December issue 2004

It can happen to just about anyone. Asia’s most silent epidemic can prey upon a nine-year-old girl as indiscriminately as on a 60-year-old man. It starts off with a few seemingly insignificant symptoms, but left untreated, can cause blindness, kidney failure — even death. And nobody is immune to it.

Popular television star, Zeba Bakhtiar, was diagnosed with diabetes in her early ’20s. And cricketer par excellence, Wasim Akram, has been a diabetic for years. It took several months before either star was diagnosed with the disease. Both had experienced symptoms like frequent urination, blurry vision, and dizzy spells, but neither had a family history of the disease. When the prognosis was finalised, both stars suffered from an immediate psychological fallout. “Wasim was emotionally devastated when he found out,” says his wife, Huma Mufti. “Regular injections in his stomach proved both painful and scary.” Bakhtiar agrees. “It was a difficult time,” she concurs, “and a stressful one. I had just finished shooting Henna and had contracted a case of acute bronchitis. I believe it affected my pancreas, as did my highly stressful work schedule.”

As diabetes demands a complete lifestyle change, it is often a difficult disease to come to terms with — both physically and emotionally. On the outside, 32-year-old Tooba, for example, seems like a highly motivated, spunky media executive with a demanding job. What few of her colleagues realise, however, is that when Tooba was 14, a sudden fainting spell led her to be diagnosed as a diabetic. Since then, she has been taking insulin injections to regulate her body’s sugar levels and has had to adhere to a strict diet of non-starch and non-fat food. “Giving up regular food is the most difficult part, as is coping with constant injections and doctor’s visits,” she says. But the psychological impact proved harder to deal with. “My first reaction when I found out was that I wouldn’t be able to have a child and no one in Pakistan would marry me.” Although Tooba’s fears proved unwarranted, the now mother of two children says her biggest fear is passing on the disease to them.

An estimated 333 million people have diabetes all over the world, and this figure is expected to double over the next 25 years. What is more alarming is that three-fourths of future diabetics will hail from developing countries, like Pakistan, where roughly over 8.8 million (12 per cent of the population) have been affected so far.

Take 58-year-old diabetic Rafia Khurshid, for example. All five of Khurshid’s children — the eldest of whom is 42, and the youngest, 28 — are also diabetic. Two of her daughters suffer from high blood pressure and a third from kidney problems. Her youngest son also has high blood cholesterol. Khurshid has also had a hard time living with diabetes. Her blood sugar levels often peak to 440 mg/100 ml against a norm of 199 mg. Along with fluctuating blood pressure, Khurshid suffers from a constant need to urinate, chronic body aches, irritability, fatigue and regular diarrhoea, among other symptoms. Two months ago, Khurshid suffered a minor heart attack and underwent an emergency angioplasty (a corrective procedure for damaged or blocked heart arteries) that revealed a 90 per cent blockage in two of her arteries, and 50 per cent in the third. Prior to the attack, Khurshid showed no signs of her condition — but believes it was caused by diabetes.

Sugar, as it is commonly known, or diabetes mellitus, is a disorder that impairs the body’s natural blood glucose or blood sugar regulation process. It is classified into two major categories:

Type I and Type II diabetes, the former also known as juvenile diabetes. However, according to Dr. Naeem-ul-Haq, a senior endocrinologist at the Aga Khan University Hospital (AKUH), the term ‘juvenile’ is no longer used. While the classification criteria previously identified Type I diabetes as occurring mostly in children and adolescents, and Type II mostly in adults, research has confirmed that the onset age in both types of diabetes is interchangeable.

Type I diabetes, also known as insulin-dependent diabetes, develops when the body’s immune system attacks and destroys the beta cells in the pancreas, which produce insulin, a hormone that helps the body convert glucose from food into energy. When beta cells are destroyed no insulin can be produced and glucose stays in the blood, where it can cause serious damage to vital organs of the body. When the body fails to naturally produce sufficient insulin, a diabetic person must ingest it from other sources. Type I diabetes usually appears before the age of 30. It can be treated with insulin injections as well as through diet and regular exercise.

Type II diabetes, however, known as non-insulin dependent diabetes, occurs when the pancreas produces insulin in insufficient amounts, or when the body is unable to effectively use the produced insulin. Treatment includes diet control, exercise, self-monitoring of blood glucose and, in some cases, oral drugs.

About two to five per cent of pregnant women also develop high blood sugar during pregnancy, or gestational diabetes. Although the condition usually disappears after the birth of the child, women who have had gestational diabetes are at a high risk of eventually developing Type II diabetes.

According to Dr. Ghazala Rafiq, a community health specialist at the AKUH and the Diabetic Association of Pakistan, the lack of a comprehensive strategy to check its incidence has made it likely that diabetes in Pakistan will reach “epidemic proportions.” The World Health Organization (WHO) estimates there will be 14.3 million diabetics in the next 25 years. According to WHO estimates, Pakistan ranked eighth among countries with the highest number of diabetics in 1995. By 2025, however, it will rank fourth, unless serious intervention is undertaken.

The Diabetic Association of Pakistan and the WHO carried out a national diabetes prevalence survey between 1994 and 1998. It found that type I diabetics comprise less than two per cent of the total number of diabetics in Pakistan. In a recent study undertaken in Karachi, its incidence was found to be 1.01 in males and 1.04 in females per 100,000 people per year. The highest rate of incidence was found among 12-year-old females. According to the survey, diabetes prevails in about 12 per cent of the general population aged 25 years and above, while Impaired Glucose Tolerance (IGT), i.e. borderline diabetes, is found in 10 per cent (about 6 million people) of the total populace. Among borderline diabetics, about half are expected to show symptoms of full blown diabetes. However, IGT is reversible if affected individuals adopt healthier eating and exercise habits.

Locally, the peak age of diabetes is between 40 and 50 years, and women have a higher tendency than men to contract the disease. People over 40 years of age, however, fall in the higher risk category. Those with obesity, a diabetic family history, pregnancies with large babies, etc., are equally at risk. Diabetics also have a two to three times higher risk of fatality compared to non-diabetics.

“In Pakistan there is a misconception that diabetes is merely an elevation of sugar levels, whereas it’s actually a disorder showing various syndromes,” says Dr. Haq. “It is a condition in which the amount of glucose (sugar) in the blood is high because the body cannot use it properly.” Glucose comes from the digestion of starchy foods like bread, rice, potatoes, and chapattis, as well as sugar from other foods. The goal through treatment is to regulate blood glucose and pressure levels. This, together with a healthy lifestyle, can protect against long-term damage to the eyes, kidneys, nerves, heart and major arteries.

Contrary to common belief, diabetes is not caused by eating too much sugar or obesity. Both genetic and environmental triggers are being studied as potential causes and the interaction or combination of dietary factors, viral infections, toxic agents as well as stress are being considered possible causes. According to doctors, increasing rates of urbanisation, changing lifestyles, dietary deregulation — both in terms of quality of food and meal timings — as well as less physical activity are the main culprits. According to Dr. Naeem-ul-Haq, developing nations like Pakistan are more at risk as compared to developed countries because healthier eating habits and lifestyle patterns abroad work towards curtailing the disease. However, this does not mean that those who work harder are less at risk. “It is commonly assumed that the people from the lower socio-economic strata don’t develop diabetes. However, that is a misconception — their diet is rich in unhealthy fatty saturates. This coupled with late night eating habits, makes our society’s makeup a strong pre-disposing factor,” says Haq.

The main symptoms of untreated diabetes are increased thirst, frequent urination, especially at night, extreme tiredness, weight loss, genital itching or regular episodes of thrush in women, and blurred vision.

Diabetes is the leading cause of kidney failure in the industrialised world and most developing countries, including Pakistan. This can cause a substantial drain on finances. Kidney failure requires dialysis treatment which can cost upto 15,000 rupees per session, while a kidney transplant requires at least 400,000 rupees with an additional 20,000 rupees per month for drugs and lab test follow-ups. According to Professor Jaffar Naqvi from the Kidney Centre, diabetes is now the most common cause of end-stage renal failure, which almost one third of diabetics suffer within 10 to 15 years of its onset. Naqvi says that Pakistan requires about 5.6 million rupees for drugs and 901.7 million rupees for dialysis, while our total health budget is only 29.6 billion rupees. “How can we afford it?” he asks. “It is beyond our resources. Prevention is the only option. Early diagnosis and treatment can save millions of rupees,” he asserts.

It is a strategy that diabetes awareness activist, Zeba Bakhtiar, agrees with. “Though I have been working formally to raise awareness for diabetes for over a year now,” she says, ” I have still not been able to provide free drugs, testing and treatment to patients who cannot afford to pay for it.”

Macro vascular complications associated with diabetes, like heart diseases and strokes, are also responsible for a major part of the socio-economic burden of diabetes. Research regarding the financial burden on low income families with one diabetic, estimate that 25 per cent of household earnings are taken up by the patient’s bills. “How can low income families afford such expensive treatment, especially when the attitude of officials is apathetic?” asks Naqvi. He recalls meeting a health minister who rejected a suggestion for commencing public awareness programmes because mass awareness would add to the ministry’s financial problems. “It would lead to increased requests for lab tests and subsequent treatment through the government,” he says.

Wasim Akram, who has been involved in various awareness-raising campaigns, states that something must be done urgently to address the apathy of health officials with regard to diabetes. “Although working on major promotions with Roche and Biocon in India, my local work in the arena has been very limited,” he says.

Approximately 81 per cent of Pakistani people with Type II diabetes use oral medicine for treatment, while 15 per cent are treated through diet control and two per cent through insulin injections. The remaining two per cent of the population do not use any form of treatment. Home remedies are popular, along with herbal treatments. A recent study conducted by the Department of Human Nutrition, NWFP Agricultural University, Peshawar, in collaboration with Nutrients Requirements and Functions Laboratory, Beltsville Human Nutrition Research Center, Beltsville, Maryland, has shown that taking a small quantity of cinnamon, from one to six grammes per day, may reduce serum glucose, triglycerides, LDL (‘bad’) cholesterol, and total cholesterol in people with Type II diabetes. Including cinnamon in the diet may reduce risk factors associated with diabetes and cardiovascular diseases. The study underlines the fact that medicinal/culinary herbs have been reported to yield hypoglycemic (sugar lowering) effects in patients with diabetes. Examples of these include bitter melon, Korean ginseng, onions, water-soaked fig and garlic, among others.

However, many such home remedies are fallacies, like the popular belief that bitter gourd or karaila reduces blood sugar. The only way gourd can affect glucose levels is if the patient consumes at least two kilograms of sun-dried and purified gourd peel on a daily basis — an impractical and tedious remedy. Many local quacks and pirs also claim to successfully treat diabetes with similar remedies. A famed cleric from Hyderabad was known to insist that patients stop all modes of medical treatment and also lift all dietary restrictions. His ‘cure’ relied on pure sugar that had been ‘blessed’ with divine powers that he personally gave to affected males. Thousands of people from all over the country visited his shrine in the hope of a miraculous cure, some waiting for days in mile-long queues outside his home. The hoax was eventually exposed when a large amount of his believers suffered a rapid death.

Zeba Bakhtiar, however, is a great believer in alternative therapy. She believes her sugar level is kept under control by yoga and Reiki. In spite of being diabetic for over 12 years, Bakhtiar’s eyesight has not shown any signs of detoriation — a common occurance among diabetics. “I attribute this to regular yoga, especially inverted exercises like head and shoulder stands, which increase blood flow to the cranial region,” she says. Zeba also believes that drinking four to six glasses of water before breakfast and before meals helps keep her sugar level in check. There is no medical evidence, however, to support her contentions, except that a healthy diet is crucial in preventing diabetes and also aids its treatment.

It is essential for people with diabetes to manage a balanced food intake and exercise regularly to maintain normal blood sugar levels in an attempt to avoid hypoglycemic as well as hyperglycemic (high blood sugar) reactions, which can be fatal. People who use oral pills tend to neglect diet and exercise, expecting medicine to do miracles. However, whenever people eat anything they want, medicinal agents prove to be ineffective. A healthy diet is the key to preventing diabetes and aiding its treatment. Regular exercise can help reduce the risk of diabetes. Activity can also reduce the risk of developing related complications like heart diseases, strokes, kidney failure or blindness.

Current estimates indicate a 40 to 60 per cent prevalence of erectile dysfunction among diabetic men, even though libido and ejaculatory functions are normal. Smoking also damages blood vessels and contributes to heart diseases, strokes and poor circulation of blood in the limbs. Thus diabetic smokers are at a higher risk of developing complications than diabetic non-smokers.

Undoubtedly, life with diabetes calls for strict vigilance and rigorous self-discipline. Eating right and exercising are essential for a healthier life in all respects, especially since the disease is currently incurable.