In India, one in every 11 adults is living with diabetes, which means India has the second largest diabetic population (16.6%) in the world after China (25.1%), according to the International Diabetes Federation's Diabetes Atlas 2019. The report projects that India will continue being on the second spot right up till 2045 — an alarming 33% rise — from 101 million diabetics by 2030 to 134.2 million by 2045.

India has already seen an 11.5% increase in diabetes patients in the age group of 20-79 years —77 million in 2019 from 69 million in 2015, according to a Lok Sabha response in February 2021.

The theme of World Diabetes Day 2021-23, observed every year on November 14 to raise awareness, is 'Access to Diabetes Care --If Not Now, When?'. The campaign is represented by a blue circle logo (symbol for diabetes awareness), which was adopted in 2007 after the passage of the United Nations Resolution on diabetes.

In 2019, India, on an estimate, saw more than 1 million people die of diabetes and related complications of the 1.2 million diabetes deaths recorded in the South-East Asia region, shows the IDF report.

Among states, Kerala (23.6%) has seen the highest diabetes prevalence, followed by Goa (23.3%) and Puducherry (20.3), while Uttar Pradesh (4.2%), Bihar (4.3%) and Meghalaya (4.5%) have seen the lowest prevalence, according to a February 2020 Lok Sabha response.

One in every two Indians (47%) living with diabetes is unaware of their condition, and only about a quarter (24%) manage to bring it under control. Since this clearly indicates that Indians are either ignorant or misinformed around topics related to different types of diabetes, diagnosis and its management, FactChecker spoke to experts about myths surrounding the disease.

Diabetes Mellitus is a chronic, metabolic and non-communicable disease which results in increased levels of blood glucose (or blood sugar). If not managed in time, it could lead to serious damage to the heart, blood vessels, eyes, kidneys and nerves, according to the World Health Organization.

Types of Diabetes

There are more than three types of diabetes, the most commonly found are Type 1, Type 2 and Gestational diabetes. Type 1 diabetes is caused by an autoimmune reaction in which the body's immune system attacks the insulin producing beta cells of the pancreas. Hence, the body produces very little or no insulin. People with Type 1 diabetes need daily insulin injections to maintain their glucose level.

The causes of Type 1 diabetes are not fully understood, but health experts FactChecker spoke to said it is a combination of genetic predisposition and environmental conditions such as infections and dietary factors. The typical symptoms are excessive thirst, blurred vision, bedwetting, frequent urination, fatigue, constant hunger and sudden weight loss.

On the other hand, Type 2 diabetes which is the most common type of diabetes is caused due to inability of body's cells to respond fully to insulin. Here the body either resists insulin which is termed as insulin resistance or the hormone is ineffective and produces inadequate insulin. Over time, this can result in failure of pancreatic beta cells. Type 2 diabetes presents similar symptoms to Type 1, but it is less severe or can also be symptomless.

Further, gestational diabetes is first seen in a pregnant woman who did not have diabetes before she was pregnant, according to the Centers for Disease Control and Prevention (CDC). Insulin is a hormone made by the pancreas that acts like a key to let blood sugar into the cells in the body for use as energy. Gestational diabetes occurs when the body can't make enough insulin during pregnancy.

FactChecker spoke to Dr Somashekara Reddy KS, consultant diabetologist and endocrinologist with Fortis Hospital, Bengaluru, and Dr Rahul Pandit, Director of Critical Care Medicine and ICU at Fortis Hospital, Mumbai. Here are the five myths they busted:

Myth 1: Diabetes only occurs in older adults

Diabetes can develop at any age. In fact, Type 1 diabetes which is also called juvenile diabetes often appears during childhood or adolescence. Moreover, India saw a 33.2% rise in juvenile diabetes patients in just two years —171,281 in 2019 from 1,28,500 in 2017. Although Type 2 diabetes is commonly seen in older adults, it is increasingly seen in children and young adults due to rising levels of obesity, physical inactivity and inappropriate diet.

Myth 2: Only consuming sweets affects sugar levels

Both doctors said every food we eat is ultimately converted to sugar and that it is glucose that the body needs for functioning. Many factors affect blood sugar levels and it is far more complicated than just consuming refined sugar.

Stress, cholesterol, high blood pressure, lack of sleep and exercise, excess weight, pollution, steroids, alcohol, pregnancy, etc are some of the other factors that can contribute to elevated sugar levels.

Myth 3: People with diabetes cannot eat fruits, starchy food

Fruits can be a part of one's diet as long as the portion is maintained. However, both doctors said the way one eats fruits and starchy food should be checked. Fresh, frozen and whole fruits are better than processed canned fruits or fruit juices. This is because juices or canned fruits may have added sugar and less fibre. Further, checking the glycemic index (GI) value of fruits and carbohydrate fruits could help patients select appropriate foods to eat.

Gl is a ranking system of carbohydrate-comprising foods on a scale of 0 to 100, according to their effect on blood glucose levels. Several factors such as acidity, cooking time, processing, ripeness and fiber content are taken into account while assessing GI.

According to the American Diabetes Association, any food scoring a GI below 55 is low and doesn't spike sugar levels, and a 70 plus GI score is high. A score between 56-69 is considered moderate. For instance, foods such as watermelon (GI 76), instant oat porridge (GI 79) and white rice ( GI 73) will spike glucose levels because of their GI Index. On the other hand, foods with a low GI index (20-49) are apples, avocados, legumes, etc. Ideally, the GI, food carbohydrate content and serving size need to be considered, experts said.

Myth 4: Artificial sweeteners such as sugar free products are good alternatives

Although artificial sweeteners have zero calories, they contain chemically altered sweeteners such as sucralose, saccharin, acesulfame, aspartame. For instance, sucralose is non-caloric and chemically changed so it is 600 times sweeter than real sugar. The human body and brain respond differently to these sweeteners and could drastically change the way we taste food.

According to Dr. David Ludwig, an obesity and weight-loss specialist at Harvard-affiliated Boston Children's Hospital, "Non-nutritive sweeteners are far more potent than table sugar and high-fructose corn syrup. A miniscule amount produces a sweet taste co

mparable to that of sugar, without comparable calories. Overstimulation of sugar receptors from frequent use of these hyper-intense sweeteners may limit tolerance."

It's possible that people could shun healthy foods with nutritive value and crave for artificially sweetened food. It could also prevent people from associating sweetness with caloric intake which could be counterintuitive.

Myth 5: Diabetes cannot be reversed

Diabetes cannot be cured but it can be reversed or managed for a long period of time by improving insulin sensitivity in people with Type 2 diabetes. This is mainly done through diet, lifestyle changes and weight loss. Some even prefer to undergo bariatric surgery. When a person is able to reach normal sugar levels without medication, they are considered to have reversed their diabetes. But both doctors warned that there is always a chance for symptoms to return. So, they recommended consulting a diabetologist or endocrinologist before considering any diabetes related holistic approach.

Is there a link between diabetes and depression?

Diabetes and depression have bidirectional influence on each other, Akansha Pandey, consultant clinical psychologist at Fortis Hospital, Bengaluru, told FactChecker. "Patients diagnosed with depression and treated with antidepressant drugs can increase the risk of diabetes upto 25% and diabetic patients treated with insulin can increase the risk of depression by 50%," said Pandey.

This chronic stress, she said, can cause Hypercortisolemia resulting in insulin resistance, visceral obesity and metabolic syndrome. She said environmental factors like low socio-economic status, childhood adversity, poor social environments, lower physical activity and maternal stress prior to birth can play a crucial role in both conditions.

"These factors can result in activation of stress systems like the hypothalamic-pituitary-adrenal axis [controls reaction to stress and regulates digestion and immune system] and the sympathetic nervous system," Pandey explained.

According to a 2010 study by the National Collaborating Centre for Mental Health, people with chronic physical health problems (such as cancer, diabetes, heart disease and stroke) are 2-3 times more likely to undergo depression.

It is natural to feel overwhelmed and burned out while dealing with daily diabetes care. And when results aren't seen, this could lead to diabetes distress, a combination of stress and anxiety, according to the CDC. Moreover, another psychological complication is a media-coined term called Diabulimia — an eating disorder in which patients, commonly women aged between 15-30 with Type 1 diabetes restrict or deliberately skip insulin injections to lose weight. "This can lead to early onset of serious diabetes complications such as blindness and amputations... and involves a complex interaction of factors, such as insulin, blood glucose, emotions, and body image, that cross diabetes care and mental health," says The British Medical Journal.

The clinical psychologist said it is important to achieve euthymia with euglycemia to treat diabetes patients with depression. Euthymia means a pleasant state of mind and euglycemia is the normal level of sugar in the blood. "Management of depression can involve antidepressant drugs, cognitive behavioural therapy, supportive and interpersonal therapies, relaxation and mindfulness exercises and brain stimulation procedures, etc," said Pandey. "Achieving euthymia can ensure euglycemia and it is always encouraged to seek professional help from mental health experts."

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