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Diabetes is a chronic condition that affects the way the body processes glucose, the main source of energy for cells. Glucose levels are regulated by insulin, a hormone produced by the pancreas. When the body does not produce enough insulin or does not use it effectively, glucose accumulates in the blood, leading to high blood sugar levels. This can cause various complications, such as nerve damage, kidney failure, heart disease, and vision loss.
According to the World Health Organization (WHO), diabetes is a global public health problem that affects more than 422 million people worldwide, especially in developing countries like India and China . India alone has about 77 million people with diabetes, making it the second most affected country after China. Moreover, Indians have a higher prevalence of diabetes than other populations, both in India and abroad . For instance, the prevalence of diabetes among Indians living in the UK is about four times higher than that of the general population.
What makes Indians more prone to develop diabetes and other metabolic diseases, such as obesity, hypertension, dyslipidemia, cardiovascular disease, and non-alcoholic fatty liver disease? The answer lies in a complex interplay of genetic, environmental, and lifestyle factors that increase their risk of developing insulin resistance (IR), a condition where the body does not respond well to insulin. IR is the main cause of type 2 diabetes, which is the most common form of diabetes. IR can also lead to other metabolic diseases, which are collectively known as the metabolic syndrome.
## Genetic Predisposition
One of the factors that contribute to IR in Indians is their genetic makeup. Indians have a higher percentage of body fat and abdominal fat, which are associated with IR, for any given body mass index (BMI) . BMI is a measure of body weight relative to height, and is commonly used to assess obesity. However, BMI may not accurately reflect the body composition and fat distribution of different ethnic groups. For example, a BMI of 25 kg/m2, which is considered overweight, may correspond to different levels of body fat and abdominal fat in different populations. Indians tend to have more body fat and abdominal fat than Caucasians or Africans at the same BMI . This means that Indians may be at a higher risk of IR and diabetes even at a normal or slightly elevated BMI.
Body fat and abdominal fat are harmful because they secrete various hormones and inflammatory substances that interfere with insulin action and increase blood glucose and lipid levels. Abdominal fat, also known as visceral fat, is particularly dangerous because it surrounds vital organs, such as the liver, pancreas, and kidneys, and affects their functions.
Indians also have a lower muscle mass, which reduces their glucose uptake and metabolism. Muscle is the main site of glucose disposal and storage in the body.
When muscle mass is low, glucose remains in the blood, causing hyperglycemia. Moreover, muscle is an important source of energy expenditure and thermogenesis, which help to burn calories and prevent weight gain. When muscle mass is low, energy expenditure and thermogenesis are reduced, leading to obesity and IR.
Additionally, Indians may have genetic variants that affect their insulin secretion and sensitivity. Insulin secretion is the process by which the pancreas releases insulin in response to glucose. Insulin sensitivity is the ability of the cells to respond to insulin and take up glucose. Both insulin secretion and sensitivity are essential for maintaining normal blood glucose levels. However, some genetic variants may impair insulin secretion and sensitivity, resulting in IR and diabetes. For example, Indians have a higher frequency of a variant in the TCF7L2 gene, which is involved in the regulation of insulin secretion. This variant increases the risk of type 2 diabetes by about 40% in Indians.
## Environmental and Lifestyle Changes
Another factor that contributes to IR in Indians is the rapid environmental and lifestyle changes that have occurred in the past few decades due to industrialization and urbanization. These changes have led to alterations in dietary patterns, physical activity, and exposure to pollutants, which can affect IR.
For example, Indians tend to consume more refined carbohydrates, saturated fats, and sugars, and less fiber, fruits, and vegetables, than their traditional diet.
Refined carbohydrates, such as white rice, bread, and pasta, have a high glycemic index, which means that they cause a rapid rise in blood glucose levels after ingestion. Saturated fats, such as butter, ghee, and cheese, have a high caloric density, which means that they provide a lot of calories per gram. Sugars, such as sucrose, glucose, and fructose, are simple carbohydrates that are easily absorbed into the bloodstream. These dietary components can increase blood glucose and lipid levels, and stimulate insulin secretion, which can lead to IR and diabetes over time.
On the other hand, fiber, fruits, and vegetables have a low glycemic index, which means that they cause a gradual rise in blood glucose levels after ingestion. They also provide various vitamins, minerals, antioxidants, and phytochemicals, which have beneficial effects on glucose and lipid metabolism, insulin action, and inflammation. A high intake of fiber, fruits, and vegetables can help to lower blood glucose and lipid levels, and prevent IR and diabetes.
Indians also tend to be less physically active and more sedentary than their ancestors. Physical activity is any bodily movement that requires energy expenditure, such as walking, jogging, cycling, swimming, or aerobics. Sedentary behavior is any activity that involves sitting or lying down, such as watching TV, using a computer, or reading. Physical activity has multiple benefits for glucose and lipid metabolism, insulin action, and inflammation. It can increase glucose uptake and utilization by the muscles, reduce blood glucose and lipid levels, enhance insulin sensitivity, and prevent weight gain and obesity. It can also stimulate the release of various hormones and factors that improve blood flow, reduce oxidative stress, and modulate inflammation. A regular physical activity of at least 30 minutes a day, five days a week, can help to prevent IR and diabetes.
Sedentary behavior, on the other hand, has detrimental effects on glucose and lipid metabolism, insulin action, and inflammation. It can decrease glucose uptake and utilization by the muscles, increase blood glucose and lipid levels, impair insulin sensitivity, and promote weight gain and obesity. It can also induce the production of various hormones and factors that impair blood flow, increase oxidative stress, and exacerbate inflammation. A prolonged sedentary behavior of more than four hours a day can increase the risk of IR and diabetes.
Furthermore, Indians may be exposed to environmental toxins, such as pesticides, heavy metals, and air pollution, which can induce oxidative stress and inflammation, and impair insulin signaling. Oxidative stress is a state of imbalance between free radicals and antioxidants in the body. Free radicals are unstable molecules that can damage cells and tissues by stealing electrons from other molecules. Antioxidants are substances that can neutralize free radicals by donating electrons to them. Oxidative stress can impair the function and survival of pancreatic beta cells, which produce insulin, and reduce insulin secretion. It can also interfere with the binding and signaling of insulin to its receptors on the cell membrane, and reduce insulin sensitivity.
Inflammation is a process by which the immune system responds to injury or infection by producing various cells and molecules that fight against foreign invaders or damaged tissues. Inflammation can be beneficial in the short term, but harmful in the long term. Chronic inflammation can damage the pancreatic beta cells and reduce insulin secretion. It can also activate various pathways that interfere with insulin signaling and reduce insulin sensitivity.
## Psychological Stress
A third factor that contributes to IR in Indians is the high level of psychological stress that they face in their daily lives. Psychological stress is a state of mental or emotional strain or tension that results from adverse or demanding circumstances, such as work pressure, family conflicts, social discrimination, and financial problems. Psychological stress can affect both mental and physical health, and increase the risk of IR and diabetes.
Psychological stress can increase the levels of cortisol, a hormone that is released by the adrenal glands in response to stress.
Cortisol has various effects on glucose and lipid metabolism, insulin action, and inflammation. It can increase blood glucose levels by stimulating the breakdown of glycogen, the storage form of glucose in the liver and muscles, and the production of glucose from non-carbohydrate sources, such as amino acids and fatty acids. It can also suppress insulin action by reducing the expression and activity of insulin receptors and signaling molecules. Moreover, it can trigger oxidative stress and inflammation by increasing the production of free radicals and inflammatory cytokines.
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