Sunday, May 6, 2001		Keeping fit

DIABETES MELLITUS has assumed alarming proportions all over the world but much more ominously in the developing countries. It ranks seventh among the leading causes of death and even higher if its fatal complications are taken into account. Diabetes can lead to heart disease, brain stroke, blindness, renal failure, loss of limbs and endless suffering because it predisposes one to infections. In Britain, it has been estimated that over 10 per cent of the budget of the National Health Service is spent on diabetes and its related complications. Diabetes is like a neighbour who is nice if you show him regard and consideration, but becomes hostile if you ignore him. We all need to know some basic facts about this ubiquitous disease.

The word diabetes (Latin) means ‘running through a siphon’. The name was given because a large amount of urine passes out in some varieties of diabetes. The word mellitus means ‘sweet’ (in diabetes insipidus, a large amount of water is passed out but no sugar).

India’s famous ayurvedic physician and surgeon, Charak and Susharata, seem to have made a large number of observations about this disease and named it madhumeha, meaning ‘raining of honey’. Even at that stage they had noticed that there were two varieties of diabetes mellitus, one with stout built, gluttony and indulgent behaviour (modern type-II diabetes) and the other one characterised by loss of weight, excessive urine formation, thirst and increased appetite. During the 19th century, a lot of observations were made regarding physiology and association of this disease with Islets of Langerhans of the pancreas which finally led to the discovery of insulin by the Nobel prize-winning team of Banting and West in 1921. The first oral pill for diabetes was introduced in 1955 by Franke and Fucks. Great advances have been made in the understanding and treatment of diabetes since then.

What is diabetes mellitus?

The basic ingredients of human nutrition are carbohydrates or sugars, ready-made fuel for energy, proteins, the tissue builders, and fats, also a source of energy as well as the storage of energy. This diabetes is a disturbance in the metabolism of carbohydrates in which the body is unable to handle or regulate the level of blood glucose. Apart from certain secondary causes of diabetes, like hormonal, nutritional and other factors, a major cause is genetic predisposition.

In case of diabetes occurring in adults, the shortage of insulin is only relative, whereas in the diabetes occurring in the young, known as type-I diabetes, the islet cells of the pancreas are destroyed due to the auto-immune phenomena (body reacting to its own tissues) and insulin is not available. That is why the later variety is also known as insulin-dependent diabetes, meaning, thereby, that in this kind of diabetes, administration of insulin is mandatory. I am oversimplifying this classification as there is a lot of overlapping between the two. But that is more for the experts.

The glucose level is regulated by hormones like insulin, glucagon, adrenaline and to some extent other adrenal hormones. Insulin and glucagon are the two main hormones which maintain the level of blood glucose within the normal range. Insulin is produced by the body when there is an intake of carbohydrates and glucagon is produced when there is a shortage of glucose. In other words, one is for the feast and the other one is for the fast. The metabolism is much more complex than this with various other factors coming into play. But the end result is that the body is unable to regulate its glucose levels in this disease for one reason or the other.

Besides the genetic predisposition and auto-immune process causing diabetes, the factors which enhance the predisposition to this disease are obesity, hypertension, lack of physical activity, malnutrition, various hormonal disturbances and drugs. A relatively new observation has been made that it is not only obesity which is an important factor, but the distribution of fat is also important. Excessive fat deposit in the middle of the body predisposes a person to diabetes and this kind of fat distribution is highly prevalent among Indians all over the world. This pattern of obesity seems to promote resistance to insulin, which is the first step in type-II diabetes mellitus.

Magnitude of the problem

The incidence of diabetes is increasing by leaps and bounds and in my own professional career spanning four decades, the incidence in the adult population seems to have gone up from nearly 2 per cent to the present estimated 15 per cent in the urban population and about 8-10 per cent in the rural population. At present, there are nearly 30 million diabetics in India out of an over 100 million global diabetic population. By the next 20-25 years, it will grow nearly to 70 million in India and about 150 million globally. We will, therefore, be harbouring nearly half of the world’s diabetics. This will be coupled with another distinction of being the most populated country. It is not, however, sparing the developed countries either. In one of the September, 2000, issue, the Time Magazine lamented about the diabetic explosion in the USA, summarising that the USA is getting fatter and fatter and diabetes is occurring in younger and younger victims and the incidence there has grown from 4.9 per cent to 6.5 per cent during the past decade, an increase of nearly 33 per cent to 35 per cent. During the same period, the level of obesity has gone up with 44 per cent to 54 per cent Americans being overweight and nearly 20 per cent being technically obese. The weight and diabetes seems to go fairly parallel.

It is an amazing disease in clinical medicine. The type-I or the insulin-dependent diabetes can be recognised even by a medical student by its classic combination of polyuria, polydysia, polyphagia (meaning excessive urine, thirst, hunger) and loss of weight. In the second variety of diabetes, the onset is insidious, silent and can present itself with serious complications for the first time. This deceptive clinical picture has earned it the dubious label of ‘silent killer’. Every adult, therefore, should be alert to its onset and presence particularly if there is a family history of diabetes, obesity, propensity to repeated infections, presence of heart disease, high blood pressure, any eye problem, stroke, numbness of the limbs or gangrene of one of the toes or foot. The last few mentioned complications will, of course, leave no choice and person will be forced to seek medical attention. But it is the first few accompaniments which should make a person look for it and there is nothing like a periodical medical check-up, may be once a year.

It is not my intention to go into the details of the medical aspects of diabetes and its complications which need a lot of professional input. I would like to mention that great advances have been made in the treatment of diabetes, including the purification of insulin, the development of human insulin, very easy delivery system like pre-packed syringes and insulin pumps. A large number of oral drugs have come in rapid succession, making it easier to control this disease. Lot of research has been done in the transplanting of the tissue producing insulin, including the transplant of the pancreas itself and now efforts are being made to transplant the insulin-producing islet cells.

Genetics of this disease are being explored and with the stupendous discovery of human genome, one hopes that more light will be shed on the inheritance of this disease. Having said that, I would like to add that the drug treatment of diabetes is only one and perhaps a small component of treatment of diabetes. What is needed is a wholesome discipline in nutrition, physical exercise, weight control, with no smoking and no alcohol. It has now been shown fairly convincingly by a large number of trials that a tight control of diabetes would minimise various complications of diabetes and the effort is worth it.

Considering the above facts, preventive steps in diabetes are of paramount importance. Prevention does not necessarily mean that this can be prevented in the absolute sense. If there is a strong family history or if one is unfortunate to develop the auto-immune disorder affecting the islets cells, this may not be possible. The prevention in this respect means taking steps to delay its onset, prevent complications by good control and finally to tackle these complications in time, if and when these arise. It means keeping the weight within limits by dietary and physical effort, a regular check-up for early detection and setting the goal for tight control by regular medical supervision. In fact, therapeutic as well as preventive measures at each stage of this disease go hand in hand. Diabetes affects virtually every cell of the body but its special targets are the heart, brain, eyes, kidneys, nerves and sexual function.

Nevertheless, one is happy to strike a positive note at the end that numerous patients live a very happy, well-adjusted and full life with a disciplined approach to this disease. Let us start doing it and see the result.

Checklist for potential diabetics Family history of diabetes. In a child or young person, excessive thirst, appetite, urine or weight loss. Obesity, especially central obesity. High blood pressure, heart disease strokes, high cholesterol or their combination. Albumin in the urine. Numbness of the limbs. Early loss of vision or cataract. Gangrene of the toes or foot. Repeatedly getting boils/abscesses. Sexual dysfunction.