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Journalism of Courage
Diabetes affects young people more disproportionately in South Asia even in the absence of a high Body Mass Index (BMI). Being overweight is a known risk factor for diabetes but having a normal weight status may not prevent them from developing the metabolic syndrome as much as it does in European populations.
This was the finding of a new series of three papers about global inequity in diabetes which was published in The Lancet Diabetes and Endocrinology journals. Analysing it, many experts argue for a nuanced approach to identifying other important types of diabetes to avoid missing key sub-populations of affected people.
WHY WE NEED TO LOOK AT OTHER CAUSES?
Diabetes in South Asia is likely to grow by 68 per cent by 2050. The Lancet estimates indicate that three-quarters of adults with diabetes will live in low-middle-income countries by 2045 of whom fewer than one in 10 will receive guideline-based comprehensive diabetes care. South Asia has a population of 1.9 billion, of which 1.45 billion live in India and based on studies, there are an estimated two million youngsters less than 30 years of age who are diabetic. This could be not just due to Type 1 or Type 2 diabetes but other forms like malnutrition-modulated diabetes, Maturity Onset of Diabetes of the Young (MODY), fibrocalcific pancreatic diabetes mellitus and so on, says Dr Nihal Thomas, one of the authors of the series papers and a senior professor at the Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore. “In general, there is a tendency to think that anyone who is lean (thin with a BMI less than 20) with diabetes may be having Type 1 diabetes. Here it is important to remember there are other causes. Lean people with diabetes are those whose BMI is less than 20 (and do not have the typical characteristics of Type 2 diabetes where BMI tends to be higher). When we measure their body fat percentage, it is significantly higher than what is called the visceral fat inside the abdomen,” he says.
WHY ARE INDIANS MORE PRONE TO SUB TYPES?
Diabetes in South Asia is expressed differently, with regard to associations between BMI, percentage body fat and health outcomes, compared with classically defined diabetes in populations of European descent, says Dr C S Yajnik, co-author of the research and Director of the Diabetes Unit at KEM Hospital and Research Centre, Pune.
The social determinants of health are the conditions that influence individuals and groups where they work, play and live in. These might help to explain the manifestation of diabetes in South Asia where geographical inequity, chronic ecological stress, famines, low socioeconomic status and reduced decision-making power of women impacted public health status. “Before the 2000s, in some communities, mothers reduced their food intake in late pregnancy because they believed it could facilitate easy delivery. Women living in rural areas also did heavy physical work at home and outdoor manual work until late in pregnancy, which was associated with lower birth weight,” say researchers. Dr Yajnik points out that though these social norms are becoming uncommon nowadays, they might have left a lasting transgenerational impact on the structure and function of the developing foetus (intrauterine programming), which might have made South Asian populations, particularly young people, more prone to diabetes.
In essence, a combination of low in-born capacity for resilience (smaller pancreas), excessive intrinsic load (adiposity-related insulin resistance), and rapidly increasing environmental load (rapid economic transition) might make the pancreas more prone to early failure, resulting in high rates of diabetes in young individuals with a lower BMI in South Asia.
WHY DIABETES IS AN EMERGING PROBLEM IN RURAL AREAS AND URBAN SLUMS
“The social norms that were present in the past have vastly improved but their intergenerational impact is still being felt,” explains Dr Thomas. This is due to a mechanism called intrauterine programming. When the foetus is exposed to inadequate nutrition in pregnancy, it leads to what is called epigenetic changes. Subsequently these changes may result in earlier onset of diabetes, hypertension and obesity at a younger age. This intrauterine impact on non-communicable disease is passed on for many generations. You could say it is imprinted in the genes of the next generation. So the combination of a smaller pancreas, insulin resistance due to an excessive quantity of fat for a relatively lower body weight and a rapid economic transition may make the pancreas more prone to early failure and early onset diabetes.
The legacy effect is that diabetes, besides being common in urban affluent communities, is also emerging as an equally important problem in rural areas and urban slums, adds Dr Yajnik.
THE WAY FORWARD
The series has highlighted real-world interventions that have shown the potential in reducing inequitable diabetes care. Experts have called for more high-quality, real-world research. “Diabetes remains one of the biggest public health threats of our time and is set to grow aggressively over the coming three decades in every country, age group, and sex, posing a serious challenge to healthcare systems worldwide,” says series study leader Dr Shivani Agarwal, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine and Montefiore Health System, USA. “A central focus and understanding of inequity in diabetes is vital to achieving the UN’s Sustainable Development Goal to reduce non-communicable diseases by 30 per cent in less than 7 years,” she adds in the report.
A paradigm shift can be achieved if we can get our children to spend time outdoors exercising, says Dr Thomas. “We need a largescale curriculum driven policy that includes 30 per cent outdoor activities. Labelling of food and the content of items should be done in a big way and health consciousness should be taught at schools. Awareness programmes help but there is no sustainable action,” adds Dr Thomas. Another concern is energy-rich foods that are easily available and are cheap as against the expensive low-calorie foods.
