COVER STORY (Spotlight Weekly)

DIABETES

A Silent Killer

As the lifestyle and food habits of urban Nepalis have been gradually changing over the years, new diseases are making serious inroads. Diabetes has been growing at alarming levels in cities and towns, leading medical professionals to warn of the emergence of a silent epidemic. However, the government is yet to conduct a scientific study into the scale of the problem. Worldwide trends show that an explosion of diabetes cases, especially among those in the prime of their life, will have a long-term impact on the country. The good news is that the disease can be detected early and prevented through timely intervention. Is the government listening?

By KESHAB POUDEL

Something terrible was happening to Hari Sharma’s eyes. There were being poisoned; the fragile capillaries of the retina were attacked from within and were leaking blood. The first symptoms were red lines, appearing vertically across his field of vision; the lines multiplied and merged into a haze that shut out light entirely. "The blood vessels inside his eyes were popping," said his son, Suman Sharma, a graduate. Sharma, who is in his late 50s, began experiencing problems four years ago. Because of the complications, Sharma had to quit his job as a teacher. After two surgeries in the southern Indian city of Madras, Sharma has regained vision in one eye, but the other one has become completely useless.

Kidney patient : Need to change lifestyle

A few weeks ago, Bharat Shrestha, awakening one night in his bedroom, walked into a door, setting off a paroxysm of pain and nausea that has not let up yet. What caused this catastrophe was nothing as exotic as pesticides or emerging viruses. What was poisoning him was the sugar level in his bloodstream.

When Shrestha, 40, went to his physician for a routine check-up, the blood test revealed that the sugar level in his blood was abnormally high. The physician asked him to consult a dietician and regularly monitor his sugar levels through blood tests. It took nearly a year for Shrestha to recover from trauma triggered by that revelation. Physically normal, Shrestha, who still does not believe whether he is really a diabetic, is taking all kinds of preventive measures to control his sugar levels.

Medical practitioners warn that diabetes cases are shooting up in Nepal. This means more and more people are likely to experience the trauma Sharma and Shrestha are facing. "If present trends are any indication, diabetes is going to be a major cause of blindness in Nepal," says Dr. Jeevan Kumar Shrestha, an ophthalmologist with the B.P. Koirala Lions Eye Hospital at Tribhuvan University Teaching Hospital. (See box)

Apart from blindness, a surge in diabetes will also bring chaos in other areas of an individual’s life. "I cannot imagine that I have diabetes. One of the harmful effects of the disease is that I have to give up all kinds of food, including bhat and dal," says Shrestha, a resident of Kathmandu district.

Sharma and Shrestha are victims of what many public health experts believe will be the next great lifestyle-disease epidemic: diabetes. At five feet and five inches and 85 kg, Sharma is overweight; 90 percent of all diabetes sufferers are overweight or obese. Sharma and Shrestha were born and reared in Kathmandu. Studies have shown that people living in urban areas are more likely to contract diabetes than rural people are. As the urban population continues to increase and grow obese, the disease is rapidly spreading. According to medical practitioners, the prevalence of diagnosed cases of diabetes in Nepal increased by many folds between 1990 and 2000.

"Even people who have normal weight may be affected by diabetes," says Dr. Ram Prasad Shrestha, a senior surgeon and former director of Bir Hospital. "The actual number of patients is certainly higher, since many cases go undiagnosed for years."

Researchers have revealed that timely detection of diabetes could prevent costly and potentially deadly complications. Experts have found techniques of detecting people at high risk well in advance. Nepal has yet to benefit from such technological advances.

Equally worrisome is the huge financial cost involved in treating diabetes. "It is virtually impossible for the average Nepali individual to spend money to treat diabetes, which may cause blindness, kidney failure and heart attack," says Dr. Rishi Kumar Kafle. "If an individual starts early treatment, the costs could be lower." (See box)

Changing Lifestyle

The lifestyle and food habits of the urban population have drastically changed in recent years. Traditionally, Nepalis had fixed menus containing healthier foods and would walk long distances to work and other engagements. Today fast-food restaurants at almost every neighborhood corner offer a variety of foods. Members of virtually all city households use public or private transportation. This means city people take in more food and engage in less exercise, which leaves them overweight.

A health report published in the United States recently said that risk reduction is higher in people aged 60 and above who used a combination of diet and exercise. Health experts have been insisting for years that so many problems can be avoided through proper diet and exercise and by making sure people take care of themselves. "By promoting healthy lifestyles, Nepalis can improve the quality of life for all and reduce health care costs," says Dr. Kafle.

Experts argue that those who take a daily 30-minute walk and lower their fat intake to less than 25 percent of their calorie consumption can reduce the risk of diabetes. Those at high risk for Type 2 diabetes need to change their lifestyle and exercise more to prevent this and other dreaded diseases.

"The lifestyle of the urban population in Nepal is different as people have every choice of foods available according to their demand. Fast food are easily cooked and bought. This is the reason most of the people are overweight," says Dr. Shrestha

People in urban areas normally eat food heavy in carbohydrates, which causes their blood sugar levels to soar. Instead of potatoes, rice, legumes, cereals, breads, fruit, yogurt, and milk, patients have to add more low-fat protein (fish, chicken, egg substitutes, small amounts of red meat). Interestingly, in Nepal most diabetes patients had bypass surgery before they were diagnosed with the disease.

Obesity and Overweight

Obesity has been increasing among Nepali urban adults. According to a study done by Kathmandu Medical College, large numbers of adults are now considered overweight or obese. Obesity in children also has markedly increased in urban areas. Overweight and obesity increase the risk of illnesses linked to hypertension, lipid disorders and Type 2 mellitus diabetes, coronary heat diseases, stroke, gallbladder disease, osteoarthritis, sleep apnea and other respiratory problems and certain cancers.

Adults are now desperate to reduce their weight or avoid gaining it, but a large number of men and women are doing that without consulting medical practitioners. This could generate other harmful effects in the people, experts say.

Because of a changing lifestyle, the prevalence of overweight and obesity among Kathmandu's adults is set to increase. "The traditional food habit is much more hygienic and healthier than junk food, which is responsible for overweight," says Dr. Kafle.

Other tendencies are lack of health awareness among the population. People usually do not go to the doctor until the disease has affected them seriously. In most cases, diabetes patients have been found to neglect the doctor’s advice.

Most patients do not visit the doctor regularly. A diabetes patient needs to check up his kidneys, eyes and other features at least once a year. Unfortunately, most patients undergo such tests when they have severe problems. This tendency costs patients a lot of money as well as unrecoverable health decline.

Internationally, the picture is just as bleak. The World Health Organization (WHO) predicts that diabetes mellitus cases worldwide will more than double by the year 2025 to reach 300 million. Developing countries, particularly those in Asia and Africa, are expected to bear the brunt of this increase. Most alarming, however, is the spread of diabetes across the age barriers. The number of patients in their 40s continues to expand. People in their 30s are getting the disease in large numbers.

If people become diabetic at age 10 or 15 or 20, they could have terrible complications when they are 30 or 40. These people also need long-term expensive health care. Although a number of medicines are available, they are virtually out of reach for the large number of poor people.

What is Diabetes?

Diabetes is a disorder of the very engine of life, a subtle calamity at the molecular level. Its hallmark is a failure to metabolize glucose, the ubiquitous sugar molecule carried by the bloodstream to fuel every part of the body. It is not only a disease related to certain parts but also a disease affecting all parts of human life. Deprived of their prime energy supply, muscle and nerve cells slow their function, which is why early diabetes may manifest itself as lethargy and irritability. At the same time, glucose accumulates in the patient's blood, and can reach concentrations two to three times normal and even higher.

The excess is eventually excreted, which requires copious quantities of water as a dilutant. The words diabetes mellitus come from Greek. Diabetes means "to pass through, or to flow through" and mellitus means "sweet". An excess of sugar in the blood and or urine characterizes diabetes mellitus. Diabetes can be controlled with insulin, proper diet, exercise and careful monitoring.

In fact, many people believe that the diabetes is an old-people’s disease because it usually struck people middle-aged or older. Type 1 diabetes is also appearing in large numbers. Getting fat is no longer a prerogative of adults. Even children have similar problems. Diabetes is strongly linked to obesity. Too many calories and too little exercise are the risk factors for Type 2 diabetes. More than 90 percent of the people with diabetes are overweight. "The rise in the disease among teenagers is extraordinarily worrying," says Dr. Kafle. Diabetes can take decades to reveal its most appalling effects, including ulcerating sores, blindness, kidney failure, strokes and heart disease.

Once people start drinking water virtually non-stop, one can assume it is a symptom of diabetes. A lot of people are walking around with diabetes without even being aware of it. "The symptoms are not specific and they tend to come late," says Dr. S.K. Pahadi, a prominent cardiologist.

Researchers are still investigating ways in which high blood sugar levels cause damage. One obvious effect is on the arteries, especially in the eyes and kidneys; sugar seems to weaken the capillary walls and clog the small vessels. According to the WHO, diabetes mellitus is a chronic, debilitating and costly disease attended by severe complications, including blindness and heart and kidney diseases. Hemorrhages destroy the retina; impaired circulation leads to ulcers in the legs and feet for which amputation may be the only cure. The risk of heart disease doubles for men; for women it goes up fourfold. Yet the misperception of diabetes as a relatively benign condition persists. The word is not yet out about how serious it is. There is no diabetes that is not bad. It is all serious.

What is Insulin?

Glucose metabolism is regulated by the hormone insulin, which is produced by the pancreas gland, a fist-size clump of tissues behind the stomach. In normal people, the pancreas secretes insulin in response to a rise in blood sugar, which happens after a meal. The relatively uncommon Type 1 diabetes is marked by a straightforward shortage of insulin, which typically shows up around puberty.

Researchers consider this an auto-immune disease, possibly brought on by a viral infection. And the treatment is straightforward in concept, if not always in practice: you supply the missing insulin, if necessary by injecting it before meals. Juvenile diabetes has struck many and it is a disease you have for life; luckily, though, there is no evidence that its incidence is on the rise in Nepal.

According to the WHO, the major clinical classes of glucose intolerance include insulin-dependent diabetes mellitus (IDDM or Type 1), noninsulin-dependent diabetes mellitus (NIDDM or Type 2), malnutrition-related diabetes mellitus (MRDm), impaired glucose tolerance (IGT), gestational diabetes and were unified and adopted in 1979-1980.

In developing countries like Nepal, NIDDM is rare in the traditional setting, but has become very common in many urbanized communities. NIDDM is likely to rise, due to aging, a fall in infectious diseases, mortality and increase in the prevalence of putative risk factors such as obesity, lack of regular physical exercise and inappropriate diet.

A third form of diabetes, malnutrition-related diabetes mellitus (MRDM) is also reported in the Terai region. It is reported to occur in young, underweight individuals and it requires insulin to maintain adequate metabolic control.

Type 2 is an altogether more complicated disease, a spiraling derangement in a network of positive and negative feedback loops linking the pancreas, liver (which stores and releases glucose), muscles, nerves, fat cells and brain. Perversely, the muscle cells refuse to absorb glucose from the blood; a phenomenon called insulin resistance. At least in the early stages of the disease, Type 2 diabetics usually have normal insulin production. In fact, they may have above-normal insulin, as their pancreas produces more and more of it in a futile attempt to keep up with the rise in blood sugar. Over time, though, people may need more insulin than their pancreas can supply, and these patients, too, often become dependent on injecting themselves with insulin.

In Nepal Type 2, or NIDDM, is very common among overweight adults, but it starts very slowly. The diabetic may develop systems like excessive urination or passing more urine at night, excessive thirst and weight loss and weakness.

Medication

For years, the only available form of insulin was harvested from cows and pigs, but now human insulin is being manufactured directly by recombinant DNA techniques. Drug companies are coming out with new and improved insulin, engineered with molecular changes to make it last longer in the body or be absorbed more easily into cells.

Until recently, insulin had to be injected under the skin as often as five to seven times a day, in a complex calculus of food intake, energy output and dosage designed to keep blood sugar from going either too high or too low. An implantable version may be available soon. Someday, a completely self-contained unit may be able to measure blood glucose directly and deliver insulin automatically.

Sulfonylurea is one of the oldest drugs, which has been available since the 1950s, which stimulate production and release of insulin by the pancreas. Many new effective drugs are available in the market today.

According to recent studies, genetics seems to play a role in such a devastating misreading of biochemical message. Certain population groups are especially prone to diabetes. The very complexity of the glucose-insulin cycle, though, affords numerous opportunities to intervene with therapies. The obvious therapy is, of course, insulin.

Prevention and screening programs for diabetes may be seen as a heavy economic burden on society, which may be an obstacle to their implementation. The cost of the treatment of diabetes mellitus and its consequences are so high that prevention would be beneficial in economic terms quite apart from the benefits to the health of individuals and society.

As soon as someone’s diabetes is detected, it is important that one immediately begins a program to control the disease. The aim of the treatment plan will be restore the balance of sugar and insulin the human body and to prevent and relieve symptoms through medications and, most importantly, by understanding the disease, its complications and its treatment. Food with higher glycemic indices pushes more rapidly intro the blood stream, taxing the insulin response.

Treatments

When diet and exercise do not keep diabetes in check, drugs or insulin can help. As several classes of medication are available in the market, the patients have choices.

a) Stimulators drugs like Glucotrol prompt pancreatic cells to make more insulin and

b) Sensitizes glucophage and related treatments help make cells more responsive to whatever insulin is present in the body.

c) Carblicers precose and Glyset help regulate blood-sugar levels by slowing the breakdown of carbohydrates in the digestive tract.

Effects

Uncontrolled diabetes can trigger a series of serious health problems.

a) Nerves: Most diabetics suffer nerve damage, and many end up requiring leg amputations.

b) Genitals: Eight percent of diabetic men suffer from impotence.

c) Heart: Diabetics suffer two to four times the usual rate of cardiovascular disease.

d) Kidneys: Nearly half of new cases of end-stage kidney disease stem from diabetes.

e) Eyes: Diabetes is the leading cause of new cases of blindness in people between ages 20 to 74 years.

Diabetes Symptoms

Type 1 Type 2

Frequent urination Excess weight

Increased Thirst Drowsiness

Unusual hunger Blurred vision

Weight loss Tingling and numbness in hand and feet

Irritability Skin infections

Weakness and fatigue Slow healing of cuts (especially on feet)

Nausea and vomiting Itching

Source: American Diabetic Association

There is an urgent need for proper measures to control diabetes in Nepal. Once someone is affected, it would prove costly in terms of economic and other factors. This in turn would place a great burden on a country with few resources to meet the challenge. For Nepal’s health planners and policy makers, the time has come to contain the killer disease before it is too late.

‘Integrated Approach Needed To Confront Diabetes’

— Dr. S.K. PAHADI

Dr. S.K. PAHADI is one of the prominent cardiologists of Nepal. Even after retiring from government service, Dr. Pahadi is still very active in his profession. He is the chairman of Nepal Medical College and is also involved in many other activities. One of the well-known senior royal physicians, Dr. Pahadi spoke to SPOTLIGHT on various issues relating to the health status of the country. Excerpts:

From the perspective of your long involvement in the health sector, how do you assess the overall situation of diabetes in Nepal?

We don’t have data showing the overall position of diabetes in Nepal. Of course, the incidence of diabetes is rising in urban areas. Different geographical regions have different types of health problems. If you look at the cases in Bir Hospital and TU Teaching Hospital, you may find more patients suffering from diabetes and heart ailments. However, the situation in the hill region may be different, as people there suffer more from infectious diseases. The absence of accurate data makes it difficult to paint an overall picture. When I visited different parts of the country during the regional tours of late King Birendra, I tried to gather data relating to diseases prevalent in those areas. In Surkhet, we had a health camp 15 years ago where we found more than half of the patient had gastrology, respiratory and other diseases. We did not find heart patients and people suffering from blood pressure. Our study showed that infectious diseases were more prevalent in the hills. During my tenure at Bir Hospital, I treated some cases of juvenile diabetes. Most of the patients died because they didn’t have money to buy insulin. It was fatal. Now one can survive if he or she can afford to buy medicine.

Are people sufficiently aware that medicines can help control diabetes?

Although many types of medicines are available in the market, many people do not use those prescribed by us. We always urge diabetes patients who visit us to be sure to take medicine on time, but most of them ignore our advice. A diabetes patient may contract many complications, including kidney and heart troubles. Many people do not take medications because they don't know about the serious consequences of the disease. Even highly educated people are found to show such behavior. As long as the disease does not turn serious, patients do not consult the doctor. We must teach the people that a diabetes patient can survive if he or she takes medicines and follows the advice of doctors.

How do you see the flow of diabetes patient at your clinic?

Diabetes and blood pressure are on the increase, but they are not a major health problem right now. In urban areas, we see a large number of such patients.

What policy needs to be formulated to prevent diabetes?

We need to initiate an awareness campaign. We must generate awareness among the people about the disease and teach them the importance of proper exercise and a balanced diet. Even weight reduction can be effective in preventing diabetes and blood pressure.

What are your specific suggestions?

The government needs to set up a diabetes foundation at the national level. Although there are few diabetes associations, they have been unable to meet the challenge. There needs to be greater interaction among diabetes patients. We have to study what types of diabetes patients we have. Diabetes is a complex disease that affects different parts of the human body, including the eyes and kidneys. So there need to be an integrated approach.

‘Balanced Diet And Proper Exercise The Key’

— Dr. JEEVAN KUMAR SHRESTHA

Dr. JEEVAN KUMAR SHRESTHA is an ophthalmologist at the B.P. Koirala Lions Eye Care Center at TU Teaching Hospital. He spoke to SPOTLIGHT on various issues related to diabetes. Excerpts:

How do you assess the effects of diabetes on the eyes?

Diabetes is a modern disease. Like all other countries, Nepal has a mixed society of rural and urban populations. However, there are widening disparities in terms of dietary intake. While there has been rapid development in the urban population, progress in rural areas has remained stagnant. One can find diabetes patients in rural as well as urban areas, but urban people are more prone to the disease. We have not done a community study on the overall impact of diabetes, but we did a small study on the impact of diabetes on the eyes. In India, different institutions have done various studies. According to those surveys, about 2-3 percent of the rural population has problems related to diabetes. But in urban areas, the incidence is about 10-20 percent.

What is the position of diabetes in urban areas?

The urban population in Nepal is westernizing rapidly. They do fewer exercises and eat more food than previous generations. The urban people have car, TV and other facilities at home, so they normally avoid physical exercise. Urban residents consume more carbohydrates and fat but do little work to burn them. On the other hand, rural people consume less food and perform harder work. In urban areas, diabetes has increased as an epidemic. If we visualize the Indian case study, we can see how alarming is it. According to an estimate, India alone has 19 million diabetes patients. In another 20 years, that number is expected to rise to 57 million. We can draw a fair picture of Nepal along similar lines.

What factors have contributed to the increase in diabetes cases?

There are many factors, including dietary, hereditary and environmental. According to our study, we found that among 100 diabetes patients, 25 had eye problems. Among them, 5-19 percent had severe effects. Some suffered from loss of vision. Among the 100 respondent, 83 patients said they were not aware that diabetes could harm their vision. Nobody seemed to realize the need to visit the doctor to cure his or her eye disease.

What is the level of awareness?

Our study found that more people are aware about diabetes today. In the analysis of 1993-1994, among the total retina patients, 12 percent of them were diabetes. In 1995-96, the number reached 24 percent. In 1999, about 36 percent retina patients were affected by diabetes. I don't know how this increased or whether it was because of awareness or really a rise in the actual number. It may be both.

Is there any national-level program?

We have not made any effort to study the problem at the national level, as it is still not a cause of blindness. Cataract is still one of the major causes of blindness. This is why the government is focusing on cataract. In western countries, diabetes is now the leading cause of blindness. Diabetes is also a main cause of blindness. About 30-40 percent of those who visit eye centers are diabetes patients.

What do you suggest?

Prevention is better than cure. Because of high sugar levels in the blood, the rate of blindness is going to be very high. If the urban population starts to eat a balanced diet, engages in adequate physical exercise and undergoes regular health check-up, the problems may subside. Prevention of diabetes is possible only through balance diet and proper exercise.

‘Diabetes Is Not A Curse If One Treats It Carefully’

— Dr. RISHI KUMAR KAFLE

Dr. RISHI KUMAR KAFLE, a kidney specialist, works with Nepal Kidney Foundation and Medicare Hospital. One of the busiest nephrologists in the country, Dr. Kafle spoke to SPOTLIGHT on various issues related to kidney diseases and diabetes. Excerpts:

How do you view the problem of diabetes in Nepal?

If a patient follows medical advice, diabetes can be controlled. It cannot be cured by other medicines. In our society, people want relief from all kinds of disease by taking medicines. People usually do not go for health check-up until they face complications. Once an individual is infected with some disease, then he or she goes to the doctor and wants a total cure. Even after identification of the high sugar content in blood, people start to question the credibility of the pathology report. Instead of following the physician’s advice, they go for other medicines. The practice among Nepalis is to escape from treatment.

Why is this happening?

Few people seem to understand that diabetes can lead to other complications, including loss of vision, kidney failure and heart ailments. Once a patient suffers from kidney failure, he or she has to go in for dialysis, which is virtually out of the reach of the common people. According to Nepal Kidney Center, almost all kidney patients above 50 years who come for dialysis in the hospital have diabetes. Diabetes is the No. 1 killer in the United States and it is gradually penetrating all over the world. A similar situation is found in cardiology; most of the people who suffer a heart attack are usually diabetes patients. The number of diabetes cases is rising not only in Nepal but also throughout the world. Even American medical practitioners have said they can no longer afford the economic costs of treating diabetes. In our case, it will be simply impossible to treat ailments like kidney failure. This is the reason why the government must start an aggressive campaign to control it.

What needs to be done?

We need to increase awareness among people that diabetes can lead to ailments of the kidney, heart and eyes. Every individual needs to undergo regular check-up. If a kidney of a diabetes patient fails, one has no option other than to go in for kidney transplant, which is very costly. Furthermore, post-transplant dialysis costs a lot of money. A person has to spend Rs.30,000 a month for dialysis. I don't think a large number of people are in a position to survive this way. The majority of the people do not realize that diabetes may have such harmful impacts. This is the overall health scenario. We need to have facilities in all health centers for primary health check-up.

How do you assess the cases of diabetes in Nepal?

Diabetes cases continue to rise in the urban areas because of changes in food habits and lifestyle. People normally do not walk. There is a wide diversity of food available in the country. Because of this, people become obese. We need to bring changes in the health system. Diabetes is a major problem in country. If you go to the eye hospital, you can find many people suffering from blindness because of ignorance. A diabetes patient must undergo regular check-up.

Why don’t people get proper counseling?

In most cases, diabetes patients get counseling from colleagues and friends, who misguide them. They urge patients to follow other medication, without understanding the specifics of the ailment. Most patients with diabetes-nephropathy die after they get heart problems. Fifty percent die before they get kidney problems. Many patients die not from kidney problems but from heart ailments. A doctor has to spend more than an hour counseling a diabetes patient. An individual can survive even if his or her kidney fulfils 50 percent of its function. Medical convention asks us to treat blood pressure and diabetes vigorously. Dialysis is not affordable to a majority of Nepalis and the service is available only in Kathmandu. Diabetes is one of the costliest diseases to treat.

Can we control diabetes?

If we start early treatment and take precautionary measures, we can control diabetes. Diabetes is not a curse if one treats it carefully and follows the advice of medical practitioners instead of going for herbal and other treatments.

Do you mean there is no cure?

If there were a cure in homeopathy, Ayurved or natural therapy, one could earn billions of dollars. The United States has been spending billions of dollars to find a cure for diabetes. If a herbal cure were available, would people there waste time in getting it? If such herbal cure were available, patients in rich countries would be the ones to benefit the first. Therefore, instead of going any other way, a diabetes patient should follow the suggestions of his or her physician. It is not that the herbal medicine is bad. But one has to understand the purpose for which he or she is taking it.

How can you know whether you have diabetes or are prone to it?

Just because one is fit and fine and does not have any problem related to the kidneys, heart, eyes and brain does not mean one is free from problems. A person has to get a clean bill of health from a doctor at least once a year. A diabetes patient has to consult four different physicians to understand the problem. We have to develop an ideal situation. There are very simple and affordable medicines available to prevent diabetes. The sooner a person completes a health check-up, the better.

Are there institutions for regular health check-up?

Many new institutions are coming up. In addition, insurance companies insure you and your family.