Sunday, May 6, 2012

Management of Diabetes: A Philosophical Approach

The world is affected by the specter of a galloping increase in the population affected by diabetes. Diabetes, as is commonly known, represents the inability of the body to process the sugars it ingests, in a manner that it can maintain the blood sugar levels in the body at healthy levels. This inability leads to accumulation of sugar in the cells and in the blood stream leading to adverse consequences for various parts of the body. Failure of the pancreatic beta cells to produce insulin that is required to breakdown the sugars, if it occurs from the very early age causes juvenile diabetes, also called Type 1 diabetes. In most people, the failure of beta cells occurs progressively during adulthood and beyond, which is called Type 2 diabetes. While diabetes is considered to run in families and Type 1 diabetes may be considered an unfortunate genetic mishap, Type 2 diabetes may be considered as lifestyle recklessness, with adverse genetic influences.

Even as India is racing towards becoming a global economic superpower, emerging in the process as a new global capital of outsourced manufacturing, research and services, it is also racing to become the diabetes capital of the world. Of India’s estimated 1,300 million population, over 53 million constituting around 4% of the population is diabetic. Together with co-morbidities such as metabolic syndrome, cardiac and kidney complications as well as circulation and neurological problems, the percentage of population directly or indirectly affected by diabetes in India is much higher. The fact that diabetes and co-morbidities are hard to detect until they are well advanced and are in fact symptomatic is an added concern. Clearly, the increasing prevalence of diabetes with increasing prosperity of the nation is worrisome.

WHO statistics

The World Health Organization (WHO) predicts that developing countries will bear the brunt of this diabetes epidemic in the 21st century. Currently, more than 70% of people with diabetes live in low- and middle income countries. An estimated 285 million people, corresponding to 6.4% of the world's adult population, has been living with diabetes in 2010. The number is expected to grow to 438 million by 2030, corresponding to 7.8% of the adult population. While the global prevalence of diabetes is 6.4%, the prevalence varies from 10.2% in the Western Pacific to 3.8% in the African region. However, the African region is expected to experience the highest increase. Over 70% of the current cases of diabetes occur in low- and middle income countries. With an estimated 50.8 million people living with diabetes, India has the world's largest diabetes population, followed by China with 43.2 million.

The largest age group currently affected by diabetes is between 40 and 59 years. By 2030 this “record” is expected to move to the 60 and 79 age group with some 196 million cases. Diabetes is one of the major causes of premature illness and death worldwide. Non-communicable diseases including diabetes account for 60% of all deaths worldwide. In developing countries, less than half of people with diabetes are diagnosed. Without timely diagnoses and adequate treatment, complications and morbidity from diabetes rise exponentially. Type 2 diabetes can remain undetected for many years and the diagnosis is often made from associated complications or incidentally through an abnormal blood or urine glucose test.

Type 2 diabetes is responsible for 85 to 95% of all diabetes in high-income countries and may account for an even higher percentage in low- and middle-income countries. About 80% of type 2 diabetes is preventable by changing diet, increasing physical activity and improving the living environment. Yet, without effective prevention and control programs, the incidence of diabetes is likely to continue rising globally. Insulin is vital for the survival of people with type 1 diabetes and is often ultimately required by people with type 2 diabetes. Even though insulin's indispensable nature is recognized by its inclusion in the WHO's Essential Medicines List, insulin is still not available on an uninterrupted basis, and at an affordable price, in many parts of the developing world.

Expressed in International Dollars (ID), which corrects for differences in purchasing power, estimated global expenditures on diabetes will be at least ID 418 billion in 2010, and at least ID 561 billion in 2030. An estimated average of ID 878 per person would have been spent on diabetes in 2010 globally. Besides excess healthcare expenditure, diabetes also imposes large economic burdens in the form of lost productivity and foregone economic growth. The largest economic burden is the monetary value associated with disability and loss of life as a result of the disease itself and its related complications. WHO predicted net losses in national income from diabetes and cardiovascular disease of ID 557.7 billion in China, ID 303.2 billion in the Russian Federation, ID 336.6 billion in India, ID 49.2 billion in Brazil and ID 2.5 billion in Tanzania (2005 ID), between 2005 and 2015. Unless addressed, the mortality and disease burden from diabetes and other NCDs will continue to increase.

Balanced life

All researchers and practitioners in the field of diabetes and endocrinology agree that a healthy, vigorous and balanced lifestyle is essential to prevent the onset and progression of diabetes. Such a virtuous lifestyle is also essential to manage and moderate diabetes that has been detected in its later stages. Despite this universal wisdom, the followers of a healthy lifestyle to beat diabetes are few and far between. The ancient Indian way of living which had encouraged a proper food pyramid with spices, herbs and condiments with both prophylactic and therapeutic properties had been a good foundation of ancient generations’ diabetes-free way of living. All the exotic cooking inputs now recommended by Western researchers from whole grains to deep greens had always been staple food in India. The items erroneously banned by Western practitioners of diabetes and cardiac treatment, and now welcomed by them based on new research, such as coconut preparations, milk products and seed oils had also been a part of the traditional multi-course Indian diet.

The ancient Indian system, which has been predominantly agrarian, had encouraged significant domestic work and field work by all the family members. Working in the bright Sun provided the needed input of Vitamin D which is now recognized as an important element in optimizing the cholesterol and triglyceride mechanisms of the body. The modern Indian system, oriented increasingly towards urban living, fast transport, junk food, sheltered air-conditioned atmosphere, disorderly living and stressful working hours has been a perfect recipe for the spread of diabetes. While the new pattern of Indian eating dominated by polished rice and sweet meats has been bad enough the invasion of the Indian palate by sugary carbonated beverages and ice creams has spelt disaster for the Indian child. While sweets have always been a unique part of the Indian cuisine, most of such traditional sweets were products of jiggery that is low in glycaemic index and high in fiber, relative to sugar. While one answer to the growing diabetes epidemic could be a spring-back to ancient dietary habits, a more philosophical approach is required to be adopted fundamentally.

A prophylactic disease!

The greatest feature of diabetes is that when it is well understood and well managed it is a in fact a prophylactic disease (if such a phrase can be coined!) . If its risk is detected well in time and the necessary correctives to lifestyle are adopted the disease actually promotes wellness. By regulating intake of calories, and balancing it with energy expenditure one may stay fundamentally fit. By adopting a balanced food, one also provides the optimum nutrition to the body. By following the rigors of exercise and integrating the elements of yoga and meditation, one discovers harmony with nature and finds the right balance between the body and the mind. By eschewing the temptations of tobacco and spirits and a callous lifestyle, one avoids the damage to the sensitive organs of the body like liver and lungs, and keeps away dreadful diseases such as cirrhosis and cancer. In spite of the abundance of knowledge and the simplicity of prevention and cure, few people actually follow the simple yet challenging regimen required for a diabetes-free or diabetes controlled good living.

The trend in the Indian psyche to treat diabetes as an “easily treatable” disease rather than as a “carefully preventable” disease is formed and grown by the way the modern diabetic treatments are dispensed by the physicians and the way they are lapped up by the patients. While most practitioners do have nutrition and lifestyle experts with them, the practitioners themselves spend little time on lifestyle matters, focusing instead their precious time on dispensing of medicines. Most doctors and patients focus on blood sugar whether through fasting or post-prandial metric or glycogenated haemoglobin (HbA1c) metric and titrate the medicines vis-à-vis the number. While there may be no other medical way to control the blood sugars, the resort to a fast switch amongst the various diabetes medications, experimental combinations of different medications, including insulins, and hasty prescription of certain medications such as glitazones and statins as mandatory adjuvant medicines inject a needless aura of easy conquering of what is one of the most complex metabolic diseases.

Linear practice, non-linear results

One of the biggest fallacies of modern diabetes treatment is the concept of linear diabetology. The thesis here is that the higher the sugar levels, the higher ought to be the medication levels. This often translates into a dangerous self-destructing weapon in the hands of the patients with them trying to pop an extra pill or inject a few extra units of insulin to compensate for excess food intake or tame a seemingly defiant blood sugar profile, at times disastrous effects of hypoglycemia. The fact is that the pathways of insulin transport and carbohydrate and fat metabolism as well as the body’s reserves of insulin and glucagon are not understood precisely even today; neither are the pathways by which certain medicines including the most popular metformin acts. In addition, various factors such as the type of insulin, site of administration, depth and mode of injection and the nature of the tissues influence the effectiveness of the administered insulin, making it impossible to predict how certain levels of calories and certain units of insulin could be matched.

Effective diabetes treatment requires customization of the treatment to the patient and a continuous feedback mechanism between the doctor and the patient. Blood sugar measurement, any number of times in the day, and any number of days, cannot substitute the wisdom of reaching a standardized balance and staying true to it through patient-physician rapport. In fact, frequent blood sugar measurement adds little to one’s knowledge of one’s disease as the measures are mere results of the constantly dynamic equilibrium the body tends to seek by itself. Assumptions of co-morbidity and inflated treatments thereof are also equally counterproductive. Effective time management is probably the first fundamental step for initiating any treatment of diabetes. A person who is unregulated and injudicious in his or her management of time adds toxic inputs such as stress and disorderly food and deletes positive influencers like exercise and balance diet from the daily grind. In such a situation, a search for linear diabetology (a very effective phrase coined by Dr CV Krishnaswamy, the noted diabetes physician of Chennai) would be as infructuous and as irrelevant as the concept that diabetes could be cured linearly is.


Unlike any other medical condition the physiology of diabetes is easy to grasp. Yet, its simplicity is not leveraged either by the physicians and patients alike because the psychological underpinnings are not understood as the basis of treatment. In general, the more anxious the patient is for an instant cure and the more impatient the doctor is for effecting a pill or based injection based treatment, the more disorderly the treatment is likely to be. The more adamant the patient is towards effecting lifestyle changes and the more reluctant the doctor is for spending time with the patient in advocacy of lifestyle changes, the more regressive the treatment is likely to be. Proper diabetes treatment would require an open mind on the part of both the patient and the doctor to customize the treatment.

The family and office ecosystem also plays a major role in the orderly management of diabetes. A family which disregards the principles of healthy living, including the need for balanced diet and stress-free interactions, is more than likely to aggravate the diabetic state, and even lead healthy people to a state of pre-diabetes or full-fledged diabetes. An office system which does not observe regular hours or does not provide healthy eating options when people work overtime or on extended shifts is also likely to affect operational health. A diabetic patient is also truly blessed to have friends and well-wishers as well as peers and managers who recognize his diabetic state and support him in developing a healthy lifestyle. With a little philosophy and patience, and by consciously integrating certain forgotten principles of healthy living enshrined in the ancient Indian texts, and by appreciating the virtues of optimality in cuisine, serving and eating, India as a nation can reverse the diabetes epidemic.

Posted by Dr CB Rao on May 6, 2012

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