5 min readNew DelhiApr 26, 2023 12:00 PM IST
First published on: Apr 26, 2023 at 12:00 PM IST
Ram Lal was 84 years old and had been under my care for a decade. Hailing from rural Haryana, he had developed diabetes at the age of 70 and was well controlled on small doses of oral anti-diabetic medication. He owned a large farm and cycled everyday around his farm to keep an eye on his staff. His simple direct Haryanvi style of conversation was endearing and over the years we had developed a good relationship. One day he entered my room looking disturbed, and was accompanied by a chubby young man, in his 20s, who Ram Lal introduced as his grandson. “Please have a look at this young man, doctor sahib. He has developed diabetes and I am deeply worried. He is only 24 and not even married yet.” The young man had a real estate business, drove a fancy car and did not exercise at all. His Type 2 diabetes proved much harder to handle and it was months before he could be controlled after multiple medications.
Such stories are not unusual nowadays. Gone are the days when Type 2 diabetes only affected those above 40. The prevalence of Type 2 diabetes in the 20s and 30s has dramatically increased in the last two decades, particularly in India. About 25 per cent of those with diabetes onset under 25 have Type 2 diabetes.
In the conventional understanding of diabetes, children, adolescents and young adults develop Type 1 or insulin-dependent diabetes. Type 1 diabetes occurs due to substantial or total lack of insulin, the pancreatic beta cells having been damaged by an autoimmune process. The only treatment of Type 1 diabetes remains life-long insulin. With advances in monitoring and insulin delivery, most people with Type 1 diabetes do well, pursue their personal and professional goals to fruition, but insulin and glucose testing continues to be a part of their life, throughout. In the recent past, the prevalence of Type 1 diabetes has increased and it is estimated that more than 200,000 people under 20 years of age are living with it in India. Type 2 diabetes is the usual adult type of diabetes that comprises 90 per cent of all diabetes, with components of insulin resistance (ineffective insulin action) and deficiency (to a lesser degree than seen in type 1). Traditionally, Type 2 diabetes was seen in overweight individuals above 40 with a family history.
How do we distinguish Type 1 and Type 2 diabetes, particularly in the young? Type 1 diabetes classically presents with weight loss, increased thirst and urination, sometimes rapidly progressing to ketoacidosis or coma-like condition. Most children with Type 1 diabetes do not have a family history of the condition and are lean, although there are exceptions. On the other hand, Type 2 diabetes typically presents at or after the time of puberty. About 80 per cent of youth with Type 2 diabetes are obese and have a family history of the condition in parents or relatives. Some of them display classic symptoms of excessive urination, weakness and weight loss (as seen in Type 1 diabetes), but others may have no symptoms at all and are detected incidentally. Clinically, signs of insulin resistance like acanthosis (dark pigmentation of neck, underarms and other skin folds) or polycystic ovary in girls often accompany the condition. Tests like autoimmune antibodies and C-peptide (a protein released directly proportional to the amount of insulin by pancreas) are helpful to differentiate the two types of diabetes. Sometimes an observation period of one to two years may be necessary before the diagnosis becomes clear.
When Type 2 diabetes started increasing among the youth in India, it was mostly attributed to increasing weight and insulin-resistance related to poor eating habits and sedentary lifestyle. Recent data suggests that young Indians with Type 2 diabetes may also have a greater deficiency in insulin secretion. In general, early onset of diabetes means many more years of exposure to the condition, increasing the chances of complications when people are in the prime of their life, namely in the 50s and 60s. It has now been shown that young Type 2 diabetes patients have a greater risk and earlier onset of complications (such as those affecting the kidney, eyes and nerves) as compared to their insulin-dependent Type 1 counterparts.
The relative lack of insulin also makes them more prone to needing insulin at an early age. Type 2 diabetes is often associated with high blood pressure, abnormal cholesterol, fatty liver and polycystic ovary syndrome. Nearly half of Indian youngsters with Type 2 diabetes had high blood pressure as per the ICMR registry.
A small proportion (3-4 per cent) of youth with diabetes have an inherited defect of insulin secretion called MODY (Maturity Onset Diabetes of Youth). This is suspected in milder types of diabetes in non-obese individuals with a family history of youth onset diabetes. The diagnosis is confirmed by genetic testing, which shows a single gene defect (monogenic diabetes). Some of these individuals can be managed with oral medications whereas others may require insulin.
We cannot do much to prevent Type 1 diabetes or MODY. But we can do a lot to prevent Type 2 diabetes from affecting the youth. Focussing on diets low in refined carbs, high in fibre and adequate protein intake is important, as is regular physical activity. Avoiding excess weight gain in childhood and adolescence is the best we can do to keep diabetes at bay.
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Type 2 diabetes is the usual adult type of diabetes that comprises 90 per cent of all diabetes. (Photo: Getty Images/Thinkstock) 
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