Health: Diabetes; Striking Young

An exponential increase in diabetics changes the disease from an individual problem to a public worry.

The last thing Abid Lalji, 30, a whiz kid in Mumbai's frenetic advertising world, had on his mind was his health. He was overweight, with the kind of spillover belly which spells good humour and the good life. A year ago, however, he suddenly began to lose weight: the scales which had groaned at 94 kg now showed 10 less. "Well, that's good," he thought. A doctor friend, though, asked him to get his blood sugar checked after he told her about the vanishing kilos. It was well over the normal blood sugar level of 120. "They wanted to hospitalise me. I just couldn't believe I was diabetic. I felt fine, just that I used to feel very thirsty."

Mandeep Kaur

MANDEEP KAUR
Age: 23 years
"You have to live with the fact: just like you have to eat and drink, you have to take insulin. That's all." Mandeep, who works with security agency Securitas Group4 in Delhi, was told by her parents to hide the illness because no one would want to marry her. "I told them, I have seen so many one- and two-year-old diabetics at AIIMS, so what is the problem? They finally understood." Mandeep's zest for life keeps her going. "I eat a lot and I dance a lot to burn all that extra sugar. Life is not too bad."

The D-word always comes as a shock. Diabetes mellitus was always something that happened to other people. To older people: if you were unlucky, to your grandparents; to your parents, if you were unluckier yet. Today, this sweet poison is creeping down the age ladder, stalking the young. With over 30 million diabetics, India has the largest number of diabetics in the world, most of them middle-aged or old. But now doctors across the country observe that not only is the illness showing up with alarming frequency, it's striking younger people. "We hardly had any patients under 40 about 15 years ago. Today every other person is from this age group," says Dr P. Shyamsunder, who heads the endocrinology department at Osmania Medical College and Hospital in Hyderabad.

Alarmed that ever younger people are being drawn into the diabetic dragnet, doctors now put those over 25 in the danger zone. Says diabetologist Sunil Gupta of Nagpur: "We now recommend that executives in the age group of 25 to 40 be tested for diabetes." Five years ago it was the over-40s who came under scrutiny. Pravin Bhasin, 23, would have remained blissfully ignorant about his diabetes had he not gone for a routine medical checkup while applying for a visa to Australia. "I had no idea there was anything wrong with me," says the Delhi-based Bhasin who plans to go to Australia to study information technology. Nobody in his family had diabetes. The only odd thing he noticed about himself was that lately, he had started to urinate more frequently.

Harshdeep Kohli

Harshdeep Kohli
Age: 6 years
"Na, it doesn't hurt," says Harshdeep, his smile never quite sliding off his cherubic face, of the two insulin injections his father gives him every day. "I say Waheguru, Waheguru and bas, it's over," says the Delhi school boy with a shrug. It's been almost two years since he was diagnosed as diabetic: he had jaundice and began to lose weight. Today, life is back on course with few changes: he goes to a sports complex for an hour every evening.

Diabetes occurs when the insulin hormone which is produced by the pancreas is either absent, insufficient or ineffective. Insulin is needed to transform the sugar in the body into energy and the unused sugar or glucose can irreversibly damage vital organs such as the eyes, kidneys, heart and nervous system. There are basically two types of diabetes. Type 1 strikes younger people, usually under 20 -- juvenile diabetics falls in this category -- and is insulin-dependent because the insulin-secreting cells have degenerated. Sometimes an infection, viral fever or illness can trigger diabetes.

While doctors in various parts of the country have observed that more children and teenagers are being diagnosed as diabetic, the evidence is still largely anecdotal. The exponential increase is in Type 2 diabetics which is strongly hereditary, according to diabetologist Vijay Ajgaonkar. The insulin produced by the body is inadequate or defective and the diabetic is not necessarily insulin-dependent. Most diabetics come under this category and are usually over 35.

Diabetes has always been somewhat of a wallpaper illness: in the background while cancer, aids, heart disease and the ubiquitous backache occupy centrestage as the scourges of our times. But today, the red alert is finally going out on this silent killer. Warns diabetologist Shaukat Sadikot of Jaslok Hospital, Mumbai: "Diabetes has crossed the line which separates an illness associated with individuals from a worrying public health problem."

A who global study on the incidence of diabetes warns that India is likely to have 57 million diabetics by 2025. And this may be just the tip of the iceberg: screenings indicate that the unknown-to-known diabetes ratio is about 1:1 in urban areas. It could be as high as 3:1 in the rural population.

Sanjay Mehta

Sanjay Mehta
Age: 34 years
"What kills you is the lack of self-discipline. Not that bit of sugar you might have." Mehta discovered he was diabetic a year ago but he hasn't let it become the be-all of existence. Mehta, who has an electronics component factory in Mumbai and a 15-hour working day, has just put some order in his life: banished junk food and irregular eating habits, has four small home-cooked meals, exercises regularly and take special care of his feet to avoid any injuries.

The medical fraternity is now responding to the alarm bells. Last month, 400 diabetologists across the country set up the Indian Task Force on Diabetes. The organisation has as its objective improvement in the standards of diabetes care in India: doctors will train primary care physicians and also carry out epidemiological studies.

Why does diabetes get top billing in India? Doctors believe Indians may be genetically more susceptible to it. Studies in London, Singapore and South Africa have shown that migrant Indians have a higher prevalence of diabetes than other ethnic groups. And it strikes Indians at a much younger age than it does elsewhere. While the peak age for a person getting diabetes in the US is between 60 and 70, it's 40-50 years in India.

There's a theory about a thrift gene which argues that diabetes evolved after the famine/feast cycles in the past. People in India for instance ate excessively during feasts. During famines, the stored food in the body would then change into glucose to enable the brain to function. But during the course of the century there were fewer famines and more feasts. That's the good news. The bad news: the ability to rapidly change carbohydrates into glucose remained. Relative affluence was the culprit -- this explains why migrants from rural areas to the cities become more susceptible to diabetes. Interestingly, the embryo of a malnourished mother which once born is fed well may also be prone to diabetes. The thrift theory can be applied here too.

NEW CURES AND RESEARCH

Islet cell transplants: these cells in the pancreas produce insulin. The cells are removed from animal and foetal pancreas, multiplied in a culture medium and then implanted in a human body. The only hitch: rejection by the host. Scientists are now working on disguising the islet cells so that the host body is unable to recognise them.

Non-injectible insulin: Pfizer in the US is currently testing insulin inhalers which will make it easier for diabetics, especially children, to take insulin doses. Other pharmaceutical companies are developing insulin patches.

Insulin sensitisers: These tablets make insulin more effective and reduce the strain on the pancreas. However, it can affect liver function. Pharmaceutical companies are trying to eliminate the side effects.

Acarbose: These tablets delay the absorption of carbohydrates from the intestine enabling the body to metabolise only a percentage of what is eaten and ensure that the rest is excreted. Already available.

Anti-oxidants: Research is on to see how these can slow down the progression of complications of high blood sugar levels.

Insulin pens: Like ink pens, they carry insulin and are used as syringes. Traveller-friendly, though expensive and not less painful. Already available.

The fact that Indians tend to accrue a lot of fat around the stomach -- doctors call this central obesity -- also make them more prone to diabetes. Big paunches require the insulin to work much harder. Indians with a family history of the illness too have a considerably higher chance of becoming diabetic -- that is the chances of his becoming diabetic by the age of 60 is 80 per cent; in the US it would be only 25 per cent.

Doctors hold changing urban lifestyles responsible for what some call an epidemic of diabetes. "They are eating the wrong kind of food (fast and precooked) and lead more sedentary and stressful lives," says Dr M.C. Srivastava, an endocrinologist who has established the Diabetic Self-Care Foundation in Delhi. Like Randhir Khare, 40, an executive with a multinational who lives the good life with a vengeance. He spends hours on his computer lost in his world of numbers, while endless cups of coffee and pizzas keep hunger and fatigue at bay. But two years ago, Khare became restless: "I started getting bouts of breathlessness and vague chest pains." Doctors discovered incipient diabetes had already affected his heart.

Dr Sharad Bendse, a diabetologist in Nagpur, believes that the thirtysomethings are now getting diabetes because this generation has already had 10 years of changes in their food habits and life styles, added to the fact that they also encounter more stress earlier on.

Stress, that joker in the pack in most modern day urban lives, can also trigger diabetes in the genetically prone and aggravate the condition of those already afflicted by it. For example, a few months before Lalji discovered he had diabetes, he encountered a lot of problems at work. "I went through six months of a lot of stress because there were so many problems at work when I took over the business after my father retired and my brother went away," he says.

Moreover, complications which come in the wake of diabetes are setting in much earlier and, what is worse, progressing to their end stages at a much faster rate. Diabetes is the mother of all illnesses which affects almost every part of the human body. In Apollo Hospital in Chennai 30 per cent of the patients suffering from kidney failure were found to be diabetic, as were those who needed by-pass surgery. Coronary heart disease is the big killer. Sadikot says that 60 per cent of his diabetic patients die of coronary heart diseases. Diabetes is also the second largest cause of blindness in India (after Vitamin A deficiency) and of lower limb amputations after accidents.

It can also play havoc with one's sexual life. Diabetic men with uncontrolled blood sugar levels gradually lose the ability to have erections. Suresh Advani, 35, a Mumbai executive in an MNC, is a juvenile diabetic who was diagnosed at 19. He is now terrorised by the fact that he can no longer satisfy his wife and is worried she'll leave him. Penile injections may make him temporarily potent, but not happy: "They work but only at a physical level," he complains, adding, "It's a strange artificial feeling."

At least Advani, like many other diabetic males, can turn to doctors for help. The unsatisfactory sexual lives of diabetic women unfold in silence. They don't bring up the subject; and doctors don't ask. In fact, how the malady affects the intimate lives of women is not even a subject for discussion. But now in his two-year study on the emotional effects of the illness, Mumbai analyst Udayan Patel discovered that the onset of diabetes brought about changes in women's sexuality. "A pattern emerged," explains Patel. "While high blood sugar levels brought about tiredness and itchiness, it also reduced sexual desires as intercourse became painful." Significantly, when the sugar levels were controlled, sexual urges came back. As Parvati, a 39-year-old Mumbai housewife told him: "When the sugar is high I feel tired and don't feel like talking or doing any housework. And when my husband comes home I don't want to do anything with him."

Diabetes is not easy to treat: misconceptions about the malady abound and many just blame fate. And since it is a lifelong illness with no proven cure, many diabetics are reluctant to change their lifestyles, an essential element of managing the illness, and tend to resist treatment -- especially insulin. Which, as Dr A.K. Jhingan, a consultant diabetologist at Delhi's Apollo Hospital, warns can be dangerous for Type 1 diabetics. "Insulin has to be a way of life for them," says Jhingan. Which Harmeet Singh's parents didn't realise. The 16-year-old school boy is on insulin and leads a normal life. Four months ago his neighbours and family made his parents take him off insulin and took him to an ayurvedic doctor in Panipat. After 10 days Harmeet went into a diabetic coma and almost didn't come out of it.

Another reason for the reluctance to face diabetes head-on is the social stigma attached to it, something you hide from future husbands and in-laws, employers, insurance companies: many insurance companies exclude diabetics in the fine print.

Young brides being rushed to hospitals in a coma is not rare. Doctors in the emergency ward of Delhi's Safdarjang Hospital couldn't understand what was wrong with Sarita Makhija, 23. Only when Sarita became serious did her parents speak up -- she was an insulin-dependent diabetic. They hadn't told the groom or his family about it when the marriage was arranged. So when the mithais were stuffed into her mouth after the wedding, she couldn't refuse. Nor could she take insulin injections. The blood sugar rose dangerously. And Sarita slipped into a coma.

Managing diabetes would be far easier if people were to accept the sugar control and exercise a little more. Eat less, walk more seems to be what the doctors order. Exercise increases physical activity which in turn motivates the ineffective insulin in the blood and reduces the blood sugar level. And looks like grandma knew best: the traditional Indian diet of dal-roti or rice is the ideal, according to physicians. In a way, it's back to a healthier future.

Attitude has a lot to do with living with diabetes. Diabetics need emotional support from both doctors and the family. So, when Jhingan sees his young patients, he always peps them up by telling how Wasim Akram, the Pakistani cricketer, doesn't let diabetes trip him up. "It is more difficult to reconcile parents," says Jhingan. "They need to have a positive attitude, especially during exams." A time when there's much more stress and the sugar levels are likely to rise. Diabetes is a life-long and life-altering illness. But often a diabetic's fate is in his own hands. As Rohit Patel, 53, CEO of an air-freight company in Mumbai says: "You are okay if you are willing to fight and move it from your head." In other words: out of mind, out of body -- with, of course, a little help from insulin (or tablets) and exercise.

-with L.R. Jagadheesan, Amarnath K. Menon and Stephen David
(Some names have been changed on request)