Politics and policy often drive public health. And if the number of times a word used by the prime minister is any measure of its significance, then Diabetes is the public health disaster of our time. Bad governance is worse than diabetes. So said Prime Minister Narendra Modi in June 2014 in a Rajya Sabha speech. Ever since, he has called diabetes the biggest threat facing India; cautioned against the coming diabetes epidemic in his radio broadcasts; exhorted all on Twitter to defeat diabetes; urged the nation to fight diabetes through yoga.

Until the morning of April 14, nothing exceptional had ever happened at Jangla, except bomb blasts and gunfire. At the heart of the Naxal terror trail, penned in by tall teak forests, this remote Chhattisgarh village has never seen a railway station, a bank, not even an MBBS doctor. But on that day it hit the national news, as Modi visited to launch the first health and wellness centre under the Ayushman Bharat reforms announced in Budget 2018. We screened the entire population for five lifestyle diseases, says Dr Vinod K. Paul, Member, Niti Aayog, and architect of the scheme. One of the first beneficiaries was a young woman diagnosed with uncontrolled diabetes. Like 70 per cent Indians, she had no clue about it. The PM mentioned her in his speech as emblematic of the kind of healthcare advantage he wished for all Indians.

THE SUGAR RUSH

The ubiquity of diabetes is now headline news. British prime minister Theresa May appears on TV wearing glucose monitoring patches. US president Donald Tru­mp’s 12 cans of Diet Coke a day have provoked furious speculation: obesity, diabetes, heart disease, what will happen to him? In India, Union ministers Nitin Gadkari, Sushma Swaraj and Arun Jaitley have gone under the knife for diabetes-related complications. Chief ministers Devendra Fadnavis, Arv­ind Kejriwal, Amarinder Singh and K. Chandrashekar Rao have sought treatment for diabetes. And, it is said, the secret behind BJP president Amit Shah’s 20 kg weight-loss is pretty much the same.

Your body needs sugar to keep ticking. Glucose, a simple sugar and your body’s favourite fuel, is the main source of energy your brain and cells use. When you eat, glucose enters your bloodstream, but can’t get inside cells on its own. Your pancreas produces a hormone, insulin, which tells the cell doors to open up to let the glucose in. Once inside, the cells convert glucose into energy. Diabetes Mellitus, a group of metabolic diseases, starts when your blood sugar levels get too high, either because cells do not respond to or produce insulin, or both. With 82 million of the world’s 425 million diabetics, India is the second largest hub of the disease globally, reports the International Diabetes Federation.

SMOKE AND FIRE

Billions of nasty molecules swirling around: heavy metals, hydrocarbons, carcinogens. They cloak your city in a semi-transparent haze, layer the sky with unholy orange clouds, hug the ground in suspended animation. The tin­iest specks, 30 times finer than a strand of hair, enter your nose and throat, sneak past the gooey mucus, and slip deep into your lungs and bloodstream. Like minuscule bullets, they corrode and kill cells, pushing your immune system out of whack. Lungful after lungful, and your immune cells get inflamed like a slow-burning forest fore: chronic inflammation. Scientists have now revealed a frightening new reason to worry: air pollution impairs your body’s ability to process sugar, triggering diabetes.

India is one of the world’s most polluted countries, host to 14 out of the top 20 most polluted cities, according to WHO data. Dr Naresh Trehan, cardiovascular surgeon and chief of Medanta-The Medicity in Gurugram, is not surprised: Multiple studies have shown how ultra-fine PM2.5 pollutants breach the protective barrier of blood vessels, triggering inflammation, heart events, lung disease and cancer. And the pancreas is very sensitive to body signals. A new study on 1.7 million people, published in The Lancet Planetary Health, July 2018, shows how inflammation from lethal air particles puts pressure on the pancreas, leading to diabetes.

THE DIABETES EPIDEMIC

A potentially explosive increase of high blood sugardiabetesis taking place in India, reports a new, comprehensive assessment of the burden of diabetes over a quarter century, 19902016, in every state. Led by Dr Nikhil Tandon, head of the Department of Endocrinology, All India Institute of Medical Sciences, Delhi, and Dr Lalit Dandona, Public Health Foundation of India, Gurugram, along with over 24 collaborators across the country, the report (Increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 19902016′) was published in The Lancet in September. Over the course of 26 years, it shows a 39 per cent jump in prevalence of diabetes in adults above age 20.

Stark numbers reveal an 80 per cent rise in years of healthy life lost to premature death or disability due to diabetes per 100,000 population, the highest among non-communicable (NCD), chronic, lifestyle diseases in India, along with a 131 per cent rise in death rate. Complications from excess sugar in blood, including ischaemic heart disease, chronic kidney disease, stroke, tuberculosis, cancers, Alzheimer’s, dementia and cataracts among Indian diabetics amount to a whopping 2,111 years of healthy life lost per 100,000 people. Twenty-five years ago, diabetes did not feature in the top 30 causes of life-years lost to premature death or disability in India. Today, it is the 13th, says Tandon.

GIRTH OF A NATION

Blame it on your expanding waistline. Every festive season, the average Indian chows down 20 per cent more sweets. If you add festive snacking to your daily diet, it is 5,000-odd calories a day, more than double what Indians usually consume. Seven days of overeating and inactivity, and the weighing scales tip by an average of three kilograms for Indians. But overeating is tough on your body. Your cells work harder to process the extra food. Hormone insulin from the beta cells of your pancreas sends urgent messages to your cells: grab sugar out of the bloodstream and use it for energy. But as you continue to stuff your face, your cells start defying insulin. The sugar in your blood rises, some turns to fat. Your body fights back, produces more insulin, mops up and stores the fat. Your blood sugar goes back to normal once you return to your usual diet and exercise routine. But what if you don’t? Well, that’s another story.

There has been a two-fold rise in prevalence of overweight adults across every Indian state in the last 25 years, points out Tandon. The more fatty tissue you have, the more resistant your cells are to insulin. About 20 per cent of Indian adults are overweight, up from 9 per cent in 1990. About 38 in every 100 overweight Indian adults have diabetes compared to 19 globally. What’s more, the data reveals a 36 per cent jump in years lost to diabetes due to excess weight in India. The finding that in 2016 there were twice the number of people with diabetes for every 100 overweight adults versus the global average, highlights the higher risk of diabetes in India, says Tandon.

A COMPLEX REALITY

When I started my career in the 1980s, I hardly ever saw young diabetics, says Dr Ambrish Mithal, chairman and head, Endocrinology and Diabetes Division at MedantaThe Medicity, Gurugram. Now it’s a shock to me. In the last 15 years, the number of young people we get with Type 2 diabetes has gone up exponentially. Typically, in a metro, about 20 per cent people are diabetic by age 40 and at age 60 a staggering 40 per cent. If you go to the cardiac wards of hospitals, you’ll find that 65 per cent patients going through bypass surgery are diabetic, he says.

Doctors now know that there are two components to the diabetes explosion: first, it is rising due to metabolic changes induced by bad diet and lack of activity. Second, the changes inflammation brings within the body. Diabetes is rising at a much faster rate in countries like India, that are undergoing economic transformation, explains Mithal. There is a parallel bet­ween economic change and the rise in lifestyle diseases like diabetes. Quite clearly, affluence is the driver of the change, while lifestyle and dietary changes have made huge a difference to the prevalence of obesity and subsequently diabetes, he adds. The biggest bane for Indians is the increased intake of refined carbs. And now, pollution is the latest entrant to the list of diabetic triggers, along with endocrine-disruptors, or chemicals that interfere with hormones at certain doses.

The world of diabetes is now waking up to the complexity of the disease. Until recently, diabetes was considered to be either type 1 or type 2, says Dr Shashank R. Joshi, Department of Diabetology, Lilavati Hospital & Research Centre, Mumbai. In type 1 diabetes, your body attacks itself and destroys your own insulin-producing cells, he explains. That means, your body can’t make insulin and therefore is unable to deliver glucose to your cells. In type 2, your body produces insulin normally but your cells become resistant to it. Based on age and the absence of antibodies, about 85 per cent people with diabetes are classified as type 2. Now scientists are saying diabetes is actually several clusters of diseases, with significantly different characteristics, Joshi adds. Patients with diabetes could benefit from better treatment if their condition could be categorised into different types (see graphic).

SUNNY SIDE UP

It is the best of times to be an endocrinologist now. An explosion of new research, treatments, therapeutics, drugs and management modalities is changing the way diabetes is understood and treated. Diabetes has become a very fertile field for research in the last 15 years, with direct clinical implications, says Mithal. Every day new evidence is being produced to improve its prevention and treatment: Diabetes is the single disease for which maximum drugs are in development.

New molecule drugs are appearing every year. There are now 11 different categories of medications that work rapidly and in a number of ways to lower blood sugar levels, says consultant endocrinologist Dr Sujoy Majumdar of Kolkata. For instance, the SGLT inhibitors or GLP analogues that stimulate insulin release. None of them cause low blood sugar or hypoglycaemia, the bane of treating diabetes, he adds. In fact, several of the new drugs cause weight loss: They have been shown to reduce heart and kidney disease significantly, the biggest killers in diabetes. New technology has brought in a wide array of smart and less invasive monitoring and drug-delivery systems (see box).

At the cutting-edge of research is stem cell transplant. In diabetes, the cells that produce insulin are either des­troyed or stop working properly, says Dr Anil Bhansali, professor and Head of Endocrinology and Metabolism at PGIMER, Chandigarh. Scientists are testing ways to transplant these cells into people with diabetes, so they can make the insulin they need, to control blood glucose levels. Bhansali has himself pioneered work on stem cell treatment for diabetes at his institute since 2009, with the research reporting measurable clinical success. Currently, a number of human clinical trials on stem cell research are being tracked by the USFDA to treat diabetes. They might herald a new age of personalised medicine, where a patient’s own stem cells can be used for treatment.

PHYSICIANS VS POLICYMAKERS

Doctors call for public health policies to be directed at prevention. We won’t be able to do anything to prevent diabetes, says Dr Viswanathan Mohan, chairman, Dr Mohan’s Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai. Diabetes is linked to obesity. For that, you need more parks, safer sidewalks, more green spaces for people to get active, walk, jog or exercise. Why can’t the government create free gyms, he asks. Why not subsidise fruits and vegetables, instead of giving away free rice to people? Public health efforts are needed for controlling salt, sugar and fat consumption and spreading awareness about nutrition, physical activity, safe outdoor spaces and the harm from alternative medicines.

To Dr Vinod Paul, the vision of Ayu­shman Bharat will fulfil many of the public health concerns. It rests on two interlinked pillars: strengthening the primary healthcare foundation and fin­ancial health protection of vulnerable citizens. The idea is to equip the health and wellness centres to diagnose and treat common ailments like anaemia, diabetes, hypertension, chronic bronchitis, common cancers, apart from mental health and elderly care, he explains. We have introduced screening mechanisms precisely for that, he says. Each centre will also have telemedicine services, facilities for physical activity and yoga, nutrition counselling and public health awareness, all at the community level. We are trying our best to create a lasting impact on the country’s health, he says. This is just the beginning.

HARD TRUTHS AND HOPE

It’s a lazy Delhi Sunday. A bunch of youngsters sit around a table at the British Council Library. Bright-eyed and smiling, they look like any other close-knit group of friends, enjoying meandering chats about art and politics, treks and cross-country bike rides, over cups of coffee. But listen in: they are also talking about being bullied in school, asked how much sugar they had consumed as children, over-affectionate relatives who insist on serving sweets, unsolicited sermons and home cures, the never-ending stares while taking jabs in public and more.

They are all diabetic: diagnosed with Type-1 in childhood, they have lived with courage and discipline, to grow up to be doctors, engineers, executives or government officials. They have floated their own organisation recentlyDIYA (Diabetes India Youth in Action)and are busy collecting data, sharing personal stories, supporting each other and campaigning about Type-1 to make life easier for people like them. Statistically, Type-1 represents less than 5 per cent of all diabetics, but these diabetes warriors have each already reached out to 500 people like them across India.

Even with lifelong restrictions, harsh medications, insulin injections, horror stories of blackouts, amputations or blindness, it is increasingly possible to live a normal life with what is regarded as an incurable condition. A diabetic patient’s quality of life has improved dramatically, says Mithal. A cure remains elusive, but there is hope. For now, India needs to focus on policy action. With increased burden of diabetes observed in every state, policy action that takes state-level differences into account is needed urgently to control this public health crisis, says Tandon. All eyes are on Ayushman Bharat.