like the 60-year-old Muslim woman from Tirunelveli who has severe peripheral neuropathy, which means there is no sensation in her legs. She has to wear footwear all the time because sans sensation, any injury would tend to remain unnoticed. "When she came to us for treatment of swelling, fever, vomiting, etc, I asked her why she had run so much at this age and that too without footwear. And she said: `Doctor haven't you heard of the tsunami waves?'

On December 26, when the tsunami waves came, she had to run for half a mile to save her life.

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