Those who survived Covid-19 remain at a 40 per cent elevated risk for diabetes in the first year. A subsequent post-pandemic wave of new diabetes patients may be expected.
Also diabetes, on the rise among children and adolescents, is one of the leading causes of vision loss, kidney failure, heart attacks, strokes and limb amputations.
These were the views expressed by Dr R. Muralidharan, Director Endocrinology, Fortis Hospital in Mohali, Punjab.
Explaining the factors behind the increasing incidence of Type 2 diabetes, Muralidharan told IANS that it is caused by the resistance of the body to normal levels of insulin and the inability of the pancreas to meet the increase in demand for insulin.
“Though genetic factors play a major role, the rapid rise in incidence in the last few decades can be attributed to several environmental factors. Urbanization and the consequent lifestyle changes are the key reasons.
“Though living standards have improved, the downsides are sedentary habits, lack of physical activity due to time and space constraints, erratic working hours, change in food habits from traditional diets to more consumption of refined sugars and fats and easy availability of fast foods. Stress and environmental pollution are the other major contributors.”
Diabetes is fast gaining the status of a potential epidemic in India with 110 million adults currently diagnosed with the disease as per a recent ICMR study.
As per IDF (International Diabetes Federation) 2021 data, India with 74.2 million patients ranks second only to China.
In 2000, India with 31.7 million topped the world with the highest number of people with diabetes mellitus followed by China (20.8 million) with the US (17.7 million) in second and third place respectively.
According to estimates, the prevalence of diabetes is predicted to increase globally from 537 million in 2021 to 783 million in 2045 with a maximum increase in China followed by India.
“Yes obesity is the key contributor for Type 2 diabetes, ” explained Muralidharan to IANS in an interview on Saturday.
“Even in the absence of an increase in body weight to qualify as obesity, increase in fat deposition in the abdomen and waist confers a major risk of diabetes. Obesity among children and adolescents is on the rise in our country. The latest National Family Health Survey conducted in 2019-21 found that 3.4 per cent of children under five are now overweight compared with 2.1 per cent in 2015-16.”
According to UNICEF’s World Obesity Atlas for 2022, India is predicted to have more than 27 million obese children, representing one in 10 children globally, by 2030.
“We are seeing a rising trend of Type 2 diabetes in the second decade of life. Earlier we used to think any diabetes at this young age is Type 1 (insulin dependent) but as per the registry of youth-onset diabetes in India over 25 per cent of youth-onset diabetes (less than 25 years age) were Type 2 diabetes mellitus. The number is likely to increase.”
The solutions to fight diabetes are the inculcation of a healthy lifestyle from early childhood, insistence on regular physical activity in school, making urban environments conducive to outdoor physical activity and education on healthy food choices.
“Involvement of the whole family is a must, ” he advocated.
Explaining the effects of artificial sweeteners on diabetics, he told IANS that whether artificial (non-nutritive) sweeteners increase body weight in the long-term use and contribute to increase in the risk of cardiovascular disease and diabetes is the subject of intense debate and scrutiny.
Some studies have suggested this, which led to the WHO recently issuing a conditional recommendation not to use non-nutritive sweeteners as a weight loss strategy in people without diabetes.
There’s some scientific basis behind this. Studies in rats with saccharin showed an increase in appetite. In humans it is hypothesized that by intensely stimulating sweet taste receptors, the reward areas of the brain are conditioned to crave for more carbohydrates (akin to alcohol or drug addiction) causing weight gain and adverse consequences.
A more plausible explanation, he said, is that people using non-nutritive sweeteners may develop a false sense of security and overindulge in food leading to overcompensation and weight gain.
Some studies have also shown that non-nutritive sweeteners adversely affect the balance of the normal beneficial bacteria in the gut (called the microbiome), leading to adverse metabolic effects and weight gain.
"Our advice would be to restrict use of sugar and sugar substitutes in patients of diabetes. The desire to eat sweets can be easily satisfied by including more fruits in their daily diet plans. We allow all fruits, even with slightly higher glycemic index, within reasonable limits of overall daily calorie intake, ” Muralidharan advised.
Between plant-based artificial sweeteners and chemical-based artificial sweeteners, which are safer to use, he said, “Though the common perception is that anything natural is better there is no evidence to prove this. In fact, even with the plant-based sweetener stevia the FDA approval with the label GRAS (generally approved as safe) is only for the highly purified steviol glycoside compound called Rebaudioside extracted from the stevia plant. The stevia leaf per se or crude extracts of the plant do not have this approval.”
Diabetes is one of the leading causes of vision loss, kidney failure, heart attacks, strokes and limb amputations.
Patients with diabetes have two-three fold increased risk of heart disease compared to non-diabetics.
“It is a matter of grave concern that in India these complications occur at a much younger age and progress more rapidly. With 0.6 million deaths per year directly related to diabetes and its complications India ranks third in the world in diabetes related mortality, following China and the US.”
To a question regarding the impact of Covid-19 on diabetes, Muralidharan said post-viral new-onset diabetes has been an important feature of the pandemic.
“It may be because of unmasking of a previously undiagnosed condition, the acceleration of pre-diabetes, or new-onset diabetes that would not have otherwise occurred. Both Type 1 and Type 2 diabetes have been reported, the former occurring because of autoimmune damage to the insulin producing beta cells of the pancreas incited by the Covid virus.
“Direct damage to the pancreas by the virus has also been described. In a recent study new-onset diabetes at follow-up is seen in 16.7 per cent of patients who were hospitalized with Covid-19.
“The course is variable -- in some diabetes resolves completely or improves gradually on follow up. Though the severity of the illness is the factor that determines the risk, some asymptomatic cases of Covid-19 have been associated with new-onset diabetes.
“Those who survive Covid-19 remain at a 40 per cent elevated risk for diabetes in the first year. A subsequent post-pandemic wave of new diabetes patients may be expected.”
In addition to infection per se, prolonged sedentary habits like work from home and closure of schools enforced amidst the pandemic will also be major contributors to the risk, he explained.