00:02So, India is called as the diabetes capital of the world, but if you actually look at the numbers, China
00:11is little ahead of us as far as the number of people with diabetes is concerned.
00:16And the reason for that is that although the population of India and China are equal, in fact we are
00:21now ahead of China as far as population is concerned, they are a much older population.
00:26Half of our people are below 20 years of age. China has only one child's policy for long time.
00:34So, their population is much older. So, they have people who are 80 years old, 85 years old, you have
00:41lot of diabetes at that age.
00:43For that reason, the actual number of people with diabetes is higher in China.
00:49But the question was, what has changed in the last say 30 years as far as diabetes is concerned?
00:57Number one, it was considered as a rich man's disease. So, they said only rich people get disease.
01:03Then it came to middle class. Today, even poorest of the poor people, slum people are having diabetes.
01:10That is one big change from the rich to the poor. Second is that they said it is a disease
01:15of old age.
01:16When you become 60, 70, 80, you will get little diabetes. Then it started coming 50, 40, 50 years old.
01:25Then it started coming when you are 20, 30 years old. Today, type 2 diabetes, I am not talking about
01:31type 1 diabetes comes in children.
01:32That is a children's age group disease, type 1. I am talking about usual type 2 diabetes comes in adults.
01:40It has now started coming at 12 years of age, 13 years of age. I have got one or two
01:46children who are 7 years old.
01:48Already, they are so obese and they have got type 2 diabetes. That is another big shift.
01:54Coming from old age to even children, it has started coming.
01:59The third is that it was believed to be an urban disease.
02:03So, in rural areas, villages, nobody will get diabetes. Only in the big cities.
02:08It used to be like that. Then it started going to the smaller cities, tier 2, tier 3 cities.
02:14Today, even in the villages, diabetes is increasing.
02:18So, these are three big changes which have occurred.
02:22No longer a rich man's disease, no longer an urban disease and no longer restricted to old age.
02:29It started occurring in young people also. These are the major changes which have occurred.
02:34Your research highlighted that Indians develop diabetes at a young age and lower BMI compared to western population.
02:43Could you explain the concept of the Asian Indian phenotype for readers?
02:48For many years, when I started my research on this about 30 years ago, we found that there are lot
02:55of differences
02:56between diabetes in Indians, type 2 diabetes in Indians compared to the white European population.
03:04One of the things is that it occurs at a younger age.
03:07Whereas, in white Europeans, it occurs when you are 50, 60 years old.
03:13In Indians, it starts coming when you are 20, 30 years old itself, it started coming.
03:18In fact, when you look at our statistics, 50% of all type 2 diabetic patients get it before 45
03:24years of age,
03:25which is very, very uncommon in a white person.
03:29So, that is the first difference.
03:30Second is, in U.S. and in most other developed countries, diabetes is associated with obesity.
03:37So, you have to be very big obese, you have to have a lot of obesity, a lot of body
03:41weight and excess fat to get diabetes.
03:45We get it even if we are thin people.
03:47In fact, Indians are called as thin fat Indians.
03:51So, what does that mean?
03:51We look very thin on the outside, but inside we have lot of fat.
03:56So, we call it as T-O-F-I, thin outside, fat inside.
04:01So, that is the typical characteristic of the Indian and all this is what we call as the Indian phenotype
04:08or the Asian Indian phenotype or South Asian phenotype.
04:11This makes treatment also a little different because in the West, mostly it is about weight reduction.
04:17If you reduce weight, it will go away.
04:19In India, that is there, the obese patients are also there.
04:22But, we also have lot of thin people in whom there is no weight to lose at all.
04:26In fact, they should put on some weight.
04:28So, the treatment pattern, the medicines that we take all differ because of this Asian Indian phenotype.
04:35Why do Indians tend to accumulate more visceral fat even when they appear lean?
04:41Does this mean that traditional markers like BMI are insufficient for diagnostic metabolic risk in Indians?
04:48Yes.
04:49Body mass index is a very crude index, BMI we call it.
04:53It is just taking the weight in kilograms and dividing it by the height in meters squared.
05:00So, that is BMI.
05:02We are just going by the height and the weight.
05:03So, it is a very crude index.
05:05You can have a BMI.
05:06So, BMI above 25 we say is obesity.
05:09But, if you are a very muscular person, suppose you are doing lot of weight lifting and your bones are
05:14heavy, you will be classified as obese.
05:16Actually, you can be a very fit person.
05:18So, a better index of obesity and fat deposition in the body is to measure the waist circumference.
05:27If you take an inch tape and measure your waist circumference.
05:30If the waist is enlarged, it usually means there is a lot of fat inside the body.
05:35So, that is a much better index of obesity in Indians than the body mass index.
05:44Now, why do Indians develop this visceral adiposity?
05:48Studies have shown very interesting results.
05:50If you see the abdomen wall, this abdominal wall if you see, there are small adipocytes there, small fat cells
05:58there.
05:58When we eat too much of food, those small fat cells get filled up very quickly and then it has
06:06to go inside the abdomen.
06:08In the white man, in the white person, there are a lot of these small adipocytes.
06:13So, when they eat more food, those small adipocytes will enlarge and they all stay in the abdominal wall.
06:19It won't go inside.
06:20In Indians, maybe due to genetic factors or because of our diet, we have very small numbers of these small
06:27adipocytes, the small fat cells.
06:30So, very quickly they get filled up, then they go inside into the abdomen and then it becomes visceral adiposity
06:36or visceral fat or intra-abdominal fat.
06:39That then goes into the liver.
06:41Liver is where the insulin works.
06:43So, when you have fat in the liver, the insulin does not work and therefore, you can get diabetes.
06:49Same fat goes into the pancreas also.
06:51So, insulin secretion also gets reduced.
06:53That is why we get diabetes.
06:55So, cities like Chennai, Hyderabad and Bengaluru have booming IT industries but also rising lifestyle diseases.
07:04How much of this diabetes search is linked to sedentary work culture?
07:09A lot of the diabetes and obesity is due to sedentary culture.
07:15You mentioned the IT industry in, say, Chennai, Bengaluru, Hyderabad and so on.
07:22Now, when you have IT people, youngsters working for IT, very often they have to work in the night also.
07:28So, they will be working the American timings and so what happens when everybody is sleeping in India, they will
07:34be working.
07:35So, their chronobiology, the brain also gets confused because between day and night.
07:41Second, because they are working in the night, they cannot get their home food.
07:44So, they will be ordering junk food from outside, very high calorie, high sugar, high fat.
07:49So, they all promote obesity.
07:52Thirdly, because they are working in the night, they have to sleep in the daytime.
07:57So, they do not get time for exercise.
07:59So, they become sedentary.
08:00They are also sitting in the office job next to the computer all the time.
08:05That computer radiation is also occurring.
08:07All these together play havoc with the health of our youngsters.
08:13And that is why in the cities like Bangalore, Hyderabad, Chennai and many other cities, Mumbai, Delhi, all these big
08:20cities, they have so much of diabetes.
08:25Are you seeing diabetes in younger patients today compared to the two decades ago?
08:32Definitely, it is occurring at a much younger age group.
08:36That is because right from childhood obesity has started.
08:40When I was in school, 50, 60 years ago or more, there was in my whole school, 2500 students, there
08:49was only one boy who was obese.
08:51Only one in the whole school.
08:53Okay.
08:54And everybody used to make fun of him and all that.
08:56Today, in my grandson's generation, if you see, 50% of his class are obese.
09:03So, that obesity from very young age, even the age of 8, 10, they are already obese.
09:09By the time they become 15, 20 years old, they are turning into diabetic.
09:13So, therefore, young people are getting a lot more diabetes today than in my generation.
09:19Diabetes was once considered a city disease, but recent data suggests it is rising in rural India too.
09:27How do healthcare access and delayed diagnosis worsen outcomes in rural communities?
09:34What role can community health workers play in diabetes screening and prevention?
09:40In rural areas, when you get diabetes, the problem is that, number one, there are no specialists in rural areas.
09:46Most of the doctors practice in urban areas.
09:49If you see specialized equipment, hospitals, they are all in the urban areas.
09:53Rural areas, there will be primary health center only.
09:57Now, if suppose one of those patients with diabetes in rural area gets a heart attack, there is no hospital
10:03there.
10:04By the time they reach the city, very often they die.
10:07Sometimes they get an injury, they develop some ulcer in the foot.
10:13They delay for two or three days.
10:15By the time it is spread very much, then they result in amputation.
10:18Similarly, they do not have facility to screen for the eye.
10:21So, they may be having diabetic eye changes and then they can even go to a very advanced stage.
10:27Blindness can also occur.
10:28So, in rural areas, because of these poor facilities, people tend to miss the diagnosis and therefore they have complications
10:37very early.
10:38The way to do it is to reach out to rural areas, to doing mobile camps or taking equipments there,
10:45doing camps there, raising awareness there and linking them to the nearest city.
10:51So, if they have a problem, they should be able to go.
10:53By this, we can try to help the people living in the rural area.
10:57Now, by using mobile phones, by using technology, internet, it is possible to do even teleconsultation to these people.
11:06The Indian diet is often high in refined carbohydrates.
11:11How much does diet contribute to India's diabetes burden?
11:16Is rice the villain people make it out to be?
11:20What do you think about recent trends like intermittent fasting or keto diets for diabetes management?
11:26For many years, our research has shown almost a direct link between carbohydrate intake and development of diabetes.
11:35Rice is what we have studied because we are in the south.
11:38We have studied rice and there is a direct correlation with the diabetes.
11:42But not that wheat is any better because in the north and the west, they don't take much rice, they
11:48take wheat.
11:49There also the wheat is refined, highly polished wheat and that also is equally bad, as bad as rice.
11:56So, it doesn't matter whether they take rice or wheat, we take too much of it, it seems to be
12:00bad.
12:01So, we can't call it as a villain, but eating too much of it is bad.
12:07So, how do we correct this?
12:09The way to correct it is to add protein to it.
12:12In India, 62% of the calories comes from carbohydrate.
12:16Protein is only 12%.
12:18It should be at least 20%.
12:19If you are able to add 10% more as protein and reduce 10% of the carbohydrate, we will
12:26be able to prevent diabetes and also manage it well.
12:30About intermittent fasting, it is useful if the calories are cut down.
12:35If the calories are not cut down and you simply eat one heavy meal in the morning and a heavy
12:40meal in the night and nothing in between, it is not going to help you.
12:43Because ultimately, all the calories will get added up.
12:46So, while intermittent fasting is useful, it should be combined with calorie restriction.
12:51If you don't restrict the calories, it doesn't work.
12:53I am not in favor of keto diet, because while the keto diet is very low in carbohydrate, it also
13:00helps you to lose weight very rapidly.
13:02But it is an unbalanced diet, because all the carbohydrate is removed and replaced with fat.
13:08So, you end up having a 60%, 70% or even 80% fat diet, whereas the carbohydrate is very,
13:17very low and the rest is protein.
13:19So, when you have so much of fat in the diet as the keto diet occurs, then what happens is
13:26that your cholesterol will go up and your heart disease will go up.
13:29So, you may lose weight, but in the end they get heart attack.
13:32So, I am not very much for keto diet.
13:35I believe that you should reduce the carbohydrate a little bit, increase the protein, take healthy fats, take lot of
13:42green leafy vegetables, some fruit.
13:45If you are able to do that, you will have a very healthy Indian diet.
13:49So, if you had to give three lifestyle habits that could dramatically reduce diabetes risk, what would they be?
13:59The three healthy lifestyle things I would say is number one, change your diet, take less of carbohydrate, take more
14:08protein, take more green leafy vegetables.
14:11That is the first one, diet.
14:12Second is physical activity.
14:15Exercise should become a regular habit and not only just walking, but you should also do some strength training that
14:24is muscle building and also some flexibility.
14:27flexibility, I have a formula which I called as FAR, F-A-R, flexibility, aerobic exercise and resistance training, F
14:36-A-R.
14:37All the three should be done, then it is very good.
14:40The third and the most important is to reduce stress and to sleep well.
14:45If you are able to reduce stress and sleep at least six to seven hours a day, if you are
14:52able to do that and you sleep on time, these three things you are able to follow.
14:56Healthy diet, improve your physical activity and reduce your stress and sleep on time, most of diabetes can be prevented.
15:05What policy intervention could help India slow the diabetic epidemic? Should India have national-wide screening programs for diabetes?
15:15One of the things policies that we can do, the government can do is in the public distribution system, especially
15:23in the southern states I know and maybe the same in others.
15:26We are giving a lot of, when you give the free food to people or subsidized food, we are giving
15:32only rice mainly.
15:33The amount of dal that we give is very little. If we increase the proportion of dal that we are
15:41giving to people, their protein consumption will go up.
15:45The second thing for policy should be to make fruits and vegetables cheaper.
15:50We say take lot of fruit, take lot of vegetables, but fruits and vegetables are very expensive.
15:54So, people go and buy some processed foods from some bakery or from somewhere they will go or from outside
16:00they will buy.
16:01They are usually unhealthy. So, I think we should encourage people to take more of fresh vegetables and fruits and
16:09for that the government has to make it very cheap by providing subsidies.
16:13The third thing the government can do is to make free access to gyms, to parks and to plant more
16:22trees and make it more green so that more oxygen will come, pollution will also come down in the cities.
16:29So, by simple actions that the government can take for policies, changing the policy to improve the health of the
16:37people, diabetes can be controlled and even prevented.
16:40What role should food regulation and urban planning play in addressing the crisis?
16:46As far as urban planning is concerned, see what happens is that in our roads we don't have proper footpath.
16:53The footpath is all taken away. Hawkers do it or they dig up the footpath.
16:58You know, in some of the rich places, they take the footpath also as part of their home, forgetting about
17:05the common man who has to walk.
17:07So, what happens? People have to walk on the road. It is not safe to walk on the road anymore.
17:11So, if they have pedestrian friendly streets where they have nice big footpath encouraging people to walk and many parts
17:20of the city can be made only for pedestrians and then they can have any number of parks started where
17:27people can go.
17:28I know in Delhi, they have a lot of big gardens and parks, but many other cities don't have.
17:34So, the city needs lungs because enough oxygen, enough green spaces, this itself will help to improve the quality of
17:43life of people.
17:44If that is done and as I said for the diet, I already mentioned about reducing, encouraging people to reduce
17:52their carbohydrate intake and to make protein intake cheaper and available to people and also fresh green leafy vegetables.
18:02All this if it is done, it can play a big role in preventing diabetes.
18:05India has millions of undiagnosed diabetes. Why does diagnosis still come so late for many patients?
18:16Diabetes is called as a silent killer and the reason it is called as silent killer is because it does
18:21not produce any symptoms until it becomes very late in the disease when the disease is advanced.
18:27No symptoms come. So, most people are fooled because they say I am alright, I do not have any symptoms,
18:34why should I go for check-up?
18:35In fact, even those who have diabetes, including some of my close friends, when I tell them, they would have
18:41come and seen me some years ago and next five years, they would not have come.
18:44And every year, you are supposed to check for diabetes. When I ask them, they will say, I am okay
18:48doctor, I do not have any symptoms, when I have a problem, I will come.
18:51When their problem is either they develop a foot infection or vision loss or some kidney problem, then only they
18:59come. It is too late.
19:00So, you have to have regular check-ups and that is why, because they do not do regular, suppose you
19:06do a master check-up, everybody has a master check-up.
19:08If you do not pick up diabetes this year, we will pick it up next year. Whereas, if you do
19:12not go for a check-up at all, they say if I go for a check-up, they may find
19:16out I am diabetic, so I am not going.
19:17That is a very foolish thing to say. What is the point in having a disease and denying it? That
19:22means you are in denial.
19:23So, the thing that you have to do is to go for the check-up, detect it early and then
19:28try to reverse it at that time.
19:30Any awareness in the public?
19:33Awareness has to be increased in the public. It must start from the school, it must go to the college,
19:39it must go to workplaces, it must go to the public, it must go everywhere.
19:45Wherever you go, you must be given right information about diabetes. You can also go through social media.
19:51Today, what is done is, social media, we have all kinds of influencers because they have large number of people
19:56following.
19:57They just tell whatever they want. Often, they pick it up from some Google or something, they pick up something.
20:03That information may be totally wrong and they are always telling people wrong information.
20:08Don't take medicines. If you take medicine, you will get kidney problem, so stop all medicines.
20:12So, people are well controlled also, they stop the medicine and then they develop a kidney problem because they stopped
20:17the medicine.
20:18So, like this, I think correct information and awareness is very important.
20:22Otherwise, people will be misled and all kinds of complications will come.
20:27Recently, AI all data in the diabetes in the medicine.
20:31Advice in the public and treatment methods.
20:35About AI. AI is good.
20:38So, in many ways, artificial intelligence can help you to think of something which you never thought of before.
20:46Because AI has large data and it can analyze it well better than a human brain can do, AI can
20:52do.
20:52Because you have taught the computer to think like that.
20:54So, the power of AI is fantastic. It is very difficult for a single individual to do that.
21:01So, that way it is good.
21:03Only thing is, the AI must be given correct information.
21:08If you don't give correct information to AI, it will make a wrong diagnosis.
21:12Because from the data, it has only it can do.
21:14So, you must keep on building the database for the AI.
21:18So, that more and more correct information is given to it.
21:22If that is done, AI can help in diagnosis. AI can help in treatment. AI can help a doctor to
21:29treat and diagnose diseases.
21:30So, AI is good. But we should check it to make sure whether it is correct or not.
21:36About 30 years experience in the diabetes department. Your advice in the children and younger generation.
21:43We must start very early. Because if we wait until 30, we will miss a significant number of people.
21:49Today, it is starting at very young age. So, even by the age of 10, 15 years, it is starting.
21:56So, right from school, first of all, I would say even during pregnancy, we should start.
22:01Because if the pregnant lady has diabetes, that is passed on to the child.
22:07So, we must say, before the lady gets pregnant itself, reduce weight, prevent gestational diabetes during pregnancy.
22:15Then we treat the diabetes during the pregnancy well. Then the child is born normal.
22:20Otherwise, the pregnancy diabetes can give rise to diabetes in the child.
22:25So, if that is controlled well, from there itself, we are doing it.
22:28Exclusive breastfeeding is another thing. Six months, if breastfeeding is done, then the child grows up normally with normal immunity.
22:37If you stop that in two months and then start giving cereals and other food from outside, chance of developing
22:44infection, immunity going down is very high.
22:47And finally, from childhood itself, the children must be taught exercises, eat healthy.
22:54Now, in schools, they have started by saying bring fruit to the thing, don't bring junk food, don't bring pizzas
23:00and all that.
23:01Because there are very high calorie foods.
23:03So, right from that time, if we start, and even in the classes that are taught, nutrition must be taught,
23:09healthy nutrition must be taught, value of exercise must be taught.
23:13See, what happens in schools, they have a particular area and they will have a big playground.
23:18When they want to expand, the playground is removed and they put two blocks there.
23:23They build two new buildings there.
23:25Playground is gone.
23:26Then child cannot play.
23:28They should insist that every school should have some play area.
23:32Because playing is very important.
23:33Because it helps to build muscle.
23:35It develops the brain of the child, the muscles of the child.
23:39It makes the child healthy.
23:40If all that is done as they are doing in China, then the country can be really strong.
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