Interviews

World Diabetes Day was recently marked on November 14th. The goal of World Diabetes Day is to promote awareness about diabetes as a worldwide public health problem and to inform individuals about how it may be controlled and treated. India is home to more than 77 million diabetic patients that consists of world’s second highest diabetic population.  To discuss on the risk factors, diabetes in children, precautions and much more, Medically Speaking talked to a panel of experts that included: Dr Nikhil Tandon, Head of Endocrinology Department, AIIMS & Dr Ganesh Jevalikar, Principal Consultant, Pediatric Endocrinology, Sir Gangaram Hospital.

Here are a few excerpts from the interview:

Why is it so significant that we talk about diabetes, what could really be the repercussions of uncontrolled diabetes? Why is it so important that people pay focused attention to diabetes and keep it under control?

Dr. Nikhil Tandon : I’m going to speak this into two parts, one, an answer from a health system or a population and then as you very rightly and pertinently asked an answer with response to an individual. If the severity and gravity of a disease is based on how much it contributes to overall mortality, how much it contributes to disability adjusted life years which means you know what is the quality of life you have even while you are surviving. If you did an assessment of all diseases, let’s say in 1990 and say what was the rank order of top 25 diseases responsible for mortality of poor disability adjusted life years and then repeated the same analysis 25 years down the line in 2015, 2016. Diabetes is a second highest climber in that list. First highest climber was HIV Aids and it is obvious because HIV Aids hardly existed in 1990 but diabetes existed then and diabetes continues to exist now but it has climbed up massively in that list. So, it’s the single largest change in a disease contributing to mortality and disability adjusted life years. So, from a health system perspective, it is important to be aware of that, if the numbers are increasing dramatically and the system has to cope with it. But in response to your specific question, the concern about diabetes is related to complications. The complications of diabetes could be those which can be involving smaller vessels or it can be involving the eye causing blindness, the kidney, causing the kidney failure, the nerves which can then actually leave to insensitive feet resulting in loss of feet and amputation. Larger vessels which can cause heart attack or strokes. Now, obviously if you have a proportion of people with uncontrolled sugar are likely to having these complications arise and  becomes high and we can not reverse these complications if they happen. So, somebody develops vision threatening eye disease. At that point in time controlling diabetes can prevent further progression but can not reverse the loss of vision that has already happened. It can prevent the progression of further kidney disease but it can not reverse the kidney problem which has already happened. So, clearly in a disease which will be otherwise asymptomatic as  there is a lot of type to diabetes, you may end up in this very serious condition that you have complications and then you are stuck with them , because medical science today is not in a position to reverse these complications. So, It is a very serious problem and we need recognize this fact.

Interestingly, rather unfortunately I would say we are seeing a large number of cases of diabetic children, first of all take us to some data and why are we seeing this? And how do we stem this ?

Dr. Ganesh : Yes, in general public there is very little awareness about children having diabetes because most of the children, when they are diagnosed with diabetes, often parents say that this is the first case in their family where they are coming across with a child having diabetes. So, it is important to be aware that it is not just that children have diabetes but it is also a common long-term condition that children have. Now in terms of types of diabetes, majority of children, even today have diabetes which is known as TYPE 1 diabetes or which was previously known as insulin dependent diabetes.  So, if we take a group of 100 children, almost throughout the country, across many centers 90% of them would have typical type1 diabetes. You mentioned about inherited and lifestyle related diabetes, I would like to clarify here that typical type 2 diabetes, typically referred as adult diabetes, is also being increasingly reported or increasingly being seen in the past one or two decades in children. I would say, roughly the percentage of such a diabetes is about 6 to 8%, or in some of the center we see more of type 2 diabetes but this is roughly the percentage that we see. This is happening largely with respect to increase in the obesity amongst children and adolescence. Now the inherited factor is stronger in this type of diabetes because it often happens with the background of obesity and family history of diabetes. In most of the families there won’t be a family history of type 1 diabetes so the heredity component is a smaller thing in that type of diabetes.

Has covid at all led to an increase in number of perhaps diabetic children in India?

Dr. Ganesh : Now certainly the pandemic ha affected the lives of children in a very significant manner because most of the adults who were working started moving out of their houses at least after the first 5-6 months of the lockdown but children continued to be confined to their houses. And not just covid, but now even dengue and pollution and all sorts of reasons exists because of which the activities are really limited. The screen time has significantly increased because of the lockdown in online classes.

Help us understand the co-relation between diabetes and covid because we had seen post the second wave and there were multiple reports which had come in which had spoken about the relationship between diabetes and covid and it was also said that diabetes related problems are seen in the post covid era in patients who had recovered. How far is that true?

Dr. Nikhil Tandon: So, let me give you a bi-directional view, 1 is, if you had diabetes and then you ended up getting covid or ended up getting a much more severe disease, more likely to end up in an ICU and unfortunately more likely to even succumb to the disease. So, people with underlined diabetes have problems. So, now lets come back to question, so first we need to know the reality of all chronic silent non-communicable diseases in most parts of the low and middle income country stretches where 50% of people who have a disease don’t know that they have a disease. So, if you start with 100 people whom you eventually diagnose with diabetes, 50 of them today will not know they have diabetes. So, when they come to the hospital with covid, and they get a test done from their management, that’s when their diabetes is found, so it is previously established but also previously un-diagnosed disease. Now, the second thing what happens is people who are pre-disposed to diabetes, who may not have diabetes otherwise, but when they get an infection and that too a severe one, as covid was a severe infection then stress can cause an elevation in sugars , so that is unmasking of a predisposition and hopefully once the stress disappears , they will revert back to their premorbid state , that is they will still have a tendency but still not be frankly diabetic. But, their number were consistent with the diagnosis of diabetes when they were evaluated because the stress hadn’t worsen it. The third thing which happened with covid was, Steroids. Steroids worsen sugar levels and then also cause unraveling and unmasking of diabetes. Again, hopefully that exposure was limited and again over a period of time it should reverse back. And, the 4^th category is again of interest for which data is a yet limited but I am sure with passage of time and that the question which you specifically asked, did covid cause diabetes ? now there are reasons why it could have done so , the virus as you know can affect the lungs because it has receptors available in the lungs. Similarly the virus has receptors which can affect the pancreas where the location for the cells which make insulin are present. So, yes theoretically, covid can result in destruction of those cells, decline in function of those cells, therefore ending in diabetes but really long term follow up of these patients will give you the answer. It is a very pertinent question but I think the jury will come out with this soon.

Help us understand really what is gestational diabetes and can someone get it post child birth also?

Dr. Ganesh : So, I mean although there are better experts on the panel to discuss about this kind of diabetes but gestational diabetes is typically a diabetes which is often diagnosed during the second trimester pregnancy and is considered as a harbinger of future type 2 diabetes and the blood sugar levels of the mother obviously can have impact on the in-utero programming of the child and could have long term consequences for the child also. On the other hand diabetes which is pre-existing, that the mother has, can also have an impact on the outcomes of pregnancy and on the child as well.

We all have heard of how people have been able to keep diabetes completely under control just by lifestyle modification and without medication. One, is that true? If yes, then what are the type of lifestyle modifications one can do to control their diabetes?

Dr. Tandon: So, management of diabetes, if you think of it as chair, it has four legs, critical legs. Two of those legs relate to lifestyle, diet and physical activity. The third leg is medication whether it is oral or injectable and the fourth leg is monitoring which could be self-monitoring or lab-based monitoring. Obviously, we will not talk about the last two and let’s come back to the first two. It is like when you start education, you don’t go to standard 6 or standard 10 immediately. First you will go to nursery, then pre-school, then kinder-Garten and so on. That is the foundation of education and diet in lifestyle is the foundation of diabetes. Now, what are the important aspects of diet and we don’t go into specifics but again there are four important things which I would like to communicate. The quantity of food that you eat, the quality of food that you eat, the timing of that intake and the spacing of that intake. If you eat too much, it’s bad for you , you eat the wrong stuff, bad for you, you have a really large gap between you meals, not a good idea at all and if you cluster your meals together, again not a good idea at all. So, you need to look at that and then you need to look at what type of carbohydrate we are taking, the nature of the fibre, the limited amount of fat that you are permitted to take , all of these things but again these four things I mentioned are very important because if you make errors in any of the four, people say Dr. I don’t have potato and I don’t have rice but that’s not the be all and end all of diet management in diabetes, it is a much broader canvas which we have to see. In terms of physical activity you can go to the specifics but really it has to be age appropriate in terms of nature of physical activity, Dr. Dinesh will possibly tell you younger children, you can allow and encourage much longer duration but even in adults and the elderly, you know 45 mins or 35 mins depending on what they are capable of , do it.  Predominantly aerobic, by aerobic I don’t mean you have to buy fancy shoes and take a gym membership. You can go and walk outside briskly if the pollution permits you but when it comes to reversal and you talk about keeping diabetes under control, very much so you can do it in the early years of type 2 diabetes , not type 1 diabetes. In the early years of type 2 diabetes you can manage with lifestyle alone.

Can someone control the diabetes completely by lifestyle modification, can perhaps I, if I have diabetes, can I totally avoid medication? Is it possible to manage it without medication?

Dr. Nikhil Tandon: From a fair period of time you can. So, let’s look at a person who is significantly overweight, eats the wrong stuff and is entirely sedentary. So, in that human being lifestyle targeting weight reduction, the right type of food and encouraging physical activity can bring the sugars down to well within normal and leave them there for lengths of time. Now, whether if this happened t the age of 40 years, it’ll do it for the next 40 years of their life, I don’t know and I perhaps don’t think so but several years you can manage the diet lifestyle and that’s a message through the media should really encourage people to do and that’s the corner stone of management of type 2 diabetes.

What are the precautions for parents or what can someone do at a younger age and early stage to perhaps, if possible, to cure diabetes at all or if they already have to control it sir?

Dr. Ganesh: So, with respect to paediatric diabetes, the type 1 diabetes, unfortunately as of today there is no way by which type 1 diabetes can be prevented. So, there are no causes, link associated with any of the dietary factors or any of the exercise or lifestyle related factors. It is a random event which could happen to anyone. Even adults can get type 1 diabetes so it is an auto immune disease which means there is an auto-immune destruction of beta cells of pancreas which is yet unknown that, what exactly triggers this kind of process. There are many possible candidates including viruses but the exact reason is yet to be discovered. With respect to type 2 diabetes, I think, in terms of prevention, the prevention amounts to basically control obesity with respect to follow a healthy diet and healthy lifestyle routine even for children.

So, one needs to follow a healthy lifestyle right from adolescence, from a very early age so that they don’t become pre-disposed to diabetes and if right from birth how and what can someone do right from birth?

Dr. Ganesh: I mean even not right from birth, even before birth. Taking care of the nutrition of the mother, so a healthy child is delivered, because low birth rate children have more risk of metabolic complications. Exclusive breast feeding in the first 6 months, correct introduction of solids between 6 months to 2 years, introducing the food which is locally or culturally used rather than using processed foods and all sorts of things that are being given to children these days.

Nowadays we are seeing a lot of trend of gym culture, people trying to look their best, intimating fasting, slimming pills, not eating properly as you rightly said, many say I don’t eat carbs at all. Is that the right way to go? Are those people equally healthy?

Dr. Nikhil Tandon: You know we go through cycles of diets, sometimes more fashionable than scientifically proven. You need carbohydrates, you need proteins, you actually even need fat. So, these are the principles of diet and you will need them. Now, how much you need depends on what you really end up doing. So, somebody who is a manual labourer and needs ready energy at that point of time, somebody in possible fields will require high carbs because they need that burst of energy to take care of their physical activity. So, I think we need to understand the context of the diet very importantly, number one. Number 2, you say, no carbs in a meal or something, well im not sure if this total scientific evidence to endorse that fully. The key issues will always remain, I could use that moderation rather than martyrdom is what should be our target. Extremes of anything eventually don’t work out to be beneficial because it is very difficult, a- to maintain and sustain extreme interventions, you can have you know, cucumber and tomato for 7 days in a week but after the second week or third week you will just pack up in any case. So, look at what you are doing. We are not running a 100 meter race, we are running a marathon out here. Pacing yourself out , being moderate, doing something which is sustainable and absorbing the core principles of nutrition is very important. Similarly, if you are happy going to the gym and doing something, it is great I have nothing against that but again, overdoing anything is not going to solve your problem and for diabetes prevention and diabetes management, predominantly aerobic exercise, some degree of resistance exercise but non-exercise which makes you bulk up because that becomes counter productive over a period of time. Now, if you are a professional athlete and you need to bulk up, so be it. But for the average one on the street, you need to be sensible about these things.

What would be your advice to parents, perhaps youngsters watching the show? What would you like to say to them on such significant day?

Dr. Ganesh: Well there are two key messages: one is about type 1 diabetes and something I have not spoken till now is that type 1 diabetes can not be managed by diet or exercise or oral medicines alone. It has to be  managed with multiple short aids otherwise there is no way to manage type 1 diabetes. Secondly, with respect to diet and lifestyle, this starts right from the first few years of life, and like having right habits in infancy and toddlers itself will ensure that the future will be secure.

What will you tell those who have had some sort of gap, one, in getting diabetes diagnosed and if they did get diagnosed post covid and secondly, those who delayed their treatment due to fears. What would you like to tell those people?

Dr. Tandon: Two issues, one, that the government has proposed a universal screening for 5 diseases, diabetes, hypertension and three common cancers after the age of 30 years and I think that is a reasonably sensible thing to do. In any case there has to be a periodic screening so, even if you didn’t get screened during the covid era, its not a bad idea to go through testing periodically so you don’t end up with large duration of undiagnosed and untreated diseases. The second thing is fortunately, while there was some uncertainty about the legality of the teleconsultations. There is a bit more clarity about that and you can always pick up the phone and talk to people. If you are already on treatment, I think following up with your regular doctor on the phone is helpful so that there is a hand holding so that you don’t abandoned during such a period. But reaching out your doctors telephonically is better so that you don’t have to take decisions on you own. Diabetes education is a very important part of our management and the education makes you equipped to self manage. You are taught how to monitor, you are taught how to change your doses and you are given a broad set of guidance about doing things. So, diabetes education which I think should come into that fourth leg of the chair I was talking about. Monitoring plus diabetes education become important and we need to empower our patients, we need to make management patient centric and patient driven. And educated patients about diabetes is a much safer individual for him/herself because they will be able to look after themselves better. So, health education, specifically diabetes education is a must.