Diabetes: Womb-to-tomb problem

There is an over representation of the phenomenon of impaired fasting glycaemia and impaired glucose tolerance (measures of prediabetes) in screening surveys, which does not necessarily indicate subsequent progression of disease. The newer cut-off of 100mg/dl (well not so new! —instituted in 2002) for impaired fasting glycaemia leads to earlier detection of the disease and enhancing the long term prognostic outcome of pre-diabetes, falsely causing another bias in the form of “lead time bias”.All in all, the disease is undoubtly on the increase in geometric proportions, despite scientific interpretations in analysing the situation. The evolution of the epidemic is a “womb-to-tomb” phenomenon. Low birth weight is a precipitating factor for diabetes, cardiovascular disease, obesity, schizophrenia, osteoporosis and cancer, and perhaps more unperceived pestilences. This was a hypothesis proposed by Barker in the 1980s, which is no longer a hypothesis but a reality. Maternal malnutrition and the deficiency of micronutrients per se are responsible for the problem. The additive effect of poor lifestyle in childhood through adulthood therefore increases the chance of a low birth weight child in subsequently developing diabetes. The mechanisms of this problem include a reduced secretion of insulin by the pancreas, increased peripheral resistance to insulin and inability to burn calories when compared to the metabolism in a normal birth weight individual. Since low birth weight is present in almost 26 per cent of the Indian population and in a larger proportion in rural areas, the impact is self-explanatory. From a scientific perspective, epigenetic chan­ges or chemical changes in the uterus lead to changes in the genomic material, which the child is born with.The solutions are not simple, and essentially would involve proper counseling of the mothers and families of those children of those who are born low birth weight or pre-term as to how over-enthusiastic attempts to make more steep the growth curve in these children is probably likely to increase childhood obesity and lead to adverse consequences in adulthood. The ultimate solution of optimum feeding of mothers in pregnancy can be debated, but what is optimum and when? Research is on but the answer is unclear, and concepts are still evolving. Certainly economic equity is a solution in improving birth weights, but is much more easily said than done.So poverty may beget low birth weight and low birth weight begets diabetes. Unfortunately, to add to the complicity, when these children grow older they may have diabetes in pregnancy, which may be inadequately treated due to poor awareness, finances or substandard medical care. This subsequently increases the risk of their offspring getting diabetes, particularly if the diabetes in pregnancy is uncontrolled. Therefore diabetes in pregnancy ends up being a continuous and depressing trans-generational phenomenon.To add to the woes of those who are most affected by inflation, here is another quirk, which will increase the subsequent chances of the lower middle class and the poor in getting diabetes. Drewnowski and Specter in the American Journal of Clinical Nutrition 2004 have stated, that amongst subjects who belonged to the lower socio-economic group, that there was a tendency to take more carbohydrate and fat rich food in greater abundance since it was cheaper than that of the food which was lower in calories and contained a larger quantum of free radicals and vitamins. Hence the socioeconomically deprived, may in fact have a greater propensity to develop weight gain through the food which they eat, rather than those who are well off. In other words, certainly cheaper oils are abundantly available and are not expensive compared to fresh fruits and vegetables. This lends further credence to the statement: “An apple a day keeps the doctor away.”Vitamin D, which is termed the “sunshine vitamin”, has its deficiency being associated with insulin resistance (The body’s own lack of ability to respond to insulin). There is more evidence nowadays — though not entirely always with controversy — that since vitamin D deficiency has been shown by several groups, including ours (Endocrine Practice 2008) to be fairly common owing to our propensity to avoid the sun for occupational and cosmetic reasons, this in itself may pose an added risk factor for the increasing prevalence of diabetes.The magnitude of the disease in terms of its prevalence and the potential causes for the problem has now been discussed ad nauseum! The subsequent consequences of the disorder, with its impact on quality of life and even its economic impact cannot be overstated. Take for instance just one complication - the damage to the nerves (peripheral neuropathy). It is awfully common, according to an earlier study done in four centers across the country published in the Journal of Association of Physicians in India in 2005. Nerve damage was present in 15 per cent of those who had diabetes who attended the outpatient clinics at these centres. What was probably more eerie is the fact that 3-4% of those patients with diabetes also had the amputation of at least a single toe, if not a whole limb.Now try and visualize a situation that at least 1.5 million of your 62 million patients with diabetes have at least a toe or a limb that has been chopped off. This would impair not only their morale, but also their physical balance when attempting to walk and would lead to a number of those in the agrarian or labourer classes to be totally ineffective in their day to day work, without extensive rehabilitative therapy and prostheses.