The ICMR India study reveals diabetes is rapidly increasing, with 101 million affected and 136 million with prediabetes, totaling 237 million people—more than the population of many countries—highlighting the scale of the crisis
Published Nov 14, 2024 | 7:00 AM ⚊ Updated Nov 14, 2024 | 1:16 PM
Dr V Mohan’s ABCDEF Mantra on Diabetes Day
As diabetes continues to affect millions globally, the possibility of reversing the condition and the newer challenges the disorder is bringing has become a topic of significant interest.
Dr V Mohan, one of India’s leading diabetologists and Chairman of Dr V Mohan Diabetes Research Centre in Chennai, tells South First about challenges in managing and potentially reversing diabetes.
On World Diabetes Day, Dr Mohan breaks down the crucial factors — from the importance of monitoring A1C levels to the role of lifestyle changes and regular follow-ups — that can make remission achievable for some.
Q. What is the current state of diabetes in the country?
A. Diabetes is rapidly increasing in India, as highlighted by the ICMR India study, a nationwide survey conducted across all states and Union Territories. According to this study, 101 million people in India have diabetes, and an additional 136 million have pre-diabetes, totalling 237 million affected individuals. This staggering figure exceeds the population of many countries, underscoring the immense scale of the problem.
Q. Is it true that people do not know that they have diabetes? Is it a challenge?
A. Globally, about half the population with diabetes remains unaware of their condition. Diabetes is often called a silent killer because it is asymptomatic. Symptoms manifest in only about half of the cases, while the rest are diagnosed accidentally during routine check-ups or when accompanying others to the hospital. This lack of awareness is concerning, as undiagnosed diabetes silently causes damage to the body over time.
Q. When is the right age to check for diabetes?
A. If there is a family history of diabetes then I would say that one must start screening for diabetes from the age of 20 onwards. If there is no family history of diabetes or have obesity then screening should be done at least once a year from 30 years of age.
Q. What are the tests to be done to screen for diabetes?
A. Minimum test is a fasting blood glucose which means in empty stomach you take the glucose test in the blood. The ideal test to do is a GTT which is oral Glucose Tolerance Test. We take the fasting sample, then we give them glucose drink to drink about 300 ml of water, lime juice and glucose with 75g of glucose which is dissolved and given to drink. After two hours, we repeat the test and if we find that the sugar levels are going up after giving the glucose load, then that is the best test to diagnose. We call it a gold standard test.
There are other tests like random blood sugar, which is taken at any time of the day. If the blood sugar level is more than 200 more than two times of the day, then that is diabetes.
There is also another test called HBA1C which shows controlled sugar of three months. If that is above 6.5 percent then it is diabetes. Any one of these tests can be done to find out diabetes.
Q. What are some new factors that are contributing to the rise in diabetes?
A. The old ones are family history, ageing, obesity, eating too much junk food, eating the wrong food, no exercise, stress, and pregnancy. But apart from them, newer risk factors are emerging. For example, air pollution has been found to have this particle 2.5 M that we have. Pollution itself has been shown to be an endocrine disruptor and that can also lead to diabetes. It may not be the most common cause, but old ones remain.
Q. Does management of diabetes differ for young adults and older individuals?
A. Diabetes management is similar across age groups, though drug suitability varies. Older individuals may tolerate some drugs better than younger people, and vice versa. The key difference lies in prognosis and management goals.
Young people with diabetes face higher risks due to their longer life expectancy, giving complications like blindness, kidney failure, or heart disease more time to develop. Diabetes complications typically emerge 10-20 years after diagnosis. For someone diagnosed at 20, severe issues may arise by 40. Additionally, diabetes in younger individuals is often more aggressive and harder to control.
In contrast, those diagnosed later in life, such as at 60 or 70, may develop complications only in their 80s or 90s, and diabetes tends to be milder, lowering the risk of severe complications. Thus, earlier onset significantly increases risks and challenges.
Q. Many people hesitate in accepting their diabetes diagnosis and starting medication. Can we really manage diabetes with just lifestyle changes?
A. This is a sensitive topic for many people. The moment you mention the need for medication, the first question they ask is, “For how long?” The truth is that diabetes management is lifelong. However, if you tell them this upfront, it often upsets them even more. To ease their concern, we suggest starting treatment and reassessing as we go.
In the early stages of diabetes, particularly within the first one or two years after diagnosis, there is a possibility of remission, especially for individuals who are overweight or obese. If they lose five to 10 kilograms, there is a good chance their diabetes could go into remission, and they may not need medication at all. However, this only applies to about 5-10 percent of people, and it is not something that can be generalised.
When told they need to take medication, people often feel they are “stuck” with it for life, and this thought worries them. Ironically, what doesn’t seem to worry them as much are the severe complications of uncontrolled diabetes, such as blindness, kidney failure, amputation, heart attack, or even death. These are far more dangerous than taking a pill every day, yet this reality doesn’t resonate with many.
Q. Does diabetes medications harm people’s kidneys?
A. There is a a common misconception that diabetes medications cause harm. Some patients fear that taking medicines will damage their kidneys, liver, or cause cancer. These fears are unfounded.
The doses prescribed are small, safe, and supervised by doctors. If necessary, doctors can reduce or adjust the dosage. Having treated patients for decades, I can confidently say there is no evidence that properly administered diabetes medications harm organs. On the contrary, controlling blood sugar levels effectively is essential to preventing complications.
Q. How to manage diabetes?
A. The general principles of diabetes management are straightforward: Keep your blood sugar, cholesterol, and blood pressure under control; maintain a healthy weight; avoid smoking; limit or give up alcohol; eat a healthy diet; exercise regularly; and ensure proper sleep. Following these practices, even if you need one or two tablets, it will not harm you. On the other hand, if your primary focus is to avoid medications or insulin at all costs, your diabetes is likely to remain uncontrolled, and your risk of complications will increase.
Q. When will people need to start taking insulin?
A. Now, regarding insulin, most people with diabetes—90-95 percent—have type 2 diabetes, which rarely requires insulin. For the small percentage (1-2 percent) of patients with type 1 diabetes, insulin is non-negotiable and critical for survival. Without it, they risk diabetic coma or death. Type 1 diabetes requires multiple daily injections or the use of an insulin pump, which has revolutionised diabetes care.
An insulin pump, which looks like a small pager worn on the body, automatically delivers the right dose of insulin. It measures blood sugar levels and adjusts the dose using artificial intelligence, eliminating the need for frequent injections and manual blood sugar monitoring. This technology has made life significantly easier for individuals with type 1 diabetes and some severe cases of type 2 diabetes. It is almost like an artificial pancreas.
Q. Can people with diabetes eat rice? Is ragi and wheat a safe option for people with diabetes?
A. This is the most common question that I get. But let me tell you, rice, wheat, and ragi are all carbohydrates. They all contain about 70 percent carbohydrates, so there isn’t much advantage in switching from rice to wheat, or from wheat to ragi or millets. Millets do have a little extra protein, more fibre, and some phytonutrients, which give them certain advantages, no doubt. However, they are still carbohydrates. So, whether you take rice, wheat, chapati, puri, bread, millets, or ragi, the quantity has to be reduced.
Q. What should an ideal plate of a person with diabetes consist of?
A. For people with diabetes, I recommend the thali concept. Divide a full plate into two halves: one half should contain non-starchy vegetables like lettuce, cabbage, beans, spinach, broccoli, or asparagus, which are low in calories and rich in nutrients like iron and B12, preventing anaemia. Avoid starchy vegetables like potatoes, beetroot, and yam.
The other half is split into two quarters: One quarter for protein, such as fish, chicken, eggs, or plant-based options like lentils, tofu, and paneer. The remaining quarter is for carbohydrates, reduced to a small portion like a little rice, one chapati, or a small serving of ragi. This balanced approach ensures a mix of carbohydrates, proteins, fats, fibre, vitamins, and minerals while reducing excessive carbohydrate intake, which is linked to high sugar levels and diabetes.
Indians typically consume 65-70 percent of their diet as carbohydrates. Reducing this and increasing protein and fibre, especially from vegetable protein, is the key. However, completely cutting carbohydrates is challenging since protein intake should not exceed 20 percent, and eliminating carbs leads to high-fat diets, which can raise LDL cholesterol and increase heart attack risk.
Balance is crucial: Moderately reduce carbohydrates, include adequate protein, and choose healthy fats like those from nuts, seeds, and oils (E.g., groundnut, sesame, mustard). Avoid excess saturated fats from coconut oil, palm oil, and ghee. While foods like coconut oil are common in Kerala, their balanced diet with fish and vegetables supports health.
Dairy also plays a role: One glass of milk (250 ml) meets calcium needs for men, but postmenopausal women may need supplements. Curd and yogurt can also be included for a well-rounded diet.
Q. What’s the best eating pattern for managing diabetes—six small, frequent meals or intermittent fasting?
A. Six meals may be excessive but typically involves adding two small snacks between main meals, promoting small, frequent feeds. For example, a light breakfast with one dosa or idli followed by another idli after 2-3 hours helps prevent sugar spikes. Large meals cause significant sugar spikes and drops, which are undesirable.
Intermittent fasting can reduce calorie intake and aid diabetes management, especially with two limited meals, like breakfast and dinner, without snacks. This approach improves digestion and prevents sugar spikes. However, eating large meals, even twice daily, can still raise blood sugar levels. Fasting options include eight-hour, 12-hour, or 24-hour fasts.
Fasting safety depends on diabetes type and medications. For those on insulin, fasting can risk hypoglycemia unless using an AI insulin pump. Small, frequent meals are safer for those on insulin or medications. Individual results vary—intermittent fasting works for some but can cause issues like gastritis in others. The key is a personalised approach that effectively manages diabetes without adverse effects.
Q. Is diabetes reversible?
A. I have an A, B, C, D, E, F mantra for diabetes reversal:
A stands for A1C: If your A1C is not very high, reversal is possible. Normal A1C is 5.6. For diabetics, up to 7 is considered manageable. If it’s 8, reversal is still possible, but as it climbs to 9, 10, 11, or higher, the chances of reversal significantly decrease due to the severity of diabetes.
B stands for body weight: If you are overweight or obese, losing weight increases the likelihood of remission. If your BMI is higher, weight loss can significantly help reverse diabetes. However, if you are already thin, you may not have much weight to lose, making reversal more challenging.
C stands for C-peptide: This indicates the amount of insulin your body secretes. If your C-peptide levels are good, meaning your body still produces insulin, the chances of reversal are higher. If your pancreas is severely damaged and you have little to no C-peptide, as in Type 1 diabetes, reversal becomes very difficult.
D stands for duration of diabetes: If the duration of diabetes is short—say, 2, 3, or 5 years—the chances of reversal are much higher. If someone has had diabetes for 10, 15, or 20 years, reversal becomes very difficult.
E stands for enthusiastic individual: A person needs to be highly motivated and enthusiastic to follow the required diet and lifestyle changes, not just for a few months but for life. Diabetes remission is maintained only through consistent efforts. Overeating or neglecting the regimen will bring diabetes back.
F stands for follow-up: Regular follow-ups are crucial. Many people lose weight through crash diets, like keto or extreme carb restriction, and temporarily see improvements in sugar levels and weight. They stop medications and assume they’re cured. But they’re not; they’ve only gone into remission. Over time, they may regain the weight, return to their old habits, and their diabetes will come back worse than before, requiring stronger medications or even insulin.
Reversal of diabetes is possible, but it is rare. My estimate is that five percent, at most 10 percent, of people with Type 2 diabetes can achieve remission. Of these, about 50 percent lose their remission within a few months. Very few maintain remission for more than a year or two. There are exceptions—cases where diabetes was triggered by stress or conditions like COVID-19 and steroids, and once the trigger resolved, diabetes disappears. However, these are not true cases of remission.
Ultimately, achieving remission is not essential for a healthy and long life. I’ve seen patients who have lived with diabetes for 50, 60, or even 70 years, reaching ages of 100 or more without complications. They’ve taken regular medication and lived full, healthy lives. So, whether or not remission is achieved, the goal is a healthy, complication-free life.
(Edited by Ananya Rao)
