There’s a big article in the New York Times today about diabetes in India (thanks, Gitanjali and Builder). It’s impressive partly because of some surprising statistics given about the spread of both obesity and diabetes in India, and because of some touching individual interviews that illustrate some of the particular difficulties faced by Indians dealing with the disease.
I would recommend people go read the article, but here’s a summary of some of the stats I found notable:
- There are probably about 35 million people in India with Type 2 Diabetes (adult Diabetes) now. In a few years, there could be as many as 75 million. The current rate is 6 percent of adults have the disease, but that number is higher in Indian cities (in Chennai, Kleinfield reports, 16 percent of adults have Diabetes).
- Even middle-class Indians tend to remain uninsured, so Diabetes can be a financially crippling disease.
- Indians are genetically predisposed to contract Type 2 Diabetes, and they tend to get it 10 years before people in other parts of the world get it. (Which means, the danger is also high for NRIs; apparently this has already been observed with the earlier generation of immigrants)
- One of the biggest dangers in India in particular is that Diabetes, which leads to loss of sensation in the legs, often results in infections that can end in leg amputations. Since so many people go barefoot in India (even occasionally: as in, when visiting temples), the risk of foot and leg infections is much higher than in the west.
- In the world as a whole, there are now more people who are overweight than undernourished.
Any thoughts on this article, or recommendations for other things to read that will educate people on the danger of diabetes in the Indian subcontinent? I did find the tone a little irritating at some moments (“Diabetes — the dark side of India’s success”), but the research and the personal interviews were very informative.
diabesity. the fall of the world. there was a great article a few months/year? ago in national geographic about ‘FAT’ with a body and rolls of ‘lard’ on it… it showed a map of the world and the incidence of not only diabetes but heart disease, etc…india is catching up to the west…and at a great rate..
i think fast food…’fast food nation’…and healthier foods not being the cheaper options (when you go to mickey d’s, it’s cheaper to get a big mac then their ‘healthy salads’..)
i have yet to read the article amardeep..but will do so and give you my 2 sprouts worth…
here is the article from national geographic with the graphic picture ;0)
Thanks for the link, doc. The picture alone is a bit, er, frightening.
Good post! Type 2 Diabetes can be a very crippling disease – I have a few people in my family who have it. I don’t know what it is about eating healthy, but the people (in my extended family, older generation) that do have it (and quite a few who are probably well on their way to developing it) don’t really care or bother to eat healthfully, or go out for a walk once in a while. One of my uncles who is having trouble with both his eyesight and kidney as a result of the disease continues to eat as he wishes, and the man has a doctorate in the sciences! I really don’t know what it is – I was explaining to him the benefits of eating whole wheat and grains as opposed to white bread, and his response was, “it doesn’t make a difference” WTF?!?? Is it a lack of control? A failure to see the connection between what you eat and your health? Fatalism? Education?
On the plus side, I do find the younger 2nd generation desi community more interested in leading an active and healthful lifestyle. Again, this is just from my limited, personal obervation.
BTW, I find the tone (“Diabetes – the dark side of success”) irritating too!
In the west, anyways, even though the affluent are catching up, it’s the poor who are prone to becoming overweigt since this income group typically have less access to fresh, healthy foods (http://seattletimes.nwsource.com/html/health/2002260839_obese03.html)
Back in India , during my compulsory rural training part, I worked with a WHO funded group which was studying the relation between low birth weight infants and the incidence of adult onset Diabetes. There was a significant link between the two and it was actually surprising to find a high incidence of DM in the rural population. And they were supposed to be living the healthy lifestyle, away from the cities, not eating junkfood, and leading sedentary lives, which are all blamed for contributing to DM.
I remember that this was published in the Indian endocrinology journal, alas,I cant find a link to the article…..
First off, excellent article and post. I know several desi folks in their 60’s who are facing this problem.
My understanding is that malnourishment and obesity are not necessarily mutually exclusive. For example, poorer populations in the U.S. tend to eat quite a bit of fast food. Fast food has a lot of calories, thus leading to obesity, but it lacks essential dietary aspects so it still leads to malnourishment.
btw. what is a pandemic? why is obesity a pandemic?
on another note
it bugs me no end to see sportsmen and actors pushing pop in the indian marketplace. shame on them. given the impressionable folks out there – it’s an accessible part of their glamor – contributes to the rising obesity levels in india.
From the Times articles, pp.3-4, Krishnasamy Srinivasan’s story:
“He had done very well as a textile exporter, came to own four homes, and enjoyed rental income from those he did not occupy. Then diabetes hit when he was 40. He paid it little mind as it marinated inside his body. Over the last 15 years came heart problems and the need for bypass surgery. His kidneys deteriorated. He is now on dialysis.”
and his wife’s thoughts:
“We are angry with the god,” she said. “You gave us four houses in four directions and all the wealth, and now you have taken it all away. Why?”
While fortunately, no one is losing houses in my family, these actions and sentiments are eerily similar, and most of my fam live here in the West. First, not listening to the “bikwaas” of the doctors and then anger and a feeling of a lack of control. While I do feel awful for anyone who has to suffer with this disease,I am angry that even upper-middle class desis in the West, with access to health care and information, are paying no heed! (Note that health insurance is not so readily available in India, according to the Times article). What can we do to get the uncles and aunties to listen up and start taking their health seriously? You don’t know how many countless arguements I’ve had with them!!
From pages 4 and 5:
“Some concepts are easy to sell in India, Mr. Kalyanasundaram said, but health insurance is not one of them. “The capacity to pay is not there,” he said. “And many people take disease as a God-given thing to just accept. So why buy insurance?””
teamed with this: “Prevention, he recognizes, is a mountainous climb in a country with a severe shortage of medical workers. What health care money exists is overwhelmingly applied to infectious perils.” is VERY frustrating
that being said… part of me cant help but gloat… remembering all the corpulent little maharajas and maharanis i’ve seen in delhi ordering around their “naukars” … it’ll catch up with you just you wait, you fat little pieces of shite.
The last two-three years or so I’ve been seeing a new phenomenon in India; namely, instead of afternoon ‘tiffin’ people just get boxes of Grand Sweets & Snacks milksweets, jalebis, ‘murukku’ and so on…’tiffin’ used to consist of dosas or idlis, but now only unhealthy food is consumed. The waistline of several ladies in our family has increased notibly, and I blame it on the readily available and quite irresistible Indian sweets.
Bidi: “Easy access to medical care is fast becoming the newest separation between the rich and the poor all over the world.”
While, I whole-heartedly agree with this important concern, it might not be the only problem – which would explain the diabetes prevalence in desi communities in the west (http://www.sawnet.org/health/#Diabetes). Yes, we are genetically prone to developing it, but it is preventable.
From the last page of the Times Article:
“Much of the population gravitates to cryptic beliefs threaded with untruths that are hard to nullify.
People believe in bitter gourd juice and fenugreek, an Indian spice, which can temper sugar levels, but are not cures. Some years ago, the wood water cure gained considerable traction. Drink water stored overnight in a tumbler made of Pterocarpus marsupium heartwood, the promotion went, and it would wash away the diabetes.” and “others are rabid apologists for the disease. Uninterested in eating less, they say that when they feel like a big meal, a luscious plate of sweets, they just swallow an extra pill or inject themselves with more insulin.”
AND this passage says alot:
“Late in the day, back at the M.V. Hospital, he trooped upstairs to the rooftop auditorium, where 40-odd doctors had assembled to talk about prevention efforts. One thing they talked of uncomfortably: A particular profession in India, they heard, a well-paying one involving a lot of standing around, had practitioners who did not necessarily heed their own advice. The profession was thick with diabetes. It was doctors themselves.”
…. suggesting that there might be a problem with the belief system (apathy) concerning health and well-being. I dunno – I’d like to hear other people’s comments.
sorry for the harsh words in my previous post. -need sleep, food, coffee- pardon me.
As usual I will dispute this “genetical” BS. Desis are not developing diabetes because some genetic defect, but because they avoid excersize like the plague. The reason western Desis have higher percentage of High blood pressure and Diabetes is not genetic, but environmental. In Britain they conducted study of teenagers and found that their counterparts in Punjab had much better readings about Blood sugars and Blood pressure. So how does “genetics” explain it??
Amardeep,
Why do you find the tone irritating? Isn’t the author correct in stating that obesity and the rise of wealth-correllated diabetes is the other side to India’s economic success?
My significant other’s grandfather is currently dealing issues particularly related to infections/gangerene/and amputation.
Previously healthcare in India, just like rest of the western world, dealt with infectious diseases and their control. India still has some work to do in infectious disease control, but with industrialization, longer lives, different food eating habits, prosperity you start dealing with heart disease, diabetes, cancer, etc. This means government clinics offering antibiotics, quinine, or cholera vaccinations won’t be enough and the current infrastructure of Indian healthcare establishment (Insurance) isn’t designed to accomodate chronic disease treatment on a massive scale.
this is a public health issue that needs to be addressed differently for indians in india and for indians abroad.
this rise in diabetes in india was acknowledged as a considerable problem 5-6 years ago… here’s a bbc article on it published in feb. 2001. one big challenge in india is being able to cope with the rising numbers. also prevention strategies and campaigns have not reached the lay public yet. there is tons of info online but it does not reach the rural areas. many people will not be able to afford the drugs to begin with.. it isn’t a one time expense, one has to take them for life.
in the west, the biggest problem is not knowing that one is diabetic. one thing we can all do in our local communities is to organize for a doctor to come and give a briefing on diabetes and take a finger prick test to show people what their blood sugar levels are. they can then follow up with their family physician. we have done this in a spiritual gathering setting and everytime there have been a handful of people who did not know their blood sugar was high (obviously don’t do this right after a meal).
the other problem is, diet recommendations. if you tell an elderly indian person who has been eating rice in every meal for the past how many ever years that they need to give it up, it isn’t going to happen. we need to develop diet recommendations for people within the context of an indian diet and emphasize on portion control. also, for those in rural settings who have about 10-50 rupees to spend on food daily, buying expensive whole grains etc is not feasible. india has come up with diet recommendations but they are not reaching people. we often hear no rice, no sugar, no sweet… but it has been found that a better way to approach diet changes for indians is by reducing fatty foods and oil intake. read last paragraph here. reducing obesity also reduces diabetes incidence, it is a well established correlation.
“So how does “genetics” explain it??”
You know, I wondered the same thing, since the 2nd gen in the west do seem to take better care of it. Maybe it’s the predisposition? All I know is that most sources will say “South Asians are genetically predisposed to getting type 2 diabetes.” Now, whether this REALLY means “more South Asians develop diabetes than any other ethnic group” I don’t know. If that’s what it means, then yes, being genetically predisposed and actual number of incidents are very different things. Maybe a geneticist can explain this – paging Razib.
Just a thought – maybe if you are genetically predisposed to gaining weight around the waist-line, you may have a higher risk for certain diseases. Agan, this is preventable, but that may be where the genetic predisposition comes in?
here are some sites just for basic info:
American Diabetes Association CDC info on Diabetes
one of my fave sites uptodate has a patient info link for you..
tried to find some great journal articles regarding india/obesity/diabetes, but really didn’t find much info.. will search further.
metric, The reason why I dispute the “genetic” claim is because they are based on statistics alone. Now I am not an expert in genetics, but the fact that the claims about western Desis are based solely on statistics makes it harder for me to buy it.
Will a construction worker in India show the same symptoms regarding blood sugars as a software engineer of Desi decent in the US??
All the while a recent study showed that Indian/Desis in the US enjoy highest life expectancy (84.5 years)
metric: in regards to greater girth.. here is an abstract that i found online for you..
I want to mention that I dont know enough about this subject. They may have found a gene that causes Diabetes and Desis may have that gene in higher numbers. If thats the case, I will promptly accept the claim.
RC,
I agree that a number (%) of incidents in a population does not equal a predisposition, because there could be so many other factors, as pointed out in some of my previous posts. That’s why it’d be interesting to see if there is any basis to the claim (not a claim I made, just one that I read) that it is genetically predisposed.
rc: it is not only genetics but environmental… for example gastric cancer has a higher prevelence in the japaneese who live in japan as compared to those that have immigrated/migrated to the west..likely due to dietary factors, and other ‘unknowns’…
even with diabetes, esp type 2, you can change the outcome if you know it runs in your family and get diet/sugar controlled/exercise from the get go..
hence public awareness of the situation is dire… diabetes sucks… affects every organ of the body… eye, heart, vessels, infections increase, blah blah blah…
Re: the genetics angle, I have heard from several doctors and also read that for an equivalent BMI and height, a desi is at a greater risk of heart disease and diabetes than a Caucasian person. BTW, there is a new South Asian Heart Center (link) being established at El Camino Hospital in the Bay Area near San Jose.
Diabetes runs in my family on my dad’s side, so I am supposedly very prone to it. My paternal grandfather died of it when I was still a baby and some of my uncles suffer from various complaints. In my dad’s case, he started falling sick about 15 years ago, but it was detected in time, and since then he has been very disciplined in food and exercise, so he keeps in under control.
I got my parents on Medical insurance last year in India. It was quite a hassle finding a policy for my dad, since diabetes is not covered by most policies, and they refused to cover anybody who is even ‘prone to’ diabetes, especially if they are above 60. Also they tend to try and associate any medical claim with diabetes and refuse to pay sometimes. But finally, I did find a policy which was more expensive, required a lot of tests before approval, but since then has worked well for my dad. Of course, the cost is cheap by US standards ($150 /year) but I can completely see why people would not still be able to afford it.
Diet in India is very unhealthy in general for the middle class. The poor and lower middle classes eat less and light, but because they are can’t afford it. Among the newly minted middle classes, there is a perception that eating light food is beneath status. I see that a lot, even in my own family. When I was a kid, we were pretty working-class and we could not even have good-quality rice and/or chicken/fish daily, so ate a lot of soupy dal, and veggies. However, when I was in my teens, my dad got a higher-paying job in Africa and we were better off, so we started eating as befitted our status, hence both my mom and I became obese. Unfortunately, people in India are just discovering the luxuries of eating out and trying various cuisines, so this trend will NOT go away soon 🙁
It is tempting to blame MacDonald’s for this obesity trend, but I seriously doubt that these American chains are actually having much of a direct impact. I believe much of this obesity/diabetes trend in India is home-grown.
i think the incidence is rising post fast food wars in india..as it has affected the west and other nations that mickey d’s and other joints have infilitrated into… yes, we have ghee, mitthai and all that…but other things also prevail.. more transportation, less excercise, walking, less ‘manual’ labor, more sitting in front of a screen typing/etc… who knows.. it’s a huge sociological/medical nightmare that the world, not only india is facing…
Changing traditional diets and its effect on a racial group unused to Western diets has been chronicled before:
The study clearly shows that certain genetic makeup is susceptible to diabetes if the diet is radically changed. Sadly nothing new… Even the supposed “healthy” snacks one finds like Dannon yogurt is sweetened with high fructose corn syrup.
Thank you Dr. Bean (aka chick pea) in comment #25 Thats what I wanted to emphasize, that it is not just the “misfortune” of being born a Desi. There are lot of unknowns!!! It sounds better from an actual doctor, rather than in my badly written rants 🙂
Link for #29
there are studies being conducted to determine causative genetic links between south asian ethnicity and diabetes… it is very hard to come up with conclusive results, mainly because one needs very large study groups (n>1000) for population studies. and there are many other interfering factors, like lifestyle and other health issues, that need to be equalized across the whole group (confounding factors).
in any case, the genetic links if they exist have always been there, and they only predispose… lifestyle and diet definitely tip the balance to acquiring the disease. so this needs to be addressed and focussed on. sometimes people take the excuse of ‘oh it’s genetic’ to not be more pro-active and involved in maintaining their health.
RC : this is another link about genetics
I wonder to what extent obesity/diabetes in india can be attributed to a change in diet as oppossed to a greater number of wealthy indians eating like weathy indians always have.
My personal observation is that wealthy indians have always been overweight in comparison to their western peers. Even indians in the West seem to have a higher body fat percentage than non-indians, though they seem generally slimmer than well-of indians in india. The indian diet, with it’s oils, ghee, carbs, and sweets, does not strike me as the healthiest of cuisines.
But i’m just going by personal observation.
As is the case with other high-risk populations, research indicates that there is a genetic basis behind the rise in prevalence of diabetes among Native Americans. Obesity is a major risk factor for diabetes in many tribes, with increasing rates of obesity measured in several communities in the United Stated and Canada. This increase can be linked to the tribes’ move away from traditional diets and lifestyles towards more modern ways of life. One notable study showed that Pima Indians who have adopted an “Anglo” diet are three times more likely to develop diabetes over six years than are their counterparts who eat a more traditional diet. The community now has the highest rate of Type 2 diabetes in the world. In addition, these studies have shown that there is a hereditary link. In the case of Arizona’s Pimas community, diabetes rates are highest in the offspring of parents who themselves developed diabetes at a young age. This trend has also shown up in studies of other tribes.
The above is from this link about the high prevelance of diabetes in Native American populations. Seems to me like diabetes in India is following a similar trajectory with more people migrating to a ‘westernized’ life-style that is big on fast-food and not-so-big on exercise.
I have noticed however, that my younger cousins are getting into a habit of exercising, if only to look like the stars on TV! Hopefully this trend towards exercising expands to the general population and continues.
sorry the link follows http://www.rediff.com/news/2005/apr/19inter1.htm
There is truth to that, but I think that is combination of genetics and a sedentary lifestyle. Most Indians have a tendency to get that infamous “potbelly” at a fairly young age as compared with non-Indians. And abdominal fat is linked with a host of health problems as opposed to a general distribution of body fat.
in my view, the overindulgence of these is what makes our current indian diet unhealthy. eating in moderation may not have been a choice in earlier days, but a necessity when ‘goodies’ were restricted due to tight budgets. with that barrier removed people started overindulging… satvic indian diets are very different from what we eat today.
Great post Amardeep! My dad was diagnosed with very early stages of Diabetes, so the links and comments from everyone are very helpful.
The term pandemic is used to describe epidemics/diseases of world-wide proportions. (An epidemic is used to describe the rate of disease that reaches unexpectedly high levels in a country or region, for example.) Obesity is considered a pandemic because it is been seen in large rates across the world.
Thank you mph’er. Why is obesity a disease?
Can it be cured? Is it even an individual condition? Surely, one can hypothesize that this is a societal trait and its remedy lies not with surgery or exercise, but with correcting the society itself.
so what could the societal traits be. or rather, what societal functions could be linked to obesity.
public healthcare network
public recreation facilities
GDP/PPP
happiness index
access to healthcare
food marketing per square inch in publicly accessible media
illiteracy rate
etc.
these are not individual issues, but societal issues. all you quant types – do the regression modeling – and get published.
I think I agree with most of what been said here. We may be more prone to developing D, but we’re also helping it along environmentally. In my family, my maternal grandparents don’t have diabetes, obesity, heart issues etc. They’re just old. My uncles however are obese, diabetic and have some minor heart issues. I visited them recently after being in the US for many years where my diet has changed significantly with regards to consumption of sweets and rich food etc. along with more exposure to health related research, and I could see it plain as day what was going on. Highly refined rich food, lack of exercise, and lack of realization that this was an issue on a daily basis. And one of my uncles is a doc!!! I even confronted him on the lack of greens and fruits on the dining table, and you will not believe what he said – we get impure food here so its not effective to focus on fruits etc. WTF!!! I was at a loss for words! Wouldn’t ALL food be impure – chemicals etc. – including all the food they happily consume? And everyone in that family is overweight to obese. And they don’t get it as first order of business either. They do manage their diabetes but that’s not taking it head on.
I have brought up this issue with them so many times but no one gets it. I may have guilty genes but I’ll be damned if I help this disease along!
Philosophically, the existance of these ‘diseases of the wealthy’ evens out the see-saw for me. Its like the old custom of tying women’s feet in affluent chinese society – they were rich but screwed on account of it! The same is happening in India. Most rural poor who can’t afford rich food and stick with grains, veggies and daal, and seem thin do much better in terms of diabetes, and heart stuff. Now they may get knocked over by other preventables that they don’t have money to treat… This of course doesn’t fit with the obesity problem with the poor in the USA though…
Note to self: Invest in companies that make drugs for diabetes in India.
This is what happens when all you do is study and eat gulab jamun all day and ignore any kind of physical activity.
The other problem is that alot of people in India are alcholics and they drink the home made stuff. I am sure that this is some how related especially in the rural parts of india. When I was there it seemed like everyone was drunk even the little kids.
The title of the Times article is not quite correct – Modern ways open doors to Diabetes in India? Really? Diabetes has always been a problem. Maybe this is the first time we have numbers. And trying to attribute ANY increase in diabetes to “fast-food” is a joke. Especially given what the average American reader will visualize fast-food to be. These NYT articles seem to be more and more about some “modern” Indian issues that some reporter wrote looking out of his hotel window. Without tying in the eating habits (even this word would be difficult to apply in so many parts of India) to hard economics is not quite right.
i hope you see that i’m not tooting into the wind.
my premise for issue resolution is somewhat homeopathic in flavor.
this affects the distribution of public funds.
what should the government focus on to have most impact – infrastructure, hospitals, roads, food subsidies, education?
think big. be big.
Thats’s scary! Where in India were you?
this is what happens when one’s mind drifts like an aloo niblet in a bowl of sambhar in mid-sentence.
mmm.. sambhar.
Here’s one problem with the first generation city dwellers i.e. they grew up in the villages:
a) In the villages, physical labor is the lot of the unfortunates (low on the social ladder). If you’ve done well, you get to be exempt from physical work. Often there is not much dignity in physical work.
b) Peaople stick to a healthy diet since it’s affordable and sweets, meat are expensive for most poor people in the village. Fesitivities were often the only chance for them to get high calorie food and they would use grab this chance since there was no other way they could eat them otherwise.
They then move to the city and can afford high-calorie foods. Since they are used to eating these foods at every chance they got, they consume them in unhealthy quantities. They also really hate to exercise because of their negative feelings towards physical exertion.
This is a deadly combination.
My doctor patiently explained this lovely fact a couple years ago. Indians suffer from heart disease at far lower body weight than other racial populations.
Outlook had a good feature on this subject. http://www.outlookindia.com/archivecontents.asp?fnt=20060814