Diabetes Plagues Sweet-Toothed Indians

NEW DELHI, Dec. 31, 2007 — -- Andrabi Khurshid is scared of sugar.

Sugar killed his grandmother. It has made his father blind and lame.

The 43-year-old won't touch it, he says, for the rest of his life.

"For the last 10 or 15 years, I've not had a cup of tea or coffee with sugar. In the back of my mind a spoonful of sugar may trigger the whole thing."

That whole thing is type 2 diabetes, a disease running rampant in India. Caused by obesity or inactivity or genes — or all three — it often ends in blindness, amputations and heart disease.

The story of India today is one of hundreds of millions of villagers who live on less than $2 a day. But it is also one of a booming middle class that is now bigger than the entire population of the United States. India, in other words, has never been richer. But it's also never been fatter. As India rises, so does obesity — and with it, diabetes.

"India is all set to become the diabetes capital of the world," India's health minister, Anbumani Ramadoss, told reporters in November. "We have at present 25 [million] to 30 million diabetics in the country and the number is going to touch 70 [million to] 75 million within the next 15 years."

The United Nations says that for the first time, more of the world is overweight than undernourished. For Indians, that means that as their pocketbooks fatten up, so do their bellies. Diabetes is unlike the disease in the West: in the United States, the poor get fat, receive worse health care, exercise less. Here, diabetes affects the rich more than the poor; the city more than the country.

The Problem

In India's richest city at its richest hospital, S.K. Wangnoo says diabetes is getting worse.

"We are seeing on an average, 500 patients every month," the doctor said from the diabetes wing of the Indraprastha Apollo Hospital, part of the largest hospital network in Asia and the third largest in the world. "A decade back it used to be 200 to 300."

Every fourth diabetic in the world is an Indian.

"Diabetes and heart disease are emerging as the single most important medical factors for younger Indians," said Vijay Viswanathan, the managing director of the M.V. Hospital for Diabetes & Diabetes Research Centre in Chennai. "As Indians get richer, especially the urban population, physical activity comes down, their eating habits become less healthy, and they tend to put more weight on around their waist."

India's always had a disproportionate number of sweets shops, filled with artery-clogging, milk-infused confections that are part of daily life here. Now, as India's economy grows faster than any country in the world except China's, there are more restaurants to visit, more work to do, less time to exercise.

"Indians are becoming more prosperous compared to 20, 30 years ago. More multinational companies, more employment, more business opportunities," Viswanathan said. "That's hitting hard on the health. Simply, the more pressure to work has gone up now so much that what we hear from the young people, they don't have time to do exercise."

Wangnoo sees a more insidious influence.

"People are drifting toward Western culture. It's the 'Coca-Colanization' of India. Pizza Hut, McDonald's are mushrooming. The children are glued to their televisions," he said. "And with working parents, they don't have time to cook the food. So the kids are eating ready-made food, the junk food."

The World Health Organization says of the nearly 400 million diabetics that will walk the planet in 2025, three-fourths will live in the Third World.

And for a booming India, that means huge economic losses. WHO estimates that heart disease, strokes and diabetes reduce India's national income by $9 billion a year, and that unless preventive measures are effective, the losses will grow to more than $200 billion in the next decade.

For Indians, the problem is not only one of obesity. It is also genetic. The M.V. Hospital for Diabetes & Diabetes Research Centre recently found that no matter where they lived — New York, London or Delhi — Indians were more prone to diabetes and heart disease than whites.

"We get diabetes a decade earlier than Caucasians," Wangnoo said. He says diabetes rates among teenagers are growing faster than any other group, and the health-care industry has estimated that one out of every five Indian children is overweight or obese.

For a country where half the 1.1 billion people are younger than 25, and what little health insurance there is does not cover diabetics, a lifetime of insulin can cost a family a quarter, even one half of their monthly income.

Ravi Sharma, whose mother, 64-year-old Shakultlh, can't walk without his help, pays $2,500 to $5,000 per month for her medical bills out of his own pocket. "In our country, we just respect the elderly," he said with a wry smile. "We don't care for them."

The Solutions

"People are going undiagnosed until they get a heart attack or they go for an amputation — that's the sad part of it. They're going undetected," Viswanathan said.

Part of the reason is ignorance. Many Indians don't recognize the symptoms of diabetes, mostly because they've never been told what to watch for. More than 600 million people in India live in villages, the majority of which are not within reach of functioning health-care centers.

And so the M.V. Hospital for Diabetes and Diabetes Research Centre, which collaborates with the WHO, has begun a nationwide campaign of education. It recently published the first diabetes awareness handbook in the country's history, distributing 4,500 to high schools in the southern state of Tamil Nadu.

"There needs to be a concentrated effort to spread diabetes awareness — and people have to get involved with it," said Viswanathan, the center's managing director. "It's like smoking. The government can say anything it wants, but ultimately, people have to stop smoking. People have to learn how to stop diabetes themselves."

To help them replace junk food with jumping jacks and ignorance with insulin, the WHO and Indian hospitals have spent millions trying to prevent diabetes from occurring in the young, and trying to catch diabetes early among the millions who have it.

"We try to detect diabetes that is already there in the community … screening of high-risk families, make them go in for a check of their blood sugar," Viswanathan said. "We don't need sophisticated equipment to do checks. It can be done in any corner of the country."

In Chennai, some stores sell insulin for people without refrigerators. Some Indians are so scared of giving themselves insulin, shopkeepers on the side of the road sell the drug and, for an extra cost, will administer it.

The government has, slowly, begun to do something as well. Sometime in 2008 it will put out the first official health policy on diabetes. And there are new rules for high schools to combat obesity: no high-calorie snacks sold within a couple of miles of campuses. But as is so often the case in India, there is no enforcement.

Doctors are also fighting an ancient culture. This is a country that believes in miracle cures and even divine illnesses. Religious fatalism comes quickly to diabetes patients.

"It's all karma. I am receiving the fruits of my karma," said Shakultlh Sharma, who is 64 but looks much closer to 80. She has become more religious since she was diagnosed with diabetes and, in part, blames herself for contracting the disease in the first place. "Maybe," she said in the diabetes wing of the Apollo Hospital in New Delhi, "I was not religious enough to begin with."

But diabetes has made being religious more difficult for her. She's had diabetes for 15 years. It caused hypertension and, in May, a massive heart attack. She can't walk properly, has cataracts in her eyes and her lungs tend to fill with water.

"I'm very fond of going to temple," she said. "Now, I'm not able to go. I can walk only to the toilet."

A Long Way to Go

Fighting diabetes "needs a lot of cooperation from the people. They have to go for checkups," Viswanathan said.

In Delhi, the time and money spent on education seems to be having at least a little impact.

"People are getting more medically oriented," Wangnoo said.

M.L. Koul discovered his diabetes in 1984. Since then, the 70-year-old has kept an extremely strict regimen of exercise and Spartan diet. Every morning: two biscuits, "neither salty nor sweet," a cup of tea (no sugar), followed by a brisk walk. Lunch: milk, egg whites, maybe some brown bread. Dinner: a piece of bread with fish or chicken. Every day, for the last 23 years.

It has worked for Koul. But not everyone here is so educated, so lucky, so committed. "I am doing," he said, "everything a man can do. Maybe even more."