Diabetes in India: Embracing a holistic perspective to combat a growing epidemic

The puzzle of diabetes and its complex interconnections
Understanding diabetes as a complex metabolic puzzle reveals its interconnectedness with various other non-communicable diseases (NCD’s) and metabolic risk factors. The simplest explanation for this clustering of metabolic diseases is by understanding the ‘Common Soil of Origin’ hypothesis for most NCDs, including diabetes (Type 2). Accordingly, consider a strong genetic background (family history) and ethnic predisposition (race) for these NCDs as a bullet loaded in the gun. However, factors including inappropriate nutrition, lack of physical fitness, poor sleep hygiene, ever-increasing and unmanageable mental stress, and environmental pollution pull the trigger of the loaded gun, for these NCDs to manifest in an individual.⁴ The successful management of Type 2 diabetes includes not just controlling the blood glucose levels but entails ‘treat-to-target’ multiple other cardiovascular risk factors, including obesity/abdominal obesity, high cholesterol, and high blood pressure.⁵ It’s only then can doctors give high confidence to patients for future prevention of complications of diabetes (including cardiovascular, kidney, and liver). Obesity/excess fat/adiposity and Type 2 diabetes have an important bi-directional relationship, with people with obesity and/or abdominal obesity being highly predisposed to developing Type 2 diabetes, especially if they have multiple other risk factors and a family history of diabetes. Also, the co-existence of Type 2 diabetes and obesity/ abdominal obesity multiplies the future risk of developing diabetes-related complications.⁶ Hence, for the best health results it is mandated to include healthy weight loss as an integral part of diabetes management.⁷ Research indicates that even modest weight loss (fat loss) can improve blood sugar regulation and reduce the risk of diabetes-related complications.⁸ Further on, maintain the linearity of benefits of weight loss and risk reduction, greater (> 15%) amounts of weight loss (fat loss) may even lead to remission of Type 2 diabetes itself.⁹

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Implications of the diabetes puzzle
One of the most effective communications to patients with diabetes, for them to understand, execute, and ensure their longevity, good health, and wellness is the ‘Five Finger Power Punch’ anecdote, wherein each finger of the clenched fist represents an intervention required to achieve the desired health goals. And when put together the interventions multiply the health protectiveness. The health targets for people with Type 2 diabetes must include (ABC&O) i.e. HbA1c; Blood pressure; Cholesterol; Obesity management (weight loss)^10,11

• Finger 1&2: Nutrition and fitness – Enhancing the patient’s understanding by using the words ‘nutrition’ instead of ‘dieting’ and ‘fitness’ instead of ‘exercise’ gives them a strong positive boost to do better. These interventions form a platform for the management of diabetes. Simply put, nutrition advice should centre around three words: ‘quantity’, ‘quality’, and ‘timing’. Fitness advise centres around ‘duration’ and ‘intensity’. The fitness programme should include aerobic, muscle training, flexibility, yoga, and where possible meditation. These when individualised and personalised ensure the best results for diabetes management.^12,13
  
• Finger 3: Medicines – Diabetes treatment spans back at least a century, interestingly it’s been only in the past few decades that innovations in medicines, are now promising health benefits beyond sugar control. The newer medicines for diabetes provide most people with Type 2 diabetes effective and durable sugar control, excellent weight loss, blood pressure lowering, some betterment of lipid profile, and clinically proven organ (heart, liver, kidney, and brain) protection. When chosen right these drugs are likely to provide an umbrella of health to the patients.⁷
  
  
• Finger 4 & 5: Sleep and Stress management – Possibly, the two greatest contributors to the epidemic of Type 2 diabetes are mental stress and poor sleep hygiene. Stress, anxiety, and poor sleep hygiene can worsen diabetes symptoms and disrupt blood sugar management. Addressing mental health and prescribing ways to maintain sleep hygiene should be a mandatory part of the diabetes treatment protocol or prescription.¹³

Failing to address these connections holistically risks incomplete care, perpetuating a cycle of illness and dependence on treatments that target symptoms rather than underlying causes.

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This intricate web of metabolic dysfunction highlights the urgent need for a holistic approach to diabetes treatment. By tackling each piece of this complex puzzle—through lifestyle changes, balanced nutrition, and regular physical activity—healthcare providers can help reduce the risks tied to diabetes and its related conditions. This is a call to action for both healthcare providers and people with diabetes, to embrace strategies that address the underlying causes of these interconnected health challenges.¹³

New and comprehensive strategies can offer improved ways for individuals to manage and cope with diabetes. Adopting a holistic approach to diabetes care not only supports physical health but also nurtures emotional and mental well-being. As India faces a rising wave of diabetes, this shift in perspective could lead to meaningful, population-wide health improvements.

References:

1. Anjana, Ranjit Mohan Mohan, Viswanathan et al. Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17). The Lancet Diabetes & Endocrinology, Volume 11, Issue 7, 474 – 489.
2. Casari S et al. Changing Dietary Habits: The Impact of Urbanization and Rising Socio-Economic Status in Families from Burkina Faso in Sub-Saharan Africa. Nutrients. 2022 Apr 24;14(9):1782.
3. Pradeepa R, Mohan V. Epidemiology of type 2 diabetes in India. Indian J Ophthalmol. 2021 Nov;69(11):2932-2938.
4. Stern MP. Diabetes and cardiovascular disease. The “common soil” hypothesis. Diabetes. 1995 Apr;44(4):369-74.
5. Martín-Timón I, Sevillano-Collantes C, Segura-Galindo A, Del Cañizo-Gómez FJ. Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength? World J Diabetes. 2014 Aug 15;5(4):444-70.
6. Klein S et al. Why does obesity cause diabetes? Cell Metab. 2022 Jan 4;34(1):11-20.
7. American Diabetes Association Professional Practice Committee. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2025. Diabetes Care. 2025 Jan 1;48(Supplement_1):S181-S206.
8. American Diabetes Association Professional Practice Committee. 8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2025. Diabetes Care. 2025 Jan 1;48(Supplement_1):S167-S180.
9. Ko JH, Kim TN. Type 2 Diabetes Remission with Significant Weight Loss: Definition and Evidence-Based Interventions. J Obes Metab Syndr. 2022 Jun 30;31(2):123-133.
10. Vinik AI, Vinik E. Prevention of the complications of diabetes. Am J Manag Care. 2003 Mar;9(3 Suppl):S63-80; quiz S81-4.
11. Bramante CT, Lee CJ, Gudzune KA. Treatment of Obesity in Patients With Diabetes. Diabetes Spectr. 2017 Nov;30(4):237-243
12. Reynolds A, Mitri J. Dietary Advice For Individuals with Diabetes. [Updated 2024 Apr 28]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: Link
13. American Diabetes Association Professional Practice Committee. 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2025. Diabetes Care. 2025 Jan 1;48(Supplement_1):S86-S127.
14. Caturano A et al. Modern Challenges in Type 2 Diabetes: Balancing New Medications with Multifactorial Care. Biomedicines. 2024 Sep 7;12(9):2039