Dr Anoop Misra, Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology; Chairman, National Diabetes, Obesity and Cholesterol Foundation (N-DOC); Director, Diabetes and Metabolic Diseases, Diabetes Foundation (India) (DFI) shares information about diabetes, its etiology, diabetes management in India and more, in conversation with M Neelam Kachhap
What are the hallmarks of Indian diabetic patients? How are they different from other patients?
Indian patients are younger by a decade, have high body fat and low muscle mass. They also have higher increase in blood sugar after the meals as compared to other races because of dysfunctional insulin response. Indian patients have more severe problems of kidneys, eyes and heart, several times more than other races. Infections are highly prevalent because of unhygienic contacts, thus causing bacterial infections and tuberculosis. In summary, diabetes in Indian patients is more problematic, and leads to early complications and even death if not treated aggressively.
Tell us about the new diabetes management drugs in the market? How are they different from the existing drugs for glucose control?
Discovery that incretin hormones (incretins) produced in intestine decrease blood sugar has revolutionised treatment of diabetes. Use of drugs acting on these hormones does not lead to as much hypoglycemia (low sugar) as compared to conventional drugs like sulphonylureas. They have several beneficial effects for metabolism and pancreas as well; are multifaceted in action as compared to many conventional drugs which have a uni-faceted action profile. Injectable drugs also lead to significant weight loss. They have a better safety profile than many conventional drugs. These drugs are available in India since the last five years. High prices of these drugs remain an area of concern.
Diabetes is recognised as a lifestyle disorder and there is a fair bit of awareness among Indians on the same. But what are the genetic causes of diabetes?
Usually diabetes is caused by multiple factors, and genes contribute to about 30-40 per cent. More than 40 genes have been implicated in diabetes, and it is also possible that several genes together or in unison lend tendency for diabetes. In addition, several genes implicated in obesity may also be linked to diabetes. Interestingly, one gene Myostatin, researched by us, causes excess adiposity and low muscle mass, both important factors for diabetes development. There are some rare forms of diabetes which are clearly linked to single gene (e.g. maturity onset diabetes in young). Finally there are some genes which are triggered only when linked to bad food habits and physical inactivity.
What is steroid-induced diabetes and how can this be managed?
Steroids decrease body’s ability to use insulin effectively, and cause weight gain and increase blood pressure. A combination of insulin resistance and weight gain causes diabetes. Further, these drugs may uncover diabetes in those people who already have tendency to develop the disease. Diabetes may get resolve after stopping the usage of steroids. Some people who are already at higher risk of getting diabetes may continue having the disease, it needs to be managed by weight loss and correct drugs.
What is your take on stem-cells treatment for diabetes?
The potential of the stem cell approach for diabetes is particularly attractive because it offers hope for curing the disease. Unfortunately, many factors limit the usefulness of this approach; such as the type of stem cells, source from where they are obtained, number of stem cells used in therapy, and patients’ response to stem cell treatment. In general, this approach would be more useful in those with complete deficiency of insulin producing cells (type 1 diabetes) than partial deficiency of cells as in adult onset of type 2 diabetes. Some trials in type 1 diabetes have shown promise, and patients’ insulin dependency was reduced for a short period time, however, in most of the cases, insulin was required again to control blood sugar.
What is new in dietary management of diabetes?
Low carbohydrate diet: Several diets have been suggested for weight loss and control of blood sugar, but low carbohydrate diets seems to be winning according to recent studies. Evidence exists suggesting that low-carbohydrate diets can lead to improvements in HbA1c and reductions in body weight in the short term (less than one year).
Use of pistachio nuts in Indian diets: A study, carried out by the Diabetes Foundation of India (DFI) and the National Diabetes, Obesity and Cholesterol Foundation for a period of six months was published in US-based journal Nutrition two months back. Adding pistachio nuts to the diet can lead to multiple health benefits like reduced body fat, improved insulin action, reduced harmful fatty acids and improved blood oxidation. This study shows, for the first time, that Indians who have multiple risk factors could modulate their diets by including pistachio nuts.
Increasing beneficial fatty acids (monounsaturated fatty acids) in diets: In another study conducted by our group (published in US-based journal Atherosclerosis) dietary oils were replaced with oils high in monounsaturated fatty acids (Olive, rapeseed oils) in patients who have high amount of fat in the liver. After six months of intervention, and decrease in abdominal fat, significant improvement in action of hormone insulin on blood glucose and tissues, decrease in lipids; significant reduction in triglycerides, and increase in good cholesterol HDL were observed. Most importantly, liver fat decreased in about 60 per cent of patients with improvement of liver enzymes levels indicating significant improvement in liver metabolism.
Bariatric surgery is hailed as a way to manage diabetes? What are your views on this?
Bariatric surgery leads to a remarkable impact on type 2 diabetes mellitus. Remission of the disease occurs in 50-70 per cent of the patients undergoing surgery i.e. these patients are off any anti-diabetic medication while maintaining normal blood glucose levels. Interestingly, the impact may start early in the post-operative course even before any significant weight loss has occurred. Thus, factors other than weight loss are responsible. The possible mechanisms include role of gut hormones like GLP1, faster gastric emptying, and decrease in inflammatory status and improvement in insulin resistance. Recent studies have shown regression of diabetes could be maintained even upto six years after surgery. Finally, bariatric surgery, in the long term has been shown to reduce deaths due to heart disease and prolong life. Clearly, management of type 2 diabetes now includes bariatric surgery as an important treatment to control blood sugar in obese patients.
What are the main points for awareness programes for diabetes?
Principally, efforts should be directed towards correct diet and exercise in the following manner:
- Five dietary principles:
- Decrease carbohydrates, and opt for complex carbohydrates (Whole cereals, unpolished rice, barley [jaun], buckwheat [kuttu], oats [jai], millets, etc.)
- Limit sugar intake
- Eat high fibre foods (100 g of whole wheat flour gives 1.9 g of fibre).
- Limit fats but take more of monounsaturated fats (nuts, olive and rapeseed oil) and omega-3 fatty acids (fish, flaxseeds)
m Salt intake should be less than 5 g of sodium chloride (or about 2 g of sodium)/ day.
- Three principles of physical activity: recommended physical activity for adults is 45-60 min every day
- At least 30 min of moderate intensity aerobic activity (leisure time)
- 15 min of work-related activity (five minute walk every 2 hours of working in office)
- 15 min of muscle strengthening/ resistance exercises.
- Quit smoking and alcohol