By Chittaranjan S Yajnik
We read about the Global Burden of Disease study in The Lancet which focuses on the simultaneous double burden of undernutrition and obesity worldwide. Most reports are cross-sectional but Indian data provides a unique insight into the evolution of diabetes and obesity in individuals born small and undernourished. India has double trouble: Of early life undernutrition and diabetes and obesity. There is a long legacy of undernutrition — whereas Europeans gained 15 cm in height in the last two centuries (1830-1980), Indians gained nothing. However, the current generation of children are 5 cm taller than their parents. Long deprivation followed by rapid development is a recipe for malnutrition. Is there a solution? Yes, learn from nature’s wisdom.
It is lost on us that “obesity day” and “women’s day” are juxtaposed. We have failed to understand that early life undernutrition, diabetes and obesity are the price we pay for neglecting the nutrition and health of our young mothers for centuries. Research suggests that improving the nutrition and health of young women and their babies when they are in the womb can curtail these epidemics. Trying to douse the fire later in life is like closing the door after the horse has bolted.
As a doctor at the BJ Medical College and Sassoon Hospital, Pune, in the 1970s, I was struck by the large number of patients in the diabetes clinic. They were from the poorer sections of society and few of them matched the “old and obese” description of patients with diabetes given in Western textbooks. I wondered why Indians get diabetes at a younger age and much lower obesity than Westerners.
Training in Oxford in the early 1980s, I was 55 kg and unequivocally thin (measured as Body Mass Index BMI— kg/m2). Volunteering in research, I was struck by the finding that my glucose-insulin metabolism was worse than my 80 kg English colleague — I was thin but had the metabolism of a fat person. I was <5 lbs at birth, and was bearing the double burden of malnutrition in my late 20s, even though the term didn’t exist then. Around the same time, a survey in Southall, London, showed that diabetes was many times more common in Indian migrants than in the British. It was then that I discovered that Indians have higher fat than the British at any given BMI. The concept of a “thin-fat” Indian was born.
Our studies soon discovered that Indians deposit most fat in and around the abdomen (central obesity, simply measured as waist size). The highest glucose levels were in those who had the lowest BMI but the highest waist measurement. An Indian pancreas secretes less insulin, and the secreted insulin cannot act efficiently because of fat deposition in and around different organs. Everyone suggested that this must be genetic. To some extent it is but something more dramatic was to be learned.
Busy trying to sell my idea of a diabetes-prone “thin-fat” Indian, one Monday morning in 1991, I got a call that an English scientist wanted to meet me: He had novel ideas about diabetes. I met professor David Barker and his student Caroline Fall at the KEM Hospital and learned of their remarkable discovery in the UK that babies born with lower birth weight had a higher risk of diabetes later in life (didn’t I know?). They had come to India in the hope of finding support for their idea because Indian babies are reputedly the smallest in the world. Barker suggested that the malnutrition of babies while still in the womb alters the structure and function of the developing organs, reducing their capacity to cope with stress (overnutrition, inactivity, psycho-social stress, migration, etc). He called this idea “intrauterine programming”.
We soon made a remarkable discovery that the small Indian baby that weighs 800 gm less than an English baby (2.7 kg vs 3.5 kg) has more fat. Remarkably, the blood chemistry of an Indian newborn spells out the future risk of diabetes — a horoscope is inscribed. These characteristics result from a lack of adequate and balanced nutrition from the mother, reducing the deposit of protein-rich tissues while continuing to deposit extra fat. Surprisingly, many of these mothers also suffer from “gestational diabetes” which adds to the baby’s fat. The overarching message is that exposure to a challenging environment in the womb (undernutrition, maternal diabetes, infections, stress and others) increases the risk of future diabetes, obesity, and heart disease. This was first observed in the Dutch who had faced the severe “Dutch winter hunger” in their mother’s womb during World War II.
Thus, in addition to genetic factors (which explain less than 10 per cent of the risk of obesity and diabetes), adverse intrauterine experiences increase the risk of future disease. This type of inheritance is called “epigenetics” and acts by influencing the expression of genes rather than changing the sequence of DNA. Unlike classic genetics, it is modifiable by influencing the mother’s health. This offers hope for the future. Indian mothers have suffered adversities of various kinds for generations and given birth to small babies that are not able to cope with the challenges of rapid socioeconomic development. If we improve maternal health, nutrition, and metabolism, the babies born will be more resilient and will enjoy a healthy life. Many national policies have targeted the health of adolescent girls and women of reproductive age which will improve the prospect for future generations. This science is called “Developmental Origins of Health and Disease” and India is a major contributor to this research.
Let’s resolve to invest in the health of young women rather than fall prey to the promises of the sickness industry to cure obesity and diabetes. We have a double duty to perform.
The writer is director, diabetes unit, KEM Hospital and Research Centre, Pune
