Diabetes and Indian lifestyle

Yes, I know it's kind of ironic that I post this on Diwali (btw, Diwali greetings to everyone !), but I felt this needs to take precedence over any festive candle pictures etc. Don't think I'll be touching gulab jamum or jalebi for a while......

Article (N.Y.Times)

Modern Ways Open India’s Doors to Diabetes

CHENNAI, India — There are many ways to understand diabetes in this choking city of automakers and software companies, where the disease seems as commonplace as saris. One way is through the story of P. Ganam, 50, a proper woman reduced to fake gold.

Her husband, K. Palayam, had diabetes do its corrosive job on him: ulcers bore into both feet and cost him a leg. To pay for his care in a country where health insurance is rare, P. Ganam sold all her cherished jewelry — gold, as she saw it, swapped for life.

She was asked about the necklaces and bracelets she was now wearing.

They were, as it happened, worthless impostors.

“Diabetes,” she said, “has the gold.”

And now, Ms. Ganam, the scaffolding of her hard-won middle-class existence already undone, has diabetes too.

In its hushed but unrelenting manner, Type 2 diabetes is engulfing India, swallowing up the legs and jewels of those comfortable enough to put on weight in a country better known for famine. Here, juxtaposed alongside the stick-thin poverty, the malaria and the AIDS, the number of diabetics now totals around 35 million, and counting.

The future looks only more ominous as India hurtles into the present, modernizing and urbanizing at blinding speed. Even more of its 1.1 billion people seem destined to become heavier and more vulnerable to Type 2 diabetes, a disease of high blood sugar brought on by obesity, inactivity and genes, often culminating in blindness, amputations and heart failure. In 20 years, projections are that there may be a staggering 75 million Indian diabetics.

“Diabetes unfortunately is the price you pay for progress,” said Dr. A. Ramachandran, the managing director of the M.V. Hospital for Diabetes, in Chennai (formerly Madras).

For decades, Type 2 diabetes has been the “rich man’s burden,” a problem for industrialized countries to solve.

But as the sugar disease, as it is often called, has penetrated the United States and other developed nations, it has also trespassed deep into the far more populous developing world.

In Italy or Germany or Japan, diabetes is on the rise. In Bahrain and Cambodia and Mexico — where industrialization and Western food habits have taken hold— it is rising even faster. For the world has now reached the point, according to the United Nations, where more people are overweight than undernourished.

Diabetes does not convey the ghastly despair of AIDS or other killers. But more people worldwide now die from chronic diseases like diabetes than from communicable diseases. And the World Health Organization expects that of the more than 350 million diabetics projected in 2025, three-fourths will inhabit the third world.

“I’m concerned for virtually every country where there’s modernization going on, because of the diabetes that follows,” said Dr. Paul Zimmet, the director of the International Diabetes Institute in Melbourne, Australia. “I’m fearful of the resources ever being available to address it.”

India and China are already home to more diabetics than any other country. Prevalence among adults in India is estimated about 6 percent, two-thirds of that in the United States, but the illness is traveling faster, particularly in the country’s large cities.

Throughout the world, Type 2 diabetes, once predominantly a disease of the old, has been striking younger people. But because Indians have such a pronounced genetic vulnerability to the disease, they tend to contract it 10 years earlier than people in developed countries. It is because India is so youthful — half the population is under 25 — that the future of diabetes here is so chilling.

In this boiling city of five million perched on the Bay of Bengal, amid the bleating horns of the autorickshaws and the shriveled mendicants peddling combs on the dust-beaten streets, diabetes can be found everywhere.

A Noxious Sign of Success

The conventional way to see India is to inspect the want — the want for food, the want for money, the want for life. The 300 million who struggle below the poverty line. The debt-crippled farmers who kill themselves. The millions of children with too little to eat.

But there is another way to see it: through its newfound excesses and expanding middle and upper classes. In a changing India, it seems to go this way: make good money and get cars, get houses, get servants, get meals out, get diabetes.

In perverse fashion, obesity and diabetes stand almost as joint totems of success.

Last year, for instance, the MW fast-food and ice cream restaurant in this city proclaimed a special promotion: “Overweight? Congratulations.” The limited-time deal afforded diners savings equal to 50 percent of their weight (in kilograms). The heaviest arrival lugged in 135 kilograms (297 pounds) and ate lustily at 67.5 percent off.

Too much food has pernicious implications for a people with a genetic susceptibility to diabetes, possibly the byproduct of ancestral genes developed to hoard fat during cycles of feast and famine. This vulnerability was first spotted decades ago when immigrant Indians settled in Western countries and in their retrofitted lifestyles got diabetes at levels dwarfing those in India. Now Westernization has come to India and is bringing the disease home.

Though 70 percent of the population remains rural, Indians are steadily forsaking paddy fields for a city lifestyle that entails less movement, more fattening foods and higher stress: a toxic brew for diabetes. In Chennai, about 16 percent of adults are thought to have the disease, one of India’s highest concentrations, more than the soaring levels in New York, and triple the rate two decades ago. Three local hospitals, quaintly known as the sugar hospitals, are devoted to the illness.

The traditional Indian diet can itself be generous with calories. But urban residents switch from ragi and fresh vegetables to fried fast food and processed goods. The pungent aromas of quick-food emporiums waft everywhere here: Sowbakiya Fast Food, Nic-Nac Fast Food, Pizza Hut. Coke and Pepsi are pervasive, but rarely their diet versions.

The country boasts a ravenous sweet tooth, hence the ubiquitous sweet shops, where customers eagerly lap up laddu and badam pista rolls. Sweets are obligatory at social occasions — birthdays, office parties, mourning observances for the dead — and during any visit to someone’s home, a signal of how welcome the visitors are and that God is present.



“When you come to the office after getting a haircut, people say, ‘So where are the sweets?’ ” said Dr. N. Murugesan, the project director at the M.V. Hospital for Diabetes.

The sovereignty of sweets can pose ticklish choices for a doctor. Trying to set an example, Dr. V. Mohan, chairman of the Diabetes Specialities Centre, a local hospital, said he had omitted sweets at a business affair he arranged, and nearly incited a riot. Last year, his daughter was married. Lesson learned, he laid out a spread of regular sweets on one side of the hall and on the other stationed a table laden with sugar-free treats. Everyone left smiling.

In the United States, an inverse correlation persists between income and diabetes. Since fattening food is cheap, the poor become heavier than the rich, and they exercise less and receive inferior health care. In India, the disease tends to directly track income.

“Jokingly in talks, I say you haven’t made it in society until you get a touch of diabetes,” Dr. Mohan said. He points out that people who once balanced water jugs and construction material on their heads now carry nothing heavier than a cellphone. At a four-star restaurant, it is not unusual to see a patron yank out his kit and give himself an insulin injection.

The very wealthy have begun to recoil at ballooning waistlines, and there has been a rise in slimming centers and stomach-shrinking operations. In high-end stores, one can find a CD, “Music for Diabetes,” with raga selections chosen to dampen stress.
The rest of urban India, however, sits and eats.

In Chennai, workers in the software industry rank among the envied elite. Doctors worry about their habits — tapping keys for exercise, ingesting junk food at the computer. Dr. C. R. Anand Moses, a local diabetologist, sees a steady parade of eager software professionals, devoured by diabetes. “They work impossible hours sitting still,” he said.

S. Venkatesh, 28, a thick-around-the-middle programmer, knows the diabetes narrative. Much of his work is for Western companies that operate during the Indian night. So he works in the dark, sleeps in the day.

“The software industry is full of pressure, because you are paid well,” he said. “In India, if you work in software, your hours are the office.”

His sole exercise is to sometimes climb the stairs. A year and a half ago, he found out he had diabetes.

Unshod, and Unprotected

The diabetic foot is a recurrent backdrop among the unending cases that clog the waiting area at the M.V. Hospital. Dr. Ramachandran, its managing director, sees the parade of festering sores and frightful infections. He knows that only creative thinking can help.

The difficulty is that bare feet prevail here. People shuck their shoes before funneling into homes, some offices and always the temple. Farmers go barefoot in the country. In the cities, autorickshaw operators thunder through town, flesh pressed against hot pedals.

Diabetes, though, ruins sensation in the legs, and foot infections go undetected and are often a preamble to amputations. So doctors like Dr. Ramachandran strongly recommend against going barefoot. Yet the culture demands precisely the opposite.

Seeking a middle ground, Dr. Ramachandran presses his patients to don what he calls Temple Socks during worship. They are made at his hospital, conventional socks with rubber bases stitched inside. They are a slow sell.

Dr. Vijay Viswanathan, the hospital’s joint director, gives patients stickers to affix to their bathroom mirrors: “Take care of your feet.” Like doctors elsewhere, he promotes custom shoes. He drifted into them because of leprosy footwear.

Leprosy damages feet and requires special shoes, with tougher undersoles and without nails or sharp edges, that also suit diabetics. But when the diabetics in the telltale footwear appeared at restaurants, they were shooed away, thought to be lepers. So now the hospital makes distinctly different designs.

The consequences of the diabetic foot can be grim. While the affliction knows no class distinctions, the solutions do.

In his lectures, Dr. Ramachandran recounts the case of an impoverished diabetic with a hideously infected leg. Unable to find medical care, he laid the leg across the railroad tracks. The next train to hurtle past did the surgery.

For a limb replacement, the very poor may make do with a $50 wooden leg that does not bend. A woman like Mrs. Chitrarangarajan, 49, who runs a school for the autistic and is married to an oil executive, opts for the best. Her right leg was surrendered to diabetes in 2001. She found a German leg for $6,000 and ordered it over the Internet.

S. P. M. Ameer owned a shoe store when diabetes befell him 30 years ago. Soon, circulatory problems attacked, he closed his shop, he lost his wife, then his leg last January.

Now, at 58, occupying a mirthless room in a cheap hotel on a rackety side street, he no longer recognized the solemn shape of his life. He rarely left his squalid room. “Who hires a man without a leg?” he asked.

He had yet to arrange for a prosthesis. He had no way to pay for one. “God has to apply,” he said.

These stories circulate. But the cultural imperatives hold strong. Even in the sugar hospitals, with admonishments plastered on the walls, some patients insouciantly stride about barefoot. Directly outside the office of one local sugar doctor, beside a sign preaching against the perils of bare feet, another sign notified patients to remove their shoes before entering. And so, barefoot, they sat before him and heard him lecture them not to go barefoot.

Sick Without a Safety Net

Krishnasamy Srinivasan, 66, did not look good. He rarely did anymore. He was recumbent in a hospital bed, his shirt off, his eyes underslung with bags. He had come in by train for another checkup. He now lived deep in the suburbs, where it was cheaper, part of the sad new mix of his life.

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.

He held up the needle-marked right arm of his malfunctioning body, identifying it as “my dialysis arm.”

He had to stop working. To cover the medical costs, he sold three of the homes. His family has been living off the evaporating proceeds, their past irreclaimable.

Diabetes is bankrupting people in the country, often the reasonably well off, and mainly because of a lack of insurance.

Few in India have health insurance, and among those who do, policies generally do not cover diabetes. Middle-class diabetics often exhaust a quarter or more of their income on medications and care. Instances abound where the sick must sell their possessions and compress their lives to feed the diabetes maw.

S. Kalyanasundaram, the chief regional manager in charge at the Chennai office of the National Insurance Company, one of the country’s biggest, explained that the issue with insurance was the odds. “Insurance can only work if the law of averages applies,” he said. “There are too many people with diabetes.”

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?”

Things are beginning to change, even the possibility that policies may cover diabetes for an appropriate premium, but who knows how much they will change? Mr. Kalyanasundaram mentioned that certain preferential customers merited customized policies with an unorthodox clause. If they have diabetes and claim no expenses for four years, then afterward their diabetes will be covered.

“We are testing a belief,” he said. “We think it possible that if diabetes doesn’t manifest in those four years, then it will not manifest in the future.”

It was an odd thought for a disease that usually worsens with time. As for the results, he said it was too early to know how the test was going. “We are still testing.”

With many things it is still too early in India. And so rural dwellers often cope with unavailable or inaccessible health care, frequently relying on unlicensed doctors, many knowing little, if anything, about diabetes. Diabetes researchers estimate that three-quarters of those stricken with the disease in rural villages do not know they have it.

In urban areas, the sick, other than the poorest, prefer to bypass beleaguered government hospitals and seek private care. But without insurance, the cost of a long-term illness can be crushing.

Mr. Srinivasan’s wife, Srinivasan Muthammal, 61, also has the sugar, but not its complications yet. Like her husband, she is overweight. As she listened to him talk of their black hours, her face was frozen.

“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?”

Mr. Srinivasan suggested they had cash for one more year, perhaps a little more.

“I’m angry with the diabetes,” he said. “You are a pauper all because of the sugar.”

Till Diabetes Do Us Part

Divorce is rare in India, but in these changing times it is very much on the upsweep. Diabetes, here and there, even figures in the marital strife. Women may be stigmatized. Men find themselves impotent and then newly single.

K. Sumathi, a Chennai lawyer who sometimes deals in the accelerating number of divorces, appreciates the impact of diabetes in a country where different centuries breathe side by side.
She said a young woman with diabetes, for example, is often deemed damaged and unmarriageable, or must marry into a lower caste. Indian law recognizes five broad grounds for divorce, one being if either spouse acquires a chronic disease. Diabetes can rapidly debilitate a breadwinner and impose impotency, either outcome a solid marriage wrecker.

She told the story of a recent case: A wife, living as custom has it with her in-laws, said the stress of the circumstances contributed to her getting diabetes. She wound up in a diabetic coma and had to be hospitalized. Her husband, a dentist, chose to attend to cavities rather than visit her. The divorce was completed seven months ago.

There was also the account of a husband who accused his unhappy wife of sneaking extra sugar in his tea, hoping he would acquire diabetes and die. It proved to be a poor concept. He survived. The marriage did not.

J. Vasanthakumari, a marriage counselor who is friendly with Ms. Sumathi, said she has seen the disease percolate in the back stories of some of her clientele. Diabetes. Then sexual dysfunction. Unhappiness. Appointments with her.

“You must understand one basic thing,” she said. “People in personal matters will not bring diabetes to the surface. But women tell me, ‘He’s not affectionate, he’s not taking care of me, he’s not like before.’ It’s the diabetes.”

She went on: “Sometimes someone gets diabetes partly because he’s an alcoholic. The marriage falls apart. The real reason is the alcoholism. But the diabetes becomes the last straw on the camel’s back.”

Folklore and Frustration

The shabby disease remedy shop was small for its outsize promises. A dusty storefront crunched between souvenir stands, it sat near the Kapaleeswarar temple, a familiar tourist choice in Chennai. Inside spilled a teetering mass of ready relief for arthritis, heartburn, gout, piles. Beneath the scalding sun, an ox cart pounded past, scattering a swarm of people padding down the street.

The grizzled proprietor, who was asked if he had anything for diabetes, readily proffered a bottle of pea-soup-colored liquid. It cost roughly $3. Its exact contents, the man said, were as privileged as Coke’s formula. But drink a capful twice a day for three months, he assured, and the diabetes would vanish.

Though no universal cure exists for diabetes, “cures” and other mischievous medicines nonetheless abound in India. 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.

All this exasperates Dr. Murugesan. He is among those trying to stanch the spread of the disease. Diabetes education is hard enough, without tomfoolery and witchcraft to discredit.

He had something to show on his desktop computer at the M.V. Hospital for Diabetes, a prevention program known as “Chubby Cheeks.” Animated mothers on the screen merrily admitted that they associated being chubby with health. Animated chubby students chafed that their parents refused to let them play, but forced them to study endlessly so they could become doctors and engineers. They studied, they sat, they enlarged. Dr. Murugesan takes his cautionary tale around to schools and waves it like a lantern.

Dr. Murugesan is himself an Indian diabetes story. A health educator, he devoted 20 years to erasing leprosy in southern India. Two years ago, with that scourge largely beaten back, he itched for a fresh menace. He chose diabetes. He saw its rapid ascent.
What’s more, he had diabetes.

Upon enlisting in the sugar fight, he felt it behooved him to test the blood sugar levels of his own family, and he excavated truths he had not wished for. His wife, daughter and one of his sons were all bordering on becoming diabetic. His other son, just 28 then, already had diabetes.

“I say it’s like Jesus Christ,” he said. “When you don’t look for him, he’s not there. When you look for him, he’s there. You look for diabetes, and it’s there.”

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.

The health minister, Dr. Anbumani Ramadoss, recently said he would begin a diabetes program, but the timetable and scope are unclear. Indian politicians in pursuit of votes rarely campaign on matters of health, but promise the poor cheap rice or free color televisions.
All of which perpetuates a dual continuum. Rural Indians flock to the cities, only to encounter diabetes, while Westernization sweeps its way to the villages, carrying diabetes as its passenger.

Thus Dr. Mohan, among other efforts, dispatches prevention teams to Chunampet, a cluster of villages a couple of hours south that are a feeder area for Chennai. Most of the villagers have no idea what diabetes is.

Meanwhile, Dr. Murugesan has enlistees operating in the Srinivasapuram slum, a grid of cramped thatched huts and makeshift tents that hug Chennai’s long beach.

The diabetes rates among these raggedly lives are notably below those of the middle and upper classes. But they are catching up. When evening gushes over the slum and the mosquitoes emerge, a scattering of diabetics drift over to the tiny Vijaya Medical shop. They are poor at “self-poking,” as they explain, and have no refrigerators to chill their insulin. Some fill mud pots with water and stuff their vials in there. Others rely on the medical shop proprietor, a merry young man with legs withered by polio.

He tapes their names to the appropriate bottles and, each day, administers shots.

Misconceptions populate the conversations. Some residents say they occasionally have diabetes: a few years with it, then a few years without it. They think that diabetes pays visits.
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.

“They don’t understand,” Dr. Murugesan said. “They don’t see the darkness of this disease.”

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.