Diabetes has existed for millennia. It has been recognized by several ancient cultures including Indian, Egyptian, Chinese, and Persian. Sushruta, a surgeon and physician who lived around 600BC in the Varanasi area in northern India, documented it in his works. They recognized that ants were attracted to the urine of affected individuals and it was named Madhumeha (Sanskrit; madhu- honey).
Ancient physicians also recognized that there were two types of conditions that involved excessive urination and loss of weight. This recognition of excessive sugar in individuals affected by diabetes was refined over the next 2000 years, and in the 18th century, England Johann Peter Frank is credited with the identification of two forms of diabetes- diabetes mellitus and diabetes insipidus. Mellitus (Greek; honey) was associated with high levels of sugar in the urine, while insipidus was not. In fact, diabetes insipidus is an unrelated condition related to hormonal control of the kidneys, leading to excessive urination.
By the 5th century physicians in India and China had noticed that there are two kinds of diabetes mellitus- one of which was prevalent in older and heavier individuals. Methods to recognize, understand and treat diabetes mellitus have evolved with technological developments. Relatively rapid progress since the 18th century has identified insulin as the hormone secreted by the pancreas that plays a central role in this indication, and also defined type 1 and type 2 diabetes.
Type 1 (also termed ‘early onset’ and ‘insulin dependent’) is a condition that generally develops in children and younger individuals where insulin production by the pancreas is compromised or completely shut down due to several reasons. Type 2 diabetes (also termed ‘adult onset’ and ‘non-insulin-dependent’) is the focus of this article and has become a global health problem.
In its current trend of prevalence Type 2 diabetes, or T2D, has blurred two boundaries. It was previously confined to low- and middle-income countries but is now on the rise even in the higher-income countries. Secondly, the age of onset is not confined to older patients. Among the Indian population worldwide, T2D is gaining numbers within India and also within expatriate Indian and southeast Asian communities. Some studies put the number of Indians in the US as the group with the highest incidence of diabetes than any other racial group at an age group above 20. Similar reports have been made with respect to Europe and UAE. Within India itself the numbers of T2D in adults 20 years and above has tripled over the past 3 decades.
This appreciable increase in T2D in southeast Asian expatriate communities, and also within their countries especially India and China, is thought to be due to the relatively recent cultural changes in diet and lifestyle over the past 50 years, such as an increase in consumption of fried foods, fast food, refined grains and sugars, lack of dietary fiber, and sedentary lifestyles.
In addition to these behavioral changes T2D is caused by an interplay of genetic and environmental factors, and familial history serves as an indicator for individuals to be forewarned about their own health. That said, considering the speed with which changes in the age of onset and frequency of T2D are being documented, it appears that environmental, diet, and lifestyle changes are the major contributors to the current epidemic. Also, in general, Indians have a higher degree of insulin resistance than Caucasians, which occurs when the cells of the body lose the capacity to respond to insulin even when it is being produced by the pancreas.
The burden of the long-term health effects of T2D are significant to the individual and from a public health perspective. The more stark chronic manifestations include neuropathies, foot ulcers, blindness, kidney dysfunctions, accelerated aging, and a general decline in health and productivity. In addition to insulin, newer medicines exist to control blood sugar and insulin response, and other therapies are being developed including stem cell therapeutics.
If there is a good aspect to T2D it is that it can be prevented or the onset delayed. The fact that onset can be delayed is a point of practical importance, as most of the clinical manifestations arise due to cumulative effects of high circulating sugar. Prevention is the best cure, as the adage goes. A regular health check-up will flag a ‘pre-diabetes; condition. Glucose intolerance tests, HbA1c levels in the blood, body mass index, and overweight are common tests to gauge pre-diabetes. This indication should be taken as a warning, and acted upon seriously and with a positive attitude.
The trinity of diet, exercise, and stress management are often called upon. Eat less. Eat on time. Walk more. In general, the lifestyle changes that are recommended are geared towards helping maintain an even level of blood sugar and reduction to, or maintenance of, an optimal body weight.
Processed grains, and refined carbohydrates like maida (all-purpose flour), have a high glycemic index. As against whole grains, they are quickly metabolized to sugar and result in a sudden spike of increase in glucose in the blood. Our standard fare includes white rice or chappatis/other breads as a base, and this can be substituted with brown rice and atta (whole wheat).
Instead of serving up a plate with a large portion of rice and sides of vegetables and protein, switch around the amounts and serve up rice as a side dish instead. Control portion sizes, and maintain steady time intervals between meals and snacks. Include soupy low-calorie items which will serve to fill up the stomach. Fasting is not recommended. Eat a diet of high fiber which includes green leafy vegetables and excludes starchy vegetables, skim milk-based yogurt, and whole grains. High fiber dals (moong, masur, urad, etc., along with sprouted whole dals) and beans (such as chole and rajma) should be a mainstay. Including methi (fenugreek) regularly in cooking, and in salads and dals after sprouting (sprouting methi completely reduces its bitter taste) adds flavor and a health benefit. Fruits that are delicious and low in sugar include papaya, guavas, blueberries, and jamoon.
Items to be conscious of and exclude, or eat in disciplined quantities, include fried foods and fatty foods in general (including our delicious tea-time snacks!), foods that include sugar and artificial sweeteners (yes, some sweeteners and bulk additives added to sweeteners can produce a sugar spike!), and processed grains. While regulating these will help with the maintenance of body weight, avoiding sugar, sweeteners and the inclusion of whole grains will maintain even levels of blood sugar. Depending on the stage of diabetes fruits may be eaten in moderation, but high sugar fruits such as mangoes, grapes, and sapotas should be avoided.
As with diet, steady exercise is highly recommended for diabetes. Even our hoary sage Sushruta recommended this, and in some studies, the inclusion of exercise had the most obvious ameliorative effect. The type of exercise will need to vary based on the individual’s age and capacities, but even a basic activity like a daily brisk walk for about thirty minutes would make a difference. Obviously, more will be required if weight loss is an objective. Although yoga is excellent for weight maintenance, it will not suffice for weight loss regimes. Walking, yoga, and exercise, in general, will also help in stress management, and others may be included, such as reading, meditation, etc., depending on individual preferences.
Tackling the diabetes epidemic at the global level would need to start with the individual.
L Iyengar has lived and worked in India and the USA. A scientist by training, she enjoys experiencing diverse cultures and ideas. She can be found on Twitter at @l_iyengar .